Health and universal coverage – Prof. Monika Steffen EUHEALTH
Summary
TLDRL'accès universel aux soins de santé, bien qu'idéal, présente des défis importants. Le script aborde la dualité des systèmes de santé, notamment dans les pays avec des services publics gratuits, où les classes sociales influencent la qualité des soins. L'accès en temps opportun, l'égalité de traitement et l'adaptation aux cultures locales sont essentiels. Cependant, des contraintes budgétaires, des listes d'attente et des soins limités complexifient l'accès équitable. Les réformes en Europe visent à concilier l'accès universel avec la maîtrise des coûts, tout en modernisant les systèmes de santé pour répondre aux besoins croissants et technologiques.
Takeaways
- 🌍 L'accès universel aux soins de santé est un concept attractif, mais sa mise en œuvre pose des défis d'équité et de qualité.
- 🏥 Certains pays comme le Brésil et la Russie offrent un accès public à la santé, mais cela peut entraîner un système à deux vitesses.
- ⚖️ L'accès universel ne signifie pas toujours un traitement égalitaire, souvent les systèmes sont séparés entre riches et pauvres.
- ⏱️ Le traitement en temps opportun est crucial pour de nombreuses maladies, soulignant l'importance des soins primaires et des systèmes de transport rapides.
- 👩⚕️ L'égalité de traitement devrait inclure une prise en compte du genre et des besoins spécifiques des femmes et des filles.
- 🗣️ Les soins centrés sur le patient doivent être adaptés aux différences culturelles et sociales pour éviter anxiété et souffrance.
- 💰 Les systèmes de santé universels nécessitent d'énormes ressources financières, humaines et technologiques pour garantir des soins de qualité.
- 🌐 Les systèmes de santé doivent être bien organisés, avec une distribution géographique équilibrée pour assurer l'accès même dans les zones rurales.
- 🩺 Les services de santé doivent être bien coordonnés entre les différents niveaux de soins (primaires, secondaires, tertiaires) pour assurer des traitements appropriés.
- 📉 Les systèmes de santé universels, comme ceux du Royaume-Uni, peuvent souffrir de longues listes d'attente, obligeant certains patients à chercher des alternatives privées.
Q & A
Qu'est-ce que l'accès universel aux soins de santé signifie pour la plupart des gens ?
-Pour la plupart des gens, l'accès universel signifie pouvoir consulter un médecin à proximité, recevoir des médicaments gratuitement et avoir accès à un hôpital public avec des portes ouvertes.
Quels sont les risques associés à un système de santé avec accès universel ?
-Un des risques est la création d'un système de santé à deux vitesses, où les personnes plus aisées bénéficient de soins privés de meilleure qualité, tandis que les plus pauvres utilisent le système public avec un niveau de soins souvent inférieur.
Pourquoi le traitement en temps opportun est-il essentiel dans l'accès universel aux soins ?
-Le traitement en temps opportun est crucial car certaines maladies, comme le cancer ou le sida, peuvent être traitées efficacement si elles sont détectées tôt, mais deviennent mortelles si elles ne sont pas soignées rapidement.
Quelle est l'importance des soins centrés sur le patient dans un système de santé universel ?
-Les soins centrés sur le patient sont importants car ils s'adaptent aux besoins sociaux et culturels des patients, garantissant que chaque individu reçoit des soins respectueux de ses croyances et craintes.
Comment les systèmes de santé nationaux, comme celui du Royaume-Uni, gèrent-ils les défis de l'accès universel ?
-Les systèmes de santé nationaux, comme le NHS au Royaume-Uni, sont fortement contrôlés par le gouvernement, ce qui peut entraîner des budgets limités et des listes d'attente pour certaines interventions.
Quel est l'effet des assurances santé privées supplémentaires dans des systèmes comme le NHS ?
-Les assurances privées supplémentaires permettent aux personnes qui en ont les moyens de contourner les listes d'attente, d'accéder à des hôpitaux privés et de bénéficier de meilleurs soins, créant ainsi une version légère d'un système à deux vitesses.
Quels défis économiques ont affecté les systèmes d'assurance maladie sociale en Europe dans les années 1970 et 1980 ?
