A health care system is an arrangement in which health care is delivered. There are many variations of health care systems around the world.
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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. [1]
There are generally five primary methods of funding health care systems:[2][3]
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."[4]
Health care has the following characteristics:
There is a debate (especially strong in the United States at present) as to whether these characteristics necessitate public ownership or increased government regulation of the health care industry.
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.
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. In 2005, Australia spent 8.8% of GDP on health care, or US$3,181 per capita. Of that, approximately 67% was government expenditure.[5]
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 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. In 2005, Canada spent 9.8% of GDP on health care, or US$3,463 per capita. Of that, approximately 70% was government expenditure.[5]
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) In 2005, Cuba spent 7.6% of GDP on health care, or US$310 per capita. Of that, approximately 91% was government expenditure.[5]
In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 78% by taxation, 20% by patients through access charges, and by others 2%. 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). In 2005, Finland spent 7.5% of GDP on health care, or US$2,824 per capita. Of that, approximately 78% was government expenditure.[5]
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.
In its 2000 assessment of world health care systems, the World Health Organization found that France provided the "best overall health care" in the world.[6] In 2005, France spent 11.2% of GDP on health care, or US$3,926 per capita. Of that, approximately 80% was government expenditure.[5]
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).[7][8][9] 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. In 2005, Germany spent 10.7% of GDP on health care, or US$3,628 per capita. Of that, approximately 77% was government expenditure.[5]
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. In 2005, Ghana spent 6.2% of GDP on health care, or US$30 per capita. Of that, approximately 34% was government expenditure.[5]
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 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 neighboring countries such as Pakistan, countries in the Middle East and some European countries by providing quality treatment at low cost. In 2005, India spent 5% of GDP on health care, or US$36 per capita. Of that, approximately 19% was government expenditure.[5]
For Ireland, see Health care in Ireland. In 2005, Ireland spent 8.2% of GDP on health care, or US$3,996 per capita. Of that, approximately 79% was government expenditure.[5]
In Israel, the publicly funded medical system is universal and compulsory. Payment for the services are shared by labor unions and the government. In 2005, Israel spent 7.8% of GDP on health care, or US$1,533 per capita. Of that, approximately 66% was government expenditure.[5]
Italy has a national health plan (S.S.N., Servizio Sanitario Nazionale), which provides for hospital and medical benefits. The public system covers in-patient treatments including tests and medications, as well as surgeries during hospitalization, family doctor visits, specialists such as pediatricians, out-patient treatments, and dental treatments.[10][11]
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.[12] Italy has one of the highest doctor per capita ratios at 3.9 doctors per 1,000 patients.[13] In 2005, Italy spent 8.9% of GDP on health care, or US$2,714 per capita. Of that, approximately 76% was government expenditure.[5]
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 a 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 remainder (upper limits apply). The monthly insurance premium is 0-50,000 JPY per household (scaled to annual income). Supplementary private health insurance is available only to cover the co-payments or non-covered costs, and usually makes a fixed payment per days in hospital or per surgery performed, rather than per actual expenditure. In 2005, Japan spent 8.2% of GDP on health care, or US$2,908 per capita. Of that, approximately 83% was government expenditure.[5]
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. In 2005, the Netherlands spent 9.2% of GDP on health care, or US$3,560 per capita. Of that, approximately 65% was government expenditure.[5]
In New Zealand hospitals are public and treat citizens or permanent residents free of charge and are managed by District Health Boards. Under the Labour coalition governments, 1999 - 2008, there were 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. In 2005, New Zealand spent 8.9% of GDP on health care, or US$2,403 per capita. Of that, approximately 77% was government expenditure.[5]
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 substantial ways perpetuates racial inequalities created in the pre-apartheid segregation era and apartheid era of the 20th century. In 2005, South Africa spent 8.7% of GDP on health care, or US$437 per capita. Of that, approximately 42% was government expenditure.[5]
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. In 2005, Sweden spent 9.2% of GDP on health care, or US$3,727 per capita. Of that, approximately 82% was government expenditure.[5]
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.[14] 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.
Each of the four countries of the United Kingdom has a separate but co-operating National Health Service: the National Health Service of England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland. They provide free physician and hospital services to all permanent residents of the United Kingdom, funded from general taxation. Hospital staff are salaried employees according to nationally agreed contracts, whilst primary care is largely provided by independent practices, who are paid, again via nationally agreed contracts, according to the number of patients registered with them and the range of additional services offered. The English, Northern Irish and Scottish health services have charges for prescriptions, with exclusions for those who are not of working age (the young and the elderly), or those who satisfy certain criteria such as low income or permanent disabilities. Prescriptions are £5 in Scotland (where charges are being phased out),[15] £6.85 in Northern Ireland (where charges are being phased out) [16] and £7.10 in England. Wales has no prescription charges. Overall, around 86% of prescriptions are provided free across the UK.
Private health services are also available. Private health care continues parallel to the NHS, paid for largely by private insurance. There are no private hospitals providing accident and emergency services. Most ambulance services are publicly run but some private and charity run ambulance services also exist. In 2005, the United Kingdom spent 8.2% of GDP on health care, or US$3,065 per capita. Of that, approximately 87% was government expenditure.[5]
The United States is alone among developed nations with the absence of a universal health care system.[17][18] 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,[19] 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 27.8% of the population[20] and make the government the largest health insurer in the nation. This care is generally provided by privately owned hospitals or physicians in private practice, but public hospitals are common in older cities. Just over 59% 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 number of people cannot obtain health insurance through their employer or are unable to afford individual coverage. The U.S. Census Bureau estimated that 15.3% of the U.S. population, or 45.7 million people, were uninsured in 2007. More than a third of the uninsured are in households earning $50,000 or more per year.[20] 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.[21] In 2005, the United States spent 15.2% of GDP on health care, or US$6,347 per capita. Of that, approximately 45% was government expenditure.[5]
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