Health care systems

From Wikipedia, the free encyclopedia

A health care system is an organization to deliver health care. There are many variations of health care systems around the world.

Contents

[edit] Goals of Health Care Systems

The goals for health systems, according to the World Health Report 2000 - Health systems: improving performance (WHO, 2000), are good health, responsiveness to the expectations of the population, and fair financial contribution. Duckett (2004) proposed a two dimensional approach to evaluation of health care systems: quality, efficiency and acceptability on one dimension and equity on another.

[edit] Financing

There are generally five primary methods of funding health care systems:[1][2]

  1. direct or out-of-pocket payments,
  2. general taxation,
  3. social health insurance,
  4. voluntary or private health insurance, and
  5. donations or community health insurance.

One recent study published by the National Bureau of Economic Research found no systematic relationship between the cost efficiency of health care systems and the type of financing used. The author concluded "that almost all financing choices are compatible with efficiency in the delivery of health care."[3]

Health care has the following characteristics:

  • The provision of critical health care treatment is often regarded as a basic human right, regardless of whether the individual has the means to pay—some treatments cost more than a typical family's life savings.
  • Health care professionals are bound by law and their oaths of service to provide lifesaving treatment.
  • Asymmetric information
  • High risk level

There is a debate whether these characteristics necessitate public ownership or increased government regulation of the health care industry[citation needed].

[edit] Health care systems models

  • Purely private enterprise health care systems are comparatively rare. Where they exist, it is usually for a comparatively well-off subpopulation in a poorer country with a poorer standard of health care–for instance, private clinics for a small, wealthy expatriate population in an otherwise poor country. But there are countries with a majority-private health care system with residual public service (see Medicare, Medicaid).

In almost every country with a government health care system a parallel private system is allowed to operate. This is sometimes referred to as two-tier health care. The scale, extent, and funding of these private systems is very variable.

For the application of health care systems in schools see school health services.

[edit] Examples in different countries

[edit] Australia

In Australia the current system, known as Medicare, was instituted in 1984. It coexists with a private health system. Medicare is funded partly by a 1.5% income tax levy (with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that heavily subsidises prescription medications.

[edit] Canada

Canada has a federally sponsored, publicly funded Medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors, (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most all family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. A physician cannot charge a fee for a service that is higher than the negotiated rate - even to patients who are not covered by the publicly funded system - unless he opts out of billing the publicly funded system altogether. Pharmaceutical costs are set at a global median by government price controls. Other areas of health care, such as dentistry and optometry, are wholly private.

[edit] Cuba

Healthcare in Cuba consists of a government-coordinated system that guarantees universal coverage and consumes a lower proportion of the nation's GDP (7.3%) than some highly privatised systems (e.g. USA: 10.2%) (UNDP 2006: Table 6). The system does charge fees in treating elective treatment for patients from abroad, but tourists who fall ill are treated freely in Cuban hospitals. Cuba attracts patients mostly from Latin America and Europe by offering care of comparable quality to a developed nation but at much lower prices. Cuba's own health indicators are the best in Latin America and surpass those of the US in some respects (infant mortality rates, underweight babies, HIV infection, immunisation rates, doctor per population rates). (UNDP 2006: Tables 6,7,9,10)

[edit] Finland

In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 76% by taxation, 20% by patients through access charges, and by others 4%. Patient access charges are subject to annual caps. For example GP visits are (11€ per visit with annual 33€ cap), hospital outpatient treatment (22€ per visit), a hospital stay, including food, medical care and medicines (26€ per 24 hours, or 12€ if in a psychiatric hospital). After a patient has spent 590€ per year on public medical services, all treatment and medications thereafter are free. Taxation funding is partly local and partly nationally based. Patients can claim re-imbursement of part of their prescription costs from KELA. Finland also has a much smaller private medical sector which accounts for about 14 percent of total health care spending. Only 8% of doctors choose to work in private practice, and some of these also choose to do some work in the public sector. Private sector patients can claim a contribution from KELA towards their private medical costs (including dentistry) if they choose to be treated in the more expensive private sector, or they can join private insurance funds. However, private sector health care is mainly in the primary care sector. There are virtually no private hospitals, the main hospitals being either municipally owned (funded from local taxes) or run by the teaching universities (funded jointly by the municipalities and the national government).

[edit] France

In France, most doctors remain in private practice; there are both private and public hospitals. Social Security consists of several public organizations, distinct from the state government, with separate budgets that refunds patients for care in both private and public facilities. It generally refunds patients 70% of most health care costs, and 100% in case of costly or long-term ailments. Supplemental coverage may be bought from private insurers, most of them nonprofit, mutual insurers. Until recently, social security coverage was restricted to those who contributed to social security (generally, workers or retirees), excluding some poor segments of the population; the government of Lionel Jospin put into place the "universal health coverage". In some systems, patients can also take private health insurance, but choose to receive care at public hospitals, if allowed by the private insurer.