-La crise économique, la mondialisation, et la diminution des cotisations dues à un ralentissement de l'économie ont créé des problèmes de financement pour les systèmes d'assurance maladie sociale, nécessitant des réformes.
Quels types de réformes ont été introduites dans les systèmes d'assurance maladie sociale dans les années 1990 et 2000 ?
-Les réformes visaient à contenir les coûts tout en modernisant la gestion des systèmes, avec des privatisations partielles, la réduction des services publics comme l'entretien des hôpitaux, et des listes de médicaments remboursés réduites.
Comment les réformes européennes ont-elles visé à renforcer l'accès universel tout en contrôlant les coûts ?
-Les réformes ont renforcé la régulation gouvernementale, modernisé la gestion publique et introduit une concurrence régulée pour maintenir l'accès universel tout en dépensant l'argent de manière plus efficace.
Quelles sont les principales conditions nécessaires pour garantir un accès universel équitable aux soins de santé ?
-Il faut un financement suffisant, une distribution géographique équitable des services, des réseaux de soins bien coordonnés, des soins centrés sur le patient et un traitement en temps opportun pour garantir un accès universel équitable.
Outlines
🌍 Accès universel aux soins de santé : une réalité complexe
Le concept d'accès universel aux soins de santé est souvent idéalisé, perçu comme l'accès gratuit à un médecin, à des médicaments et à des hôpitaux publics. Certains pays comme le Brésil et la Russie disposent de tels systèmes. Cependant, cela peut engendrer un système de santé à deux vitesses, où les classes moyennes et supérieures utilisent des assurances privées pour bénéficier de soins de meilleure qualité. La question essentielle est donc de savoir si l'accès universel garantit aussi une égalité de traitement pour tous, ou si certaines catégories sociales reçoivent des soins de meilleure qualité.
⏱️ Le traitement en temps opportun : clé de l'accès universel
L'accès universel ne se limite pas à la gratuité des soins, il inclut aussi la rapidité du traitement. Par exemple, un cancer ou le SIDA nécessite une détection et un traitement précoces pour améliorer les chances de survie. Pour cela, un système de soins primaires efficace est essentiel, car ce sont les généralistes qui détectent les maladies à un stade précoce. De plus, des systèmes de transport d'urgence rapides sont cruciaux pour garantir des soins en temps opportun, notamment lors d'urgences comme un infarctus. Le traitement rapide et l'égalité des soins doivent inclure également une dimension de genre.
💰 Les défis financiers de l'accès universel
L'accès universel nécessite d'importantes ressources en termes de financement, de main-d'œuvre et de technologies. Un défi majeur est de garantir une distribution géographique équitable des services, permettant à tous d'accéder à des soins de qualité, même dans les zones rurales. Cela implique une coordination efficace entre les différents niveaux de soins (primaires, secondaires et tertiaires). L'accès universel ne se limite donc pas à la gratuité des soins, mais implique également une gestion optimale des ressources et des infrastructures.
🇬🇧 Les systèmes nationaux de santé et leurs limites
Dans certains pays, comme le Royaume-Uni, l'accès universel est assuré via des services de santé nationaux (NHS). Ce modèle permet une inscription automatique des citoyens et un accès gratuit aux soins. Cependant, ces systèmes peuvent souffrir de budgets limités, entraînant des listes d'attente. Parfois, des accords internationaux permettent de contourner ces délais, comme les patients britanniques envoyés en France pour des opérations. De plus, ces systèmes peuvent être complétés par des assurances privées pour des soins plus rapides ou pour des services non couverts par le NHS, créant ainsi une version allégée d'un système de soins à deux vitesses.
⚖️ Assurance santé sociale : de la solidarité à la modernisation
Les systèmes d'assurance santé sociale sont basés sur la solidarité entre groupes professionnels. Cependant, certaines catégories de personnes, comme les chômeurs, les étudiants ou les femmes divorcées, ont longtemps été exclues de cette couverture. Au fil du temps, des réformes ont été mises en place pour étendre la couverture à l'ensemble de la population, garantissant ainsi l'accès universel. Malgré ces efforts, les crises économiques et les changements sociaux ont créé des défis financiers pour ces systèmes, nécessitant des ajustements et de nouvelles solutions pour maintenir l'accès universel.
