Accountability?
Ricard Tresserras, Pilar Brugulat
particular WHO’s Health for All policy and the American Healthy People initiative, both of which were inspirational. Practical implementation was guided by important technical insights into how to quantify targets, drawn from experiences in countries and subnational entities such as Scotland, Northern Ireland, Wales, Canada, England and the United States of America (Salleras and Via 1992).
Unlike in other countries (such as England) target setting in Catalonia began in the health sector and was subsequently adopted elsewhere. Regional policies were required to comply with the Spanish General Health Act and were developed within its framework. An interregional committee (Consejo Interterritorial del Sistema Nacional de Salud), brought together representatives from all Spanish regions and provided for nationwide coordination and learning from shared experience (Salleras et al. 1994).
The resulting Catalan Health Act introduced a split between financing and the provision of health care in Catalonia. This was at a time when the political climate was conducive to major reforms and produced a situation unlike that in the rest of Spain. The act was based on a series of explicit values, including equity, accessibility, effectiveness, quality and user satisfaction. These underpinned the target programme (now driven by the Catalan Health Service) but, in reality, most targets focused on effectiveness.
A Catalan Health Service was established as a purchasing organization within the Department of Health with responsibility for funding, contracting and operational planning. Health care was provided by a mix of public and private organizations. The public provider, the Catalan Institute of Health, delivered 80% of primary health-care services and 30% of hospital care.
The Catalan Department of Health periodically reported its intentions to the regional parliament in the form of a health plan. This did not require formal approval from the assembly, rather it set out the Minister of Health’s commitment to achieve certain targets within a given period. The first edition was published in 1991, this Framework Document for the Elaboration of the Health Plan for Catalonia (Departament de Sanitat i Seguretat Social 1991) provided the basis for subsequent plans. Currently, two types of document are published. A strategic document is issued every ten years and supplemented by plans that give more emphasis to operational aspects, published every three to four years. The health plans report on progress towards the targets set out in previous plans. A major evaluation is conducted prior to the publication of each strategic plan (Departament de Sanitat i Seguretat Social 1991;
Departament de Sanitat i Seguretat Social 2003; Departament de Sanitat i Seguretat Social 1992; Departament de Sanitat i Seguretat Social 1997;
Departament de Sanitat i Seguretat Social 1999).
Generating targets
The selection of initial targets involved an extensive process of consultation.
Teams sought to identify priority areas, link priorities to measurable indicators, determine the expected time needed to achieve a target, and finally, to operationalize the targets agreed. The overall goal was: “adding life to years and adding health to life.”
A three-stage process was used to define the targets. First, identification of the leading health problems (assessed by burden of disease) that were amenable to interventions was undertaken and targets were set to improve their outcomes.
Second, specification of the associated risk factors was made and the targets necessary to reduce them. Third, operational targets linked to the processes required to achieve the first two sets of targets were set. As far as possible, the formulation of targets included evidence on baseline levels, the direction and magnitude of the expected change, time over which it should be achieved and the indicators to be used for evaluation. The WHO Regional Office for Europe’s targets were used extensively. Specific goals were defined where either WHO targets had not been set or they had been achieved in Catalonia (Salleras et al. 1994; Tresserras et al. 2000).
The initial set of targets focused on health outcomes rather than processes, even though the target-setting initiative had emerged within a context of health-system reform. In the first planning period (until 2000) 19 health problems were identified as priorities, involving 22 sets of interventions.
Of course, it is important that targets engage those who will be responsible for achieving them. The initial period was characterized by enthusiasm and active participation among health professionals who welcomed the commitment to a stronger evidence base for the ongoing health-care reforms. This was followed by a period of growing scepticism, in part reflecting methodological difficulties in setting and operationalizing targets. At this point, some professionals considered this a fruitless exercise with little chance of success.
An evaluation of target setting occurred in the third period. Targets were seen as a way of reorienting health policies and services, although it was accepted that improved methods were needed. However, those working in the health sector did see the target-based approach as a way of making their needs more visible and a useful means to identify priorities.
The evaluation of the target-based system in 2000 was an important step that contributed to the credibility, transparency and legitimacy of this element of health-policy development (Salleras and Tresserras 2003; Tresserras et al. 2000).
