Thanks to mutual cooperation of Macedonian Health Insurance Fund ( HIF ) , Ministry of Health and WBI- International Project Unit in Skopje , I had chance and opportunity to attend the training programme of 2000 Flagship Course: Health Sector Reform and Sustainable Financing . This course took place at World Bank Institute in Washington D.C. from October 23 till November 22 , 2000 .

With a guidance of R. Paul Shaw – Course Director and his team , this years Flagship Course was succesfull . The course was conducted through a combination of interactive presentation by subject-matter specialists followed by solutions by participants of self-assessment exercises , individual and group assigment . The course was held in English .

At this training I learned to :

• be able to increase my role in assisting our national reform process
• to provide a policy guidance ,
• to perform technical advisory services and to share this expirience with my colleagues at work .
• assess how well our national health system rates on performance criteria such as efficiency , equity , and sustainability
• determine alternate paths our national health system could take, and why it would be desirable to pursue some new paths over others
• understand how to move our national health system from its current state to a reform-defined future state; and
• understand how to select and apply tools and procedures to make desired changes and to assess their effects

Course modules :

This first two weeks I was introduced into the ethical theories , analytical frameworks , expectations, and hypotheses that I will encounter in real life .

In this two weeks I :

• learned how ethics, politics and economics all influence our health system and how they are judged.
• was introduced into the concepts of equity and efficiency
• explored their philosophical and analytical bases , and found how to apply them into our own health system , including national health accounts and other quantitative measures.
• understood how markets in general operate and what they can achieve, and how markets for health care and health insurance differ from other markets
  
  When we analyze our health sector performance :
  
  
• first , we must DEFINE THE PROBLEM
• second , we must identify causes of the problem
• then to develop options and before the solution implementaion the most importante thing is to have a POLITICAL DECISION for the solution .Without this decision we are unable to operate and solve the problem

Beginning with a determination of "the problem"(or outcome that society has failed to achieve), the diagnostic process works "backswards" to ascertain shortcomings ih the way inputs are configured (the causes) as well as control knobs that can be utilized to produce solution by moving the sistem from point "A" to "B".

These control knobs are:

This 3 week I was introduced with:

How different providers in the health care system are paid , have an impact on their behhavior , and therefore on the achievement of the health care system ( efficiency , equity , cost containment ) .

There are three main methods of paying doctors and other health care professionals:

• Paid directly or by third party
• Definition : DRG- System , per day, office visit
• Contracts ( negotiated between proviers and funds )
• Dual input: Patient health –own income ( supply induced demand or increases in supply leading to increases in demands )
• Health care markets are not perfectly competitive , although the supply vs. demand has an elasticity according to the volume of services and budget possibilities ( Human factor often goes beyond restrictions ) .

• Fees are paid for being available to treat
• Different fees for different groups of patients
• Incentives to over treat
• Control and prediction of costs
• Equall distribution of resources
• Higher concern for entire applied population

There are three broad option for reibursing hospitals:

1. Global budgets ( Budget allocation in the public sector)

In publicly financed health care system have to be made in order to allocate resources to regional and subregional levels (eg. hospitals and primary care clinics )

2. Retrospective payment

3. Prospective payment per case

Each system creates different incetive stuctures and may influece provider responses in different ways

We must explore various aspects of payment and regulation of pharmaceutical industry :

--on the supply side ( manufacturing industry )

--on the demand side( influencing patients and prescribing doctors ).

To regulate pharmaceutical markets it is very important for ensure safety and efficacy of manufactured products, also for efficiency or cost – effeciveness .

Throughout the World , governments devote a substantial amount of financial resources to the health sector .

There are three primary reasons why government should play a role in the haelth sector :

First , many health services represent public goods ---- that is ,one person’s use of the service does not make it less available for someone else . As a result , government involvement is required to provide an adequate supply of these goods and services . Similarly , many health services have externalities ---one person’s use affects others , such as immunizations .

Second , there is a role for government to play as an intermediary between providers ( doctors and hospitals )and consumers ( patients ) .

Third , ensuring the universal availability of basic health services is an important role for the government because of the impact on health status and poverty reduction .

Government involvement in the health sector is expected to have impact on both efficiency and equity.

Desingning a package of services has certain advantages .

Grouping together services in a package has the following benefits :

• The link between treatment and prevetion
• Multiple outputs from inputs
• Identification of all required inputs
• Coordination of resources
• Directing demand for services
  

A basic package of health services has three main distinguishing features :

• It typically contains a limited subset of all health care interventions made possible by today’s medical technology
• Intervenations are not randomly assigned to the package, rather, they result from a proritization process to achieve specific technical and/or social objectives
• Intrvention are not independent from each other within the package. In fact, many are chosen to comlement or reinforce each other .
  

There are many types of packages :