🌐 Crise économique, mondialisation et réforme des systèmes de santé
Les années 90 ont marqué un tournant avec la mondialisation et l'avènement de nouvelles technologies, entraînant une pression accrue sur les systèmes d'assurance santé sociale. Avec des marchés du travail fragilisés et des dépenses de santé en constante augmentation, ces systèmes ont dû introduire des réformes pour contenir les coûts. Cela a inclus des mesures telles que la privatisation partielle des services, la réduction des lits d'hôpitaux et l'introduction de paiements partagés pour certains soins. L'objectif de ces réformes était de maintenir l'accès universel tout en modernisant la gestion et en optimisant les dépenses.
🏥 La nouvelle gestion publique et la régulation du secteur de la santé
Pour faire face aux défis financiers, les systèmes de santé européens ont introduit des réformes basées sur la 'nouvelle gestion publique', empruntant des pratiques de gestion du secteur privé. Cela a impliqué des réductions de personnel, l'externalisation de services comme le nettoyage des hôpitaux, et l'optimisation des prescriptions médicales. La concurrence régulée entre les assurances santé a été encouragée, tout en maintenant un contrôle gouvernemental strict pour garantir l'accès universel. Ces réformes visaient à maximiser l'efficacité des dépenses, tout en maintenant une couverture de qualité pour tous.
🤝 Réduire les déséquilibres et moderniser les systèmes d'assurance santé
Les systèmes d'assurance santé doivent lutter contre les déséquilibres entre différentes catégories professionnelles, certaines ayant plus de risques et de dépenses de santé que d'autres. Pour garantir une couverture universelle, des réformes ont été mises en place pour moderniser les règles d'affiliation et harmoniser les contributions. En parallèle, la combinaison entre assurance publique et privée a été repensée. Les réformes en Europe ont cherché à contenir les coûts tout en modernisant les systèmes et en s'assurant qu'ils puissent faire face à l'augmentation des dépenses de santé à long terme.
Mindmap
Keywords
💡Accès universel
💡Équité
💡Système de santé à deux vitesses
💡Traitement en temps opportun
💡Système de soins primaires
💡Infrastructures de transport médical
💡Soins centrés sur le patient
💡Ressources suffisantes
💡File d'attente
💡Assurance santé privée complémentaire
Highlights
Universal access to healthcare is a widely desired concept.
Universal access often means free healthcare services without the need for health insurance.
There is a risk of creating a two-class medical system with separate healthcare for the poor and the wealthy.
Universal access should also mean equity and equal treatment for all.
Timely treatment is crucial and should be part of universal access.
Primary care systems are essential for timely treatment and early detection of illnesses.
Rapid transportation systems are necessary for emergency situations.
Gender equality in healthcare is a component of universal access.
Patient-centered care is important for culturally sensitive healthcare delivery.
Sufficient resources in terms of funding, manpower, and technology are required for universal healthcare.
A good geographical distribution of services ensures accessibility across the country.
Coordinated networks between care levels are necessary for effective treatment.
National health services provide universal access but may have issues with waiting lists and limited care options.
Supplementary private health insurances are common in countries with national health services.
Social health insurance systems face challenges with economic crises and changing labor markets.
Reforms in social health insurance systems focus on cost containment and modernization.
Regulated competition and privatization are strategies to improve efficiency in healthcare systems.
Reinforcing patient rights and involving users in decision-making processes is part of the reform strategy.
The goal of healthcare reforms is to maintain universal access while improving quality and efficiency.