France is largely known for providing one of the leading health care systems in the world. In the film Sicko, which portrays the flaws with American health care and emphasizes the success of Canadian, British, Cuban, and French health care, the successes of the French system are noted. Health care, including dentistry and other forms of medicine are completely free at the point of need. In fact, the French hospitals pay their patients back the amount they paid to get to the hospital, such as the cost of fuel or taxis. If a woman has a newborn baby, a government nurse will come to the house daily to do the laundry and cook - for free. Also for a minimal price, the nurse will clean the whole house, so that the mother simply has more time to bond with her baby.

[edit] Germany

Germany has a universal multi-payer system with two main types of health insurance: "State health insurance" (Gesetzliche Krankenversicherung) known as sickness funds and "Private" (Private Krankenversicherung).[4][5][6] Compulsory insurance applies to those below a set income level is provided through private non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. Provider compensation rates are negotiated in complex corporatist social bargaining among specified autonomously organized interest groups (e.g. physicians' associations) at the level of federal states (Länder). The sickness funds are mandated to provide a wide range of coverages and cannot refuse membership or otherwise discriminate on an actuarial basis. Small numbers of persons are covered by tax-funded government employee insurance or social welfare insurance. Persons with incomes above the prescribed compulsory insurance level may opt into the sickness fund system, which a majority do, or purchase private insurance. Private supplementary insurance to the sickness funds of various sorts is available.

[edit] Ghana

In Ghana, most health care is provided by the government, but hospitals and clinics run by religious groups also play an important role. Some for profit clinics exist, but they provide less than 2% of health services. Health care is very variable through the country. The major urban centres are well served, but rural areas often have no modern health care. Patients in these areas either rely on traditional medicine or travel great distances for care.

[edit] Hong Kong

In Hong Kong, both private and public clinics are common, while public hospitals account for the majority of the market.

[edit] India

In India, the hospitals are run by government, charitable trusts and by private organizations. The government hospitals in rural areas are called the primary health centre(PHC)s. Major hospitals are located in district head quarters or major cities. Apart from the modern system of medicine, traditional and indigenous medicinal systems like Ayurvedic and Unani systems are in practice throughout the country. PHC's are non existent in most places, due to poor pay and scarcity of resources. Patients generally prefer private health clinics. These days some of the major corporate hospitals are attracting patients from neibouring countries like Pakistan, Middle East and some european countries by providing quality treatment at low cost.

[edit] Ireland

For Ireland, see Health care in Ireland.

[edit] Israel

In Israel, the publicly funded medical system is universal and compulsory. Payment for the services are shared by labor unions and the government.

[edit] Italy

In Italy the public system has the unique feature of paying its doctors a fee per capita per year, a salary system, that does not reward repeat visits, testing, and referrals. [7] Italy has one of the highest doctor per capita ratio's at 3.9 doctors per 1,000 patients. [8]

[edit] Japan

In Japan, services are provided either through regional/national public hospitals or through private hospitals/clinics, and patients have universal access to any facility, though hospitals tend to charge higher for those without referral. Public health insurance covers most citizens/residents and pays 70% or more cost for each care and each prescribed drug. Patients are responsible for the rest of 30% (upper limits apply). Insurance system is funded by tax(40%), insurance premium from each household (35%) and from employer (25%). Monthly insurance fee is 0-50,000 JPY per household (scaled to annual income). Supplementary private health insurance is available only to cover the copayments or non-covered cost, and usually makes fixed payment per days in hospital or per surgery performed, rather than per actual expenditure.

[edit] Netherlands

Health care in the Netherlands, has since January 2006 been provided by a system of compulsory insurance backed by a risk equalization program so that the insured are not penalized for their age or health status. This is meant to encourage competition between healthcare providers and insurers. Children under 18 are insured by the government and special assistance is available to those with limited incomes.

[edit] New Zealand

In New Zealand hospitals are public and treat citizens or permanent residents free of charge and are managed by District Health Boards. Under the current Labour coalition governments, 1999 - present, there are plans to make primary health care available free of charge. At present government subsidies exist in health care. This system is funded by taxes. The New Zealand government agency PHARMAC subsides certain pharmaceuticals depending upon their category. Co-payments exist however these are ignored if the user has a community health services card or high user health card.

[edit] South Africa

In South Africa, parallel private and public systems exist. The public system serves the vast majority of the population, but is chronically underfunded and understaffed. The wealthiest 20% of the population uses the private system and are far better served. This division in subtantial ways perpetuates racial inequalities created in the pre-apartheid segregation era and apartheid era of the 20th century.

[edit] Sweden

In Sweden, the publicly funded medical system is comprehensive and compulsory. Physician and hospital services take a small patient fee, but their services are funded through the taxation scheme of the County Councils of Sweden.

[edit] Taiwan

The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health care dollars. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[9] NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many health care providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment , NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.