The evaluation identified a number of weaknesses in the initial targets. For example, not all dimensions were included; those that were were not
well-developed. There was little attention to equity, accessibility, quality or satisfaction and greater emphasis was placed on the aggregate level of health indicators rather than their distribution, according to social class, territorial units or gender.
Accountability
Accountability was a key element of the target-based model and the Health Plan of Catalonia elicited a high level of professional participation. Details were widely disseminated and available on the Department of Health’s web site, thus seeking to ensure a high level of transparency.
As noted earlier, each health plan is presented to the Catalan parliament.
Although it is not required to grant approval, the Catalan Minister of Health is held accountable for accomplishment of the activities and achievement of the targets. Reporting is straightforward as most of the targets are quantitative, with a defined time horizon and links to a specific indicator. Thus (at least in theory), there is an effective mechanism to ensure transparency and accountability to the public and to parliament.
In practice, the outcomes of the health plans have not been subject to parliamentary scrutiny. No activity was elicited when the 2000 evaluation was presented to parliament – the opposition did not use its right to ask the government whether or not the targets had been achieved. A formal requirement for parliament to approve the health plans and scrutinize achievements could provide for a more enriching debate and even provoke a greater degree of political commitment to the policies pursued. The development of a cross-party consensus might also facilitate the adoption of policies that extend beyond a political mandate.
The question of accountability raises other issues. The diverse determinants of health mean that any strategy must take a multisectoral approach – the health sector can provide leadership but it must engage with other sectors. However, there is no mechanism to judge their contributions to overall health gain.
Examples included targets to reduce injuries associated with traffic and domestic violence against women. How to strengthen this wider accountability is a subject of continuing debate.
Collecting and using intelligence
The target-setting process led to a significant reappraisal of the use of health data, previously a low priority. In 2001, a systematic review was undertaken to map the availability of routine sources that were relevant to the targets and thus identify where new data-collection systems were needed.
The Department of Health published an official report of the health plan evaluation and 25 papers were published in the highly reputed Spanish scientific journal Medicina Clínica (Salleras and Tresserras 2003). Moreover, most of the data used to undertake the evaluation were available to the public.
Yet, there was very little interest in the evaluation at either political or technical levels despite these considerable efforts to make the relevant information available.
The evaluation highlighted the existing data’s emphasis on processes rather than evaluations of health outcomes. For example, the evaluation of primary health-care settings gave more attention to controlling risk factors rather than addressing health problems such as pneumonia. In particular, the evaluation highlighted the limited information on lifestyles and health determinants.
This led to the creation of a public health agency to address behavioural issues.
Outcomes
There has been a mixed experience of implementing targets in Catalonia.
Some positive results include a more explicit articulation of public health goals; strengthened evidence base for policy-making; and strengthened public
Girona Heart Registry (REGICOR)
Existing data Ad hoc studies
Population census Mortality data
Hospital discharge data Infectious disease notifications Drug use
Maternal and child health care Workplace injuries
Assisted reproduction Abortion
Renal disease
Catalan Health Survey
Catalan Health Examination Survey
Survey of smoking amongst professionals (physi-cians, nurses, teachers, pharmacists)
Child dental survey Physical activity survey Drug consumption survey
Evaluation of the use of preventive practises in primary health care by auditing clinical records Catalan Nutritional Survey
Nosocomial infections register Girona Heart Registry (REGICOR) Table 5-1Sources of data for monitoring targets
participation in health policy. However, it is more difficult to identify gains in health outcomes or resource allocation. Similarly, although the use of targets has strengthened accountability, there is still much to do to improve monitoring and performance management. Box 5-1 gives examples of targets and progress towards them.
The most positive benefits could be seen in the policy process. Targets became integrated into the Department of Health’s activities at both political and technical levels. This contributed to a more rational approach to health policies that has evolved positively in recent years. It can be seen in improved definition and prioritization of key health problems, and in the development of plans to tackle them. This process was increasingly underpinned by a systematic analysis of epidemiological data on the health status of the Catalan population.
There had been little public participation in health policy in Catalonia but this changed when the Catalan Health Service created health councils at regional and local levels. These included representatives from the public (trade unions,
Note:Achieved – change in the indicator equal to, or greater than, expected. Partially achieved – more than 50% of the expected change. Not achieved – less than 50% of the expected change.