Transcripts
so i start with this magic word
universal access everybody loves it
the international organization and every
every
every person would like to live in a
country with universal access to health
care but what do we mean by this well
generally people mean simply
well i will have a doctor next door and
i will get free medicine and there will
be a hospital public hospital with large
open doors and i can just walk in and
that's it
we do have such systems in
quite a lot of countries with huge
populations i don't quite know about
india but i know quite a lot of things
about brazil and russia
these countries do have public health
care systems where everybody can go like
this and they function partly without
any health insurance without any money
so it's just open doors um
but there's a risk
because when i see when i saw these
countries and they have all these
wonderful public hospitals in rio de
janeiro on the bottom of every favela
there's a brand new hospital my
colleagues from university they don't go
to that hospital they all have a private
health insurance from your their
employer from the university or from if
they work for the government and they go
to different hospitals as they see
different doctors and they seem to be
all in very good health
so
the risk the risk with this idea of
universal access just open doors
is very often you will have two separate
health care systems what we call in
in german or in french a two-class
medical system
one for the poorer people and one for
the people who have sort of middle class
upper middle class and the upper class
and they they don't use the same
institutions and from there you can
guess that probably they don't get the
same quality of care these people
so
this is the basic for me the basic issue
in
in the world in the concept of universal
access does it also mean equity does it
also mean equal treatment the same good
treatment with the same good technology
for everybody
because then you have a quite different
problem of organization
it's not enough just to set up a few
public
providers of health care now we had a
little reading on axis where it was
already a little bit extended the term
and it was explained you also need
timely treatment it means
it's not enough to have just access
let's say you have a cancer if you if
you're not treated in time you will
probably die if you treat it very early
or the same is true for
aids now if you get medicine very early
a diagnosis very early you can live with
it
so timely treatment is very is part for
me
of universal exit access it needs two
conditions
it needs to be
there needs to be an accessible primary
care system because it's a general
practitioner who does the surveillance
of people and he will see early enough
that you have some illness which if it's
not treated becomes severe severe and
maybe even a vital issue so timely
treatment is very very important and for
this you need primary care not big
hospitals
at that at that first step and you need
rapid transportation systems for
emergency imagine a man drops down in
the street with a heart attack if he's
in the hospital with a very rapid
warning system and transport he will
survive and he will survive well but if
it's three or four or five or six hours
or a day
if we get to a hospital just for dying
so
timely treatment is part of universal
access
equal treatment i said it already and i
would add it includes gender
equal treatment does not only mean that
all the boys get good treatment and all
the men it also means that all the women
and all the girls get treatment and this
is not so in every country
uh what else does it need well i would
say what we call in europe now
patient-centered care that means the
care that is delivered in a region or in
a country should be socially and
individually adapted
to the people
so the different cultures are different
ways of talking to people you know
different conceptions of health and all
this should be integrated in universal
access that you have a doctor who knows
how to talk to you without
making you
suffer or fear
so then you have very material
conditions you need sufficient resources
in terms of funding money manpower and
technology because if you want to care
for everybody in the country in a timely
way and an equal way with the same good
treatment you will need a lot of money a
lot of manpower and a lot of technology
so where does it come from who will pay
for this
you need a good geographical
distribution of the services
so that in every parts of the country
the services will be available of course
you cannot put a hospital into every
village but you can organize the
networks that every ill person from
every village will get in time
to a hospital
where he can be treated in good
conditions
so it also needs coordinated networks
between all the care levels in my first
lesson i talked about primary care level
secondary care level and tertiary care
level that's in terms of technology so
there need to be networks
between these levels in order to get
timely treatment equal treatment and the
right treatment so it starts here with
the zp with the general practitioner
so far for the term for this magic word
universal access so there's much more
behind than just open doors and free
medicine
now we talked about different health
care systems uh types of health care
systems and how do they react towards
the issue of universal access just to
record
it is universal by origin so you don't
need to add any
universal access when you people who
have lived in britain they know it you
will get an inscription in the national
health service and then you can go to
any doctor to any hospital and you don't
need to pay this is the basis of a
national health service
um but they're problems
national health services are very well
managed uh and controlled by the
government
regulation is very strong they can limit
the budget they do limit the budget they
decide how many people will be recruited
and how many hospitals will be built and
the equipment will be renewed or not
it's according to these um
discussions at the high government level
so if you then have everybody who has
access to universal care
you may have problems with not enough
means and you have waiting lists and
britain has always had waiting lists