[edit] United Kingdom

In the United Kingdom there are three separate but co-operating National Health Services of Scotland, Northern Ireland and England & Wales. They provide free physician and hospital services to all permanent residents of the United Kingdom. Hospital staff are salaried employees according to nationally agreed contracts, whilst primary care is largely provided by independent practices, who are paid, again via a nationally agreed contract, according to the number of patients registered with them and the range of additional services offered. Around 86% of prescriptions are provided free. Prescriptions are provided free to people who satisfy certain criteria such as low income or permanent disabilities. People that pay for prescriptions do not pay the full cost. For example, in 2007, most people will pay a flat fee of £6.85 (€10.16, US$13.76) for a single drug prescription regardless of the cost (average cost to the health service was £11.10--about €16.70, US$20.40--in 2002). (Charges have been abolished as a matter of government policy in Wales.) Funding comes from general taxation. Private health services are also available. Private health care continues parallel to the NHS, paid for largely by private insurance. Accident and emergency (U.S. emergency room) services are only available on the NHS.

[edit] United States

The United States is alone among developed nations with the absence of a universal health care system.[10][11] Healthcare in the U.S. does, however, have significant publicly funded components. Medicare covers the elderly and disabled with a historical work record, Medicaid is available for some, but not all of the poor,[12] and the State Children's Health Insurance Program covers children of low-income families. The Veterans Health Administration directly provides health care to U.S. military veterans through a nationwide network of government hospitals; while active duty service members, retired service members and their dependents are eligible for benefits through TRICARE. Together, these tax-financed programs cover about 27% of the population[13] and make the government the largest health insurer in the nation. In 2001, only the governments of Iceland and Norway spent more per capita on healthcare.[14] This care is generally provided by privately owned hospitals or physicians in private practice, but public hospitals are common in older cities. Just under 60% of Americans receive health insurance through an employer, although this number is declining and the employee's expected contribution to these plans varies widely and is increasing as costs escalate. A significant and growing number of people cannot obtain health insurance through their employer or are unable to afford individual coverage. Currently, the U.S. Census Bureau estimates that 16% of the U.S. population, or 47 million people, are uninsured. More than a third of the uninsured are in households earning $50,000 or more per year.[13] Some uninsured are people under age 30 who don't believe they need to purchase health care; others are eligible for Medicaid but have not applied. The cost of medicines is frequently not covered by insurance, and it is common for U.S. citizens to travel to Canada and Mexico for drug purchases at prices far below those in their home areas. A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute.[15] Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health-care providers using what is generally characterized as a charity care scheme; New Jersey is perhaps the best example of a state that employs the latter strategy. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. The U.S. legal system, which has the highest number of attorneys per capita of any country in the world, is available to assist in proving liability and collecting the money for medical bills from such insurances.

The Indian Health Service provides public funded care for indigenous peoples. Employer benefit based health insurance remains quite common with larger employers. Workers injured on the job are covered by government mandated worker compensation insurance and wage replacement benefits. These benefits vary considerably state-to-state and employers bear the cost of this insurance. Businesses with considerable risks, such as bridge-building, mining, or meat processing face far higher worker compensation insurance costs than do office based clerical businesses. Although the Medical colleges and research institutes form a backbone structure for providing healthcare, the private hospitals and nursing homes also are becoming an increasingly necessary part of the healthcare structure in the country.

[edit] See also

[edit] References

  1. ^ Eldis.com. "Social Health Insurance." Retrieved August 18, 2006.
  2. ^ "Regional Overview of Social Health Insurance in South-East Asia, World Health Organization. And Overview of Health Care Financing". Retrieved August 18, 2006.
  3. ^ Sherry A. Glied, "Health Care Financing, Efficiency, and Equity," National Bureau of Economic Research Working Paper No. 13881, March 2008
  4. ^ The Case for Universal Health Care in the United States
  5. ^ Health Insurance in Germany - MySME - Resources for Small Business in Germany in the English Language
  6. ^ http://www.willamette.edu/centers/publicpolicy/projects/oregonsfuture/PDFvol5no2/countries_healthcare.pdf
  7. ^ Health Service/Insurance Industry in Italy
  8. ^ Practising physicians per 1000 population, OECD countries, 2005
  9. ^ Fanchiang, Cecilia."New IC health insurance card expected to offer many benefits", Taiwan Journal, January 2nd, 2004 Accessed March 28, 2008
  10. ^ Insuring America's Health: Principles and Recommendations, Institute of Medicine at the National Academies of Science.
  11. ^ The Case For Single Payer, Universal Health Care For The United States.
  12. ^ Overview - What is Not Covered, U.S. Department of Health & Human Services
  13. ^ a b Income, Poverty, and Health Insurance Coverage in the United States:2006 (PDF). U.S. Census Bureau. Retrieved on 2007-08-28.
  14. ^ EarthTrends: Data Tables - Population, Health and Human Well-being
  15. ^ About.com's Pros & Cons of Massachusetts' Mandatory Health Insurance Program

[edit] Books

  • Robin Means, Sally Richards and Randall Smith (2008) Community Care: Policy and Practice, Palgrave MacMillan. ISBN 0230006744

[edit] External links