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HEALTH POLICY AND FEDERALISM:A Comparison of Five Federations The Challenge Core Features of Federal Governance Criteria For Assessing Federal Arrangements Diversity of Federal Models The National Patterns Common Patterns and Trends Policy Challenges: Access to Health Care Inter-regional Transfers Policy Challenges: Cost Containment Total Health Expenditures as Percent of GDP, Federal and Non-Federal States. 1960-1998 Public Expenditure as Percent of GDP, Federal and Non-Federal States. 1960-1998 Public Expenditure as Percent of Total Health Expenditures, Federal and Non-Federal States. 1960-1998 Successes in Cost Containment? Summary: HEALTH POLICY AND FEDERALISM:A Comparison of Five FederationsKeith G. BantingForum of Federations October 2001KGB-056Forum of Federations / Forum desfédérations¡ www.forumfed.org ¡ forum@forumfed.orgThe ChallengeThe Health Policy AgendaCommon pressuresCommon constraintsFederalism and Multi-level GovernanceA more complex process of management of health policiesDistinctive challenges and opportunitiesCore Features of Federal GovernanceDivision of Program ResponsibilitiesDetermination of policy frameworkDelivery of health care servicesDivision of Fiscal CapacityVertical Fiscal BalanceHorizontal Fiscal BalanceCoordination between Levels of GovernmentPolitical mechanismsFormal intergovernmental mechanismsCriteria For Assessing Federal ArrangementsPolicy ValuesequityefficiencyDemocratic Valuestransparency and opennessaccountabilityCultural Valuesnational communityregional communitiesDiversity of Federal Models Centralization and Decentralization in Health CareFiscal measures of decentralizationPolicy measures of decentralizationThe Decision Process: The National FrameworkDetermination by the central governmentJoint determinationKGB-059The National PatternsLevels of Centralization andConcertationBelgiumGermanyAustraliaUnited StatesCanadaKGB-032Common Patterns and TrendsCommon pattern of multi-level governanceNo case of health as the exclusive responsibility of one level of governmentCommon pressures for decentralizationRooted in complex fiscal and political trendsLimits to decentralizing processNo uniform trend towards decentralizationKGB-034Policy Challenges: Access to Health CareSocial Citizenship and Regional DiversitySocial citizenship and common health care benefitsRegional Diversity and variation in health care servicesCentral Instruments in Striking the BalanceNational Policy FrameworkInter-regional TransfersKGB-036Inter-regional TransfersImplicit TransfersPrograms delivered directly by the central governmentExplicit transfersPrograms delivered by other governments or agenciesGrowing controversy surrounding transfersBelgium, Germany, CanadaKGB-063Interregional Variation in Health Care Instruments and OutcomesCountryInstrumentsOutcomesSpecificity of Policy FrameworkInterregional TransfersInterregional Differences in Health Care SystemsBelgiumHighHighLowGermanyHighHighLowAustraliaHighHighLowUnited StatesMediumLowMediumCanadaLowMediumMediumPolicy Challenges: Cost ContainmentInstruments Defined by Institutional StructuresCost Containment in Multi-Level SystemsCost containment versus cost-shiftingFederations have greater difficulty containing pressures?KGB-066Total Health Expenditures as Percent of GDP, Federal and Non-Federal States. 1960-1998Notes: Belgium is treated as federal throughout the period. Germany data in 1990’s include East Germany. Source: OECD Health Data 2000Public Expenditure as Percent of GDP, Federal and Non-Federal States. 1960-1998Notes: Belgium is treated as federal throughout the period. Germany data in 1990’s include East Germany. Source: OECD Health Data 2000Public Expenditure as Percent of Total Health Expenditures, Federal and Non-Federal States. 1960-1998Notes: Belgium is treated as federal throughout the period. Germany data in 1990’s include East Germany. Source: OECD Health Data 2000Successes in Cost Containment?Cost containment easiest when key levers are consolidated at one level?BelgiumCanadaPopulation Health StatusLife Expectancy (1998)Infant Mortality (1998)Australia78.35Belgium77.36Canada79.16Germany77.35United States76.87Average77.86Summary: Common pattern of multi-level governance in healthDecentralizing pressures but limited decentralizationNo standard model of federalismMore success in narrowing inter-regional differences in accessLess success in containing health care costsPolicy values, democratic values, cultural valuesKGB-067