Introduction
Stewardship remains a comparatively new term in the lexicon of health policy.
Indeed, it has yet to be translated into all languages in Europe. In Germany, for instance, the term has no translation but is used in its English version. But what does stewardship mean? And why has it assumed greater importance in the context of health system reform?
In its World Health Report 2000, the World Health Organization (WHO) defined stewardship as ‘the careful and responsible management of the well-being of the population’ and as constituting ‘the very essence of good govern-ment’ (World Health Organization, 2000). It identified stewardship as ‘arguably the most important’ health system function, ranking above health service delivery, input production and financing. The reason for this is that ‘the ultim-ate responsibility for the overall performance of a country’s health system must always lie with government.’ In this respect, stewardship has similarities to the notion of public governance, although there are important distinctions to be made (Travis et al., 2002). Whereas governance includes many actions uncon-nected with improving health, the actions of stewardship are all about improv-ing health. Therefore, ‘stewardship, as one of the core functions of the health system, is a distinct entity’ (Travis et al., 2002). It is also inevitably, given its importance and centrality to the operation of a health care system, an intense-ly political activity because how it is performed and the goals it pursues, either explicitly or implicitly, involve paying attention to particular values and ignor-ing, or devoting less attention to, others.
According to WHO, stewardship embraces three core tasks undertaken by government and its agents, primarily by the health ministry charged with
overseeing and guiding the working and development of the nation’s health actions on the government’s behalf. The three tasks are:
•
formulating health policy – defining the vision and strategic direction;•
exerting influence – including approaches to regulation;•
generating and using intelligence.In their discussion of stewardship, Travis et al. (2002) elaborate on these tasks and produce an augmented set of domains, which include ensuring tools for implementation, coalition/partnership building, a fit between policy objectives and organizational structures and culture, and accountability. At the heart of the concept is the notion that resources – both human and financial – for health care must be used for the benefit of all. These resources do not ‘belong’ to those exercising stewardship; they have been entrusted to them to act on in the best interests of society. Stewardship is therefore about collective rather than individual responsibility.
The theme of this chapter is government’s stewardship role in health systems with regard to purchasing. This is a recent notion and we shall consider what it means for government to perform a stewardship function in purchasing and provide a conceptual framework for understanding it. We shall detail the core tasks of stewardship, using examples drawn from European health systems and the case studies of purchasing arrangements derived from 11 countries and spe-cially prepared for this project (Figueras et al., forthcoming) and consider what constitutes good stewardship and the barriers to its attainment. Again, the points are illustrated with examples from European experience. A final section identifies some practical guidance for policy makers in respect of the steward-ship function and the principles and mechanisms that need to be in place to ensure its effective operation.
We should point out that in examining stewardship across Europe there are strict limits on how far it is possible to generalize because its application in practice is highly context specific. Good stewardship depends on both the type of health care system in place and the type of government, decentralized or centralized. Among the health systems to be found in Europe there is ‘a plethora of complex administrative and clinical arrangements under which patients obtain health care’ (European Commission, 2001). These systems have evolved over a long period of time and are based on very different organizational pat-terns and principles. Often a mix of models adds to the complexity of health care systems. Moreover, many health care systems are in a constant state of flux, so there is dynamic movement between models with different combinations emerging. Such diversity and constant change make understanding the stewardship of purchasing a complex and incomplete endeavour.
Government as steward
Why has the notion of government as steward become an issue for health policy makers and organizations like WHO? The rise of big government following the Second World War was a consequence in part of introducing welfare systems in many European countries, coupled with the increasing complexity of tasks in
which governments unavoidably became engaged. In recent years, there has been a move to encourage governments to ‘row less and steer more’. Steering is akin to stewardship and involves making strategic policy decisions and estab-lishing the vision, whereas rowing is about operational service delivery and implementing the vision (Osborne & Gaebler, 1993). Separating the steering and rowing tasks is aimed at allowing governments more scope and space to focus on setting the strategic vision without becoming distracted by, or preoccupied with, delivery and operational concerns.
For all the public cynicism about government and its perceived inability to deliver effective public services, there is no self-evident or viable alternative to effective government involvement in shaping the strategic direction of health systems, ensuring equity, deciding priorities and financing care. As Travis et al.
(2002) point out, ‘a country’s government, through its Ministry of Health, remains the “steward of stewards” for the health system, with a responsibility to ensure that they collectively provide effective stewardship.’
If governments are to stand back and steer more while rowing less and become enablers rather than doers, major changes will be needed in the way they have traditionally functioned, especially in centralized and highly politi-cized health systems. There may be a need for some structural changes, but much more important is the need for a change in mindset and in ways of con-ducting business. Unfortunately, when it comes to health policy, most govern-ments, in the shape of ministries of health and other central departgovern-ments, are ill equipped to act as effective steering organizations. As Osborne and Gaebler point out, when governments separate policy management from service deliv-ery they often find that they have no real policy management capacity or the appropriate skills to hand; they have to be acquired or invented. Whatever their pretensions to the contrary, government departments often become embroiled in service delivery or micro-management with the consequence that policy management at a strategic level is done poorly or not at all. The case studies of European health systems, upon which we have drawn to illustrate our arguments, tend to support this conclusion.