they exported many patients to france
for hip operations for instance because
they had to wait two years in britain
and in france i could have it
immediately so we made agreements
between french hospitals and the
national health service in britain and
the people could come and then the bill
would be sent to britain to the national
health service so it was
sometimes within the european union you
can make
these type of arrangements
another problem of national health care
systems and universal access is the care
basket may be a bit limited so there may
be many things like
glasses or hearing aids or things like
this or complicated operations which
will not be done
inside the national health service
because it would cost too much money
or
which will not be done for
only for young people not for old people
and things like this
so because these problems exist very
often in national health systems we have
read it in the reading about sweden we
have read it about england
and the whole literature tells you the
same they are very often private
supplementary private health insurances
in these countries so supplementary
means that they bring a supplement there
where something is lacking
many of these private health insurances
are sponsored by your employer your
office is oh sorry he can offer it to
his employees or to his um
to his uh
most important employees for instance
and it allows you to jump the queue to
have less waiting time you go to some
other hospital a private one where
there's no waiting time it's reserved
for this private supplementary health
insurances
or you can
see privately
people from the national health service
also
you may have a right to private hospital
room or better and quicker medical
procedures more benefits like little
things like glasses hearing aids or
dental replacement they may pay for
alternative medicines like chinese
medicine or thermal course so we have
these private health insurances which
live as a supplementary thing
uh
besides the national health services to
go around the problems for
the people who can afford such a private
health insurance
because there is no option to leave the
national health service you will always
pay your contribution either to the
national health service you pay
it's paid by the general taxes you will
continue to pay your taxes to the
national health service even if you are
always cared for by private health
insurance so we will have somehow to pay
twice
you cannot there is no exit option from
the national health service in britain
or in sweden
the result of all this is
universal access understood in the way
of national health services has the risk
of
waiting lists on limited care basket
and the possibility for some people to
have a supplementary issue to get out of
this problem and it is a sort of light
version of a two-class system
a light version not a heavy version i am
precise about this
so so far for the national health system
it comes
becomes more complicated with the
social health insurance systems like i
have to explain more things three slides
because the origin if you remember of
social health insurances was some sort
of solidarity between professional
groups or between
economic branches and they had their
health insurance for their members
so people were grouped
let's say inside germany by different
groups
who had different health insurances and
they were looking after these people and
the solidarity was within this group
so there were people then of course who
were in no group because they didn't
work they were too old or they were too
ill or they were peasants didn't have
such things it came later
um domestics or you know all sorts of
groups who didn't have these uh
institutions they were then not covered
at all
so this was managed in the way that in
the inter-war time
to world wars and in the 50s and 60s in
these countries who have these
social health insurances they extended
it to other groups to complete the
universal access to make it universal
and
that was achieved more or less in most
major european health care systems in
the early 70s
but then we had an economic crisis first
oil crisis and
economic economy shrunk taxes shrunk
contributions shrunk and
more people were ill because of stress
and economic problems
so the health insurances these social
health insurances they all had a problem
with money
so they had to do something
because the world had changed social
changes people got divorced so there
were women without health insurance they
used to be insured with their men with
their spouses unemployment people who
were unemployed over a certain longer
time they were not health insured
anymore
uh young people who couldn't find a job
students who were a little bit older
already studying too long they didn't
have a health insurance so there were
all sorts of problems because we had an
economic slowdown so the old model was
some sort of breaking
so we found partial solutions which were
we did something for the unemployed we
did something for the divorced people we
did something for the young people for
the students and so on and some some
countries did a very big change in those
70s 80s italy and spain for instance
changed their health care system from a
social health insurance system to a
national health service a decentralized
one
so this somehow worked from the 70s 80s
early 90s the thing works but then came
a new big change that was new technology
globalization
with competition with countries where
wages were much lower
so the labor market was changing in
europe
and that made the same problem then the
first economic slowed down even
worser
for the health insurances because they
had less money coming in because the
economy was slower
and they had more money running out
because health expenditure was growing
it's always growing because of
technological progress because of
chronic illness where people don't die
anymore because they have this or this
illness they become chronically ill and
they need care for years and years
30 years earlier they died so you have a
natural growth of health expenditure and
then you have changing labor markets and
you have a problem you cannot manage
anymore and came a new ideology
neoliberalism
where we were told everything has to be
private then it's better