>14 yrs (by 20%); 15-24 yrs (by 18%) Box 5-1Selected targets from the Catalan experience
citizen associations, patient associations) and health sectors (health professionals). Overall health plans were subject to approval by the Catalan and regional health councils; more specific policies that acted over shorter periods also incorporated public involvement. However, the process of public involvement is challenging. Further efforts are underway to strengthen this, including greater use of the Internet, better documentation, focus groups and health surveys.
More mixed results were achieved in the pursuit of health gain. This assessment is complicated by the absence of a control group as it is impossible to know what would have happened in the absence of a target-based strategy.
However, the process was beneficial because it strengthened the culture of evaluation.
An evaluation of the health plan targets for 2000 showed that most of the health-related targets were achieved. An increase in disability-free life expectancy was observed and there were positive trends in the major measures of mortality. A total of 106 targets were evaluated, of these the majority – 68 (64.1%) were fully achieved; 9 (8.5%) were partially achieved; and 29 (27.4%) were not achieved. Success was more likely where targets related to the delivery of health services; those focused on public health issues were less likely to be successful. Five targets could not be evaluated because they had been formulated poorly or the data required could not be obtained without disproportionate cost.
There is limited evidence that targets had an effect on the allocation of resources. This may be because the predominant focus on health outcomes made it difficult for managers to see the link between their own activities and the achievement of improved health outcomes at a population level.
Furthermore, there were no financial incentives to achieve targets. More recent efforts to link budgets to the achievement of targets have been a learning process and it remains difficult to define this linkage. Recently developed steering plans linked to budgetary allocations may be the answer. These focus on a small number of health problems, with closely specified targets designed to achieve high-quality services in all parts of the Catalan Health Service. At present they focus on mental health, cancer, cardiovascular disease, ageing and the health of the immigrant population.
Lessons learned
Target setting in Catalonia has not been a straightforward process but significant progress has been achieved, going beyond the aspirational to actual implementation. The Catalan experience provides a number of lessons on how
to incorporate targets into a health-policy framework and where improvements are needed. More than ten years of experience in setting targets and developing health plans have taught the main lessons listed below.
It is difficult to tackle inequalities. Few data are available to assess the health status of disadvantaged groups, or even according to more simple variables such as sex, social class or territorial units. Considerable strengthening of existing information systems is needed.
The Health Plan for Catalonia explicitly emphasized primary health care, seeking to redress the traditional emphasis on the hospital sector. However, no one part of the health system can be considered in isolation and targets should cover the entire health-care continuum where possible.
It has been very difficult to find the link between health targets and service delivery. Service contracts have not been sufficient, even when linked to targets. Other approaches that include guidelines and benchmarking are needed.
Intersectorality remains a major problem. The involvement of other sectors is essential but difficult, often depending more on personal capacities rather than institutional arrangements.
An integrated vision is necessary, requiring complementary action to change health services. This should embrace preventive, primary care; hospitals;
intensive technology; and transportation of patients.
The involvement of health professionals is crucial. Much still needs to be done to extend knowledge and acceptance of the Health Plan for Catalonia and achieve shared ownership of its goals. Although there have been attempts to reach out to the population and involve them in the establishment of priorities, more work is needed to ensure active citizen participation.
Finally, an earmarked budget linked to the achievement of health targets would strengthen the capacity to influence health-policy development.
REFERENCES
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Introduction
To many observers, the English NHS appears to be the archetypal planned health system and it would be natural to assume that targets have been a central feature since its inception in 1948. However, this is not the case. In the early years of the NHS, the health system was dominated by the largely autonomous actions of health-care professionals, especially doctors. The only meaningful target under which local health-care organizations operated was the requirement to work within a fixed annual budget. Indeed, even this requirement was implemented flexibly. Often, local institutions (such as hospitals) were able to breach budgetary limits providing that the aggregate NHS budget was adhered to across the system as a whole.3
Traditionally, the gatekeeping role of general practitioners (GPs) has made an important contribution to cost control. Every citizen must be registered with a GP and access to non-emergency specialist care can be secured only by a GP referral. Compared with their counterparts in other developed countries, British GPs have shown a high level of restraint in making such referrals. The other major mechanism for securing adherence to budgetary limits has been the waiting list, for both inpatient and outpatient treatment. Waiting times have been a striking and persistent feature of the NHS; historically much longer than in other developed countries (Martin and Smith 1999). Demand from those wanting to avoid waiting has led to a small but significant private