Stewardship in the context of purchasing
The theoretical perspective adopted in this book is that purchasers are the government’s agents and are expected to fulfil the principal’s (the govern-ment’s) objectives. In a purchasing-based model of health care, government entrusts some stakeholders (for example, ‘hived off’ agencies, health authorities, regional governments, health funds, local governments, primary care organiza-tions) operating at some level in the system (macro, meso or micro) to purchase a range of health care services on its behalf for the population. Public funds are entrusted to purchasers either through a direct transfer from its central funds or by ensuring mandatory insurance contributions by employers and employees.
But government does not have complete information about the allocation of funds by purchasers or about their actions in regard to the delivery of health care services needed by the population and reflected in health priorities. There-fore, exercising leadership, regulation and the acquisition of intelligence become important features of stewardship (see below).
Stewardship as accountability
Another way of conceptualizing stewardship is to view it as a form of accountability. Travis et al. (2002) consider accountability a stewardship responsibility since it is about ensuring that all those engaged in health systems, including purchasers, are held to account for their actions. There are many types of accountability (Day & Klein, 1987). Two are important for this discussion.
First, there is accountability for performance, according to which governments are held to account, at least in democratic theory, by their populations for the successful implementation of their policies, including those health policies for which they are responsible and about which they have been explicit. This type of top-down accountability complements other forms that might be more bottom-up in character and are reviewed elsewhere (see Chapter 6). Much of the discussion about regulation has a bearing on this type of accountability (see below). In the context of purchasing, meeting targets and managing the performance of those organizations operating on behalf of the principal would represent important ways of ensuring accountability. Second, there is account-ability for reasonableness (Daniels, 1998), which is associated with procedural justice, that is, with how decisions are reached. The process of decision making is therefore as important as the actual substantive decision. Even in cases where the outcome of the decision-making process is contested, if the process of arriv-ing at it is transparent and defensible then this may be said to constitute good stewardship.
Stewardship and levels of government
The exercise of stewardship with respect to the purchasing function occurs in a variety of ways, including: centralized governmental arrangements, devolved governmental arrangements and non-governmental arrangements that might operate centrally and/or locally. In centralized systems, governments can mandate health care organizations to meet specified standards. In decentralized systems, issues of divided responsibility give rise to additional complexity and may produce tensions between national and local levels.
Most European countries have devolved health systems although there are marked variations between the freedoms and powers enjoyed by the various subnational bodies when it comes to purchasing health care. Even countries like the United Kingdom, with a strong tradition of centralization, are attempting to move in the direction of devolving power and responsibility as evidenced by the devolution of political power to elected assemblies in Wales and Northern Ireland and to an elected parliament in Scotland. Regional government in England remains a possibility in the not too distant future. Many other Euro-pean countries, such as Spain and Italy, have recently gone much further, and some, such as Germany, have long histories of decentralized government.
In decentralized systems there are two forms of accountability. The first involves traditional public accountability where federal and regional govern-ments report separately to their respective constituencies and give an account of the results of their policies and programmes – in the case of health, the extent to
which they have delivered on agreed targets and policy goals. The second involves regional governments accounting to the federal government in exchange for resources or because the federal government is the guardian of citizens’ rights either through adherence to general principles, as in Sweden, or to specific entitlements, as in Germany, or to both, as in Italy.
Devolving responsibility is not a neutral act and may carry profound con-sequences for the government’s strategic vision and stated policy goals (Hunter et al., 1998). In the case of the purchasing function in health, there is a major tension between striving for uniformity on the one hand and encouraging diversity, and choice on the other. Many European countries have decided in favour of diversity, and the grip of central government over the health system is weak or restricted to fiscal regulation.
Devolution is intended to increase accountability and responsiveness to local communities, and provide appropriate incentives for efficient and high quality public services sensitive to individual preferences. Devolving responsibility to local organizations, however, creates a tension insofar as they may wish to use their freedoms and purchasing power to diverge from the national policy agenda and do things differently to meet what they consider to be more import-ant local needs and circumstances. However, central governments may have other motives. Devolution may be a convenient way of absolving responsibility and diffusing and deflecting blame when/if things go wrong (Klein, 1995). In this way, central government can divest itself of any effective stewardship role and blame the periphery for getting it wrong.
There are therefore sound reasons for the concern expressed by some observers that health care systems displaying principles of universalism and solidarity might be adversely affected by devolving responsibilities for the financing and/or purchasing of health care to subnational governments.