so
we introduced a lot of reforms in our
european social health insurance systems
in the 90s and 20s
and it introduced cost sharing with more
out-of-pocket payment
de-listening medicines so medicines that
were paid by the health insurance before
if they were not really very important
they would not pay for them anymore you
would have to pay out of your pocket for
these little things
um
all sorts of things were changing as
what was
because of cost cost control yeah we had
to save money but the main thing
changing was a changing labor market
many people had not secured jobs anymore
and for that reason also were not health
insured all these fragile little jobs
um
so the result was
after the 70s when we could do with
partial solutions in the 80s and 90s
with the globalized world there was a
need for changes bigger reforms because
we had a growing number of people who
dropped out of the coverage of the
social health insurance system and the
social health insurance had to do
reforms for cost control which made
cost sharing bigger so for poorer people
this was to a problem so there was a big
problem with universal access so we had
to maintain universal access but how so
the policy report responses reforms in
europe in these social health insurance
countries were very intelligent it was
not cutting the benefits like the leo
liberals wanted and make private
insurances it was saying well we have to
spend the money better
more efficient spending we have to do
more with the same money or even with
less
so we have to reinforce regulation with
the government reinforced its control
over all the social health insurances
they were much more independent before
than they are now from the government
we had to do internal management reforms
to manage the system better and this is
what we call the new public management
here you have some details
uh formerly the healthcare system was
more or less managed in bureaucratic
ways whether it was public or private
because the heads insurance is a big big
organizations
now we try to manage them
uh according to private enterprise
management so compress the labor force
uh take away everything that can be
replaced by cheaper solutions for
instance
they checked in most countries all the
medicines we prescribed and took out of
the reimbursement list all those who
were not proven really very
efficient or the medicines a little bit
that were thrown out of the basket
uh
we restricted public works for instance
cleaning in hospitals is not done
anymore by hospital stuff it's done by
private enterprises who work with
cheaper labor we had to reduce the
hospital beds
because we wanted to save money
saving hospital beds means home care so
they're less less nurses needed less
less doctors needed
you can do all this by internet too you
don't need to travel to the home anymore
we did privatize a few things also in
order to introduce competition between
health insurances for instance
formerly you could not enter any health
insurance like this social health
insurance because they work for certain
groups
and now in
particular countries i think they opened
it you can choose freely and they can't
refuse you i think i said it already
so
they have to be managed very well they
have to have at the top a real manager
not a bureaucrat
so
this we call regulated competition and
regulated privatization because there
was always the government behind with
its control because he wanted to keep
general access and a certain quality the
thing was not only saving money it was
spending the money better
get more out of the money more quality
and more people covered
so we reform the hospitals and the care
structures
and reinforce patients rights and
patient power
in europe practically every hospital
and every community like the state the
the towns government who has to do with
medical structures they will have some
committee with the users of the health
care system and they will give their
opinion and they will be consulted for
all sorts of decisions
so choice for the users i can choose my
hospital my health insurance has also
become a policy tool which reinforces
the government control over the system
so there are policy partners now the
patients so securing the social health
insurance coverage
for universal access
it meant in reality you know i i told
you a few details now go over the
details
uh you have to counteract the
traditional imbalance of risks between
different health insurance bodies if you
have health insurances for certain
groups you have always
uh groups with a certain income in a
certain health insurance engineers for
instance or house cleaners so
the house cleaners have more health
risks
and less life expectancy and less salary
so their health insurance is much poorer
than those the health insurance of
engineers i think this is easy to
understand so if you want to have
universal coverage you have to break
this imbalance between the different
heads organize insurance organizations
whether they're public or private is not
really important but it's important that
you break this imbalance
so you have to modernize the rules for
affiliation i said already you know you
can affiliate rather freely in those
countries where you have the choice
between different health insurances in
france we don't have choice because we
have only one it's unified
um
and you have to reconsider the public
private health insurance mixed with
this exists in some countries
oh sorry it's always running away
so all these reforms
are based on combining cost containment
so that we will be in the future also
capable of paying the growing health
expenditure because there's not only now
in the past there's also the future and
it will grow the health expenditure so
course compare containment combined with
modernization of the system and its
organization and universal access this
was the idea of the reforms in europe it
took a while to work on this because
this is really a bit difficult
and the strategy is not yet finished
it's still going on we have health
reforms all the time now but it is
within this vision cost containment
modernization also in terms of research
and technology how to have a modern
healthcare system and universal access
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