Monitoring health reform: a report card approach

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Abstract

During the past several years, budget cuts have forced hospitals in several countries to change the way they deliver care. Gilson (Gilson, L. (1998). Discussion: In defence and pursuit of equity. Social Science & Medicine, 47(12), 1891–1896) has argued that, while health reforms are designed to improve efficiency, they have considerable potential to harm equity in the delivery of health care services. It is essential to monitor the impact of health reforms, not only to ensure the balance between equity and efficiency, but also to determine the effect of reforms on such things as access to care and the quality of care delivered. This paper proposes a framework for monitoring these and other indicators that may be affected by health care reform. Application of this framework is illustrated with data from Winnipeg, Manitoba, Canada. Despite the closure of almost 24% of the hospital beds in Winnipeg between 1992 and 1996, access to care and quality of care remained generally unchanged. Improvements in efficiency occurred without harming the equitable delivery of health care services. Given our increasing understanding of the weak links between health care and health, improving efficiency within the health care system may actually be a prerequisite for addressing equity issues in health.

Section snippets

Proposed framework

Table 1 outlines the proposed framework for monitoring the impact of health reform on equity and efficiency. The monitoring of access to care and of health impacts must be population-based. In such work, the entire population of an area (or of a group — defined by such characteristics as age or income level) is identified as the denominator for calculating access to care, and all care received by residents (regardless of where it is received) contributes to the numerator. Only population-based

Population health status

Several measures of population health status can be used to monitor the impact of health reform and for identifying and monitoring vulnerable, poor health groups (Table 2) (Cohen and MacWilliam, 1995, McGinnis and Lee, 1995). Using administrative data to measure health status has the major advantage over surveys in that the entire population’s health status can be assessed repeatedly over time. The mortality measures chosen (Table 2) represent the results of an extensive literature review of

Health reform

As part of downsizing the acute hospital sector, major bed closures began in fiscal 1992, in Winnipeg, the provincial capital, home to the medical faculty and a population of approximately 600,000. By the end of fiscal 1996, 24% of the acute beds (731 beds) had been closed and the continued budget increases of the previous decades had been halted. Since the beginning of health reform we have monitored the impact of changes using many of the indicators discussed in our “Proposed Framework” (

Data

Our population-based approach categorized patients according to their area of residence, regardless of where they received care. All data were taken from the Manitoba Research Data Base and based on fiscal years 1990 through 1996. Population figures were taken from the registration files, which contain a record for each resident of Manitoba eligible to receive insured health care services. Utilization data came from hospital and physician claims files, which contain encounter-based records of

Population health status

While the closure of even one-quarter of a city’s hospital beds (as occurred in Winnipeg) seems unlikely to produce detectable changes in population health status, provider groups expressed concerns that “increased morbidity and mortality” would result from these closures. Between 1990 and 1996 (acute bed closures started in 1992) we found no increases in the overall mortality rate of Winnipeg residents. Mortality rates for males and for deaths due to chronic diseases actually decreased

Discussion

Both efficiency and equity criteria show the Manitoba health care system to have adapted remarkably well to the pressures of health reform. We have provided strong evidence of a reformed system both delivering care more efficiently (via outpatient surgery and shorter stays) and preserving equity by providing relatively more care to those groups who are sicker and more vulnerable. These results are specific to Manitoba, however they highlight the importance of establishing monitoring systems in

Summary

The equity and efficiency of the health care system can and should be monitored as part of any reform effort. We have suggested a framework for monitoring and indicators that should be used; the findings may reassure the public and health care professionals that downsizing is possible without threatening access to or quality of care delivered. Despite our increasing knowledge of the weak links between health care and health, it is important to recognize and preserve the equitable delivery of

Acknowledgements

This work was supported by the Department of Health of the Province of Manitoba under a contract with the Manitoba Centre for Health Policy and Evaluation, and by a grant from National Health Research and Development Program Career Scientist Award to Dr. L.L. Roos. The authors gratefully acknowledge Charles Burchill, Leonard MacWilliam, and Marina Yogendran for their data analytic contributions, and Eileen Pyke and Carole Ouelette for manuscript preparation. The authors acknowledge the St.

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