Devolution in health systems means trading off local autonomy with national policy commitments to equity and public financing. Almost by definition, greater local responsibility, power and control are likely to result in difference and a widening of variations as local concerns and priorities jostle with national ones. However, many would argue that encouraging variation and diversity, or at the very least tolerating it, is the whole point of devolution, provided that minimum standards exist to ensure adherence to an acceptable level of quality and performance.
Multilevelled governance inevitably makes the stewardship function in purchasing health care more complex and less clear. The evidence across Europe is that countries have either devolved responsibilities over the planning and regulation of health policy to regional bodies or are in the process of doing so.
But these are dynamic developments and in countries as diverse as Hungary and the United Kingdom there are pressures operating to ensure that central government retains overall control over what happens at subnational levels. As we shall consider below, the growth of regulation can be a means through which central government can reassert itself and restore its weakened influence and power. The relationship between central government and subnational levels is therefore one that has constantly to be renegotiated as circumstances change.
Formulating health policy
The first task of stewardship lies in formulating the direction of health policy.
Government has the task of formulating a strategic vision for the health system as a whole within which the activities of purchasers are expected to occur but its ability to influence purchasing through such means can be problematic. The attempt to formulate a vision usually occurs in policy statements and strategic plans in many countries, and can take many forms. It might focus on health gain/outcomes or on the functioning of the health care system, and direct pur-chasers to emphasize cost containment or result in structural changes in health care delivery – for example, a shift from secondary to primary care or from inpatient to outpatient treatment – or to the application of clinically effective and efficient procedures such as evidence-based medicine.
Many governments seek to address both means (the amount of resources allocated to health care, or numbers of doctors and nurses, and so forth) and ends (health gain, narrowing the health gap between social groups) although there is sometimes a tendency for the means to overshadow the ends, or even become ends in themselves. There can also be questions about the link between ends and means insofar as it is not at all clear that simply putting more resources into health care services will lead to an improvement in health (Lewis et al., 2000).
Having an explicit health policy can serve several purposes. At a purely symbolic level it provides a rallying point for those seeking to change the health system as well as for those striving to maintain traditional principles. It can point the way forward to a different future and act as a route map for getting there and, by doing so, make the clash of values explicit – witness the debate over creeping privatization of the British NHS and the Italian SSN in the early 1990s. It can also be a means of prioritizing the objectives of a health system.
Health policy is, therefore, an important instrument of governments and, in WHO’s terms, ‘an important role of governance’.
When health policy focuses on health gain, it is common practice for countries to produce eloquent and usually highly ambitious strategies. These are often of an aspirational nature – long on rhetoric and good intentions but short on delivery. There are many reasons for this, including the absence of owner-ship of the strategies by those charged with their implementation. A good example of the fate that can often befall grandiose strategies can be found in the United Kingdom at the time of the first health strategy in England, The Health of the Nation, which existed from 1992 to 1997. Though welcomed by those who sought to strengthen a commitment to health rather than simply health care, the strategy largely went unimplemented. It ceased to matter as the attention of ministers and their officials continued to centre almost exclusively on the health care delivery system and its performance (Department of Health, 1998;
Hunter, 2003a).
Italy adopted a similar strategy based on health targets in 1998 with its National Health Plan. The strategy covered five key areas of population health (promoting healthy behaviour and lifestyles; combating major diseases;
improving the environment; protecting disadvantaged people; upgrading the system to European standards) and set 100 national targets for each of these.
The task of implementing the new agenda for health, possibly the most ambi-tious and challenging set by any Italian government, failed miserably, mainly because of political and institutional problems (France & Taroni, 2000) (see Box 8.1). The ‘whole health approach’ means that action at the national, regional and local levels must be coordinated, and that no single agency at any level owns the targets. Policy integration requires the different agents to form a ‘seamless’ health policy, in stark contrast to decades of intergovernmental conflicts marked by the erosion of mutual trust and respect.
Some European countries have issued no health policy statement or strategy and, even where one exists, its influence on health system outputs and out-comes is often limited. For example, in the Czech Republic, the Ministry of Health is responsible for health policy but this is simply a description of regula-tory measures and legislative plans and there is no vision for health that is related to, for example, the WHO’s ‘Health 21’. Government representatives are members of the boards of directors of the health insurance funds. These boards set the strategic direction for purchasing health services but the focus is more on maintaining financial stability than on undertaking strategic purchasing. The government has limited power to control the quality or volume of services.
Similarly, in Estonia, the role of government in setting the strategic direction has been minimal, although the regulatory powers of the central health insur-ance fund are increasing. Public health programmes are reflected in the plan of the national fund.
In Germany, the government’s role has centred on regulation rather than on producing a clear health policy vision in relation to the purchasing functions of the health funds and their ability to control patterns of service provision. As a
In Germany, the government’s role has centred on regulation rather than on producing a clear health policy vision in relation to the purchasing functions of the health funds and their ability to control patterns of service provision. As a