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Organization and financing of social health insurance systems: Current status and recent policy developments
... As it is easy to imagine, multiple variations of the original SHI model have been conceived in different countries over the decades (Saltman and Figueras, 1997;Busse et al., 2004;Wagstaff, 2010). ...
... In regulating an SHI system, a crucial dimension is the freedom of choice granted to users, and therefore, by the possibility (or not) that the sickness funds compete with each other. As mentioned in A further difference between the SHI systems concerns the extent and methods of paying sickness contributions (Busse et al., 2004). In many cases, the rate (i.e., the percentage of salary that the worker is required to pay) is the same for all funds. ...
... The classic formula is a 50:50 division between employee and employer, which is what happens, for example, in Germany. However, there are countries where contributions are paid differently (Busse et al., 2004). ...
... As it is easy to imagine, multiple variations of the original SHI model have been conceived in different countries over the decades (Saltman and Figueras, 1997;Busse et al., 2004;Wagstaff, 2010). ...
... In regulating an SHI system, a crucial dimension is the freedom of choice granted to users, and therefore, by the possibility (or not) that the sickness funds compete with each other. As mentioned in A further difference between the SHI systems concerns the extent and methods of paying sickness contributions (Busse et al., 2004). In many cases, the rate (i.e., the percentage of salary that the worker is required to pay) is the same for all funds. ...
... The classic formula is a 50:50 division between employee and employer, which is what happens, for example, in Germany. However, there are countries where contributions are paid differently (Busse et al., 2004). ...
... As it is easy to imagine, multiple variations of the original SHI model have been conceived in different countries over the decades (Saltman and Figueras, 1997;Busse et al., 2004;Wagstaff, 2010). ...
... In regulating an SHI system, a crucial dimension is the freedom of choice granted to users, and therefore, by the possibility (or not) that the sickness funds compete with each other. As mentioned in A further difference between the SHI systems concerns the extent and methods of paying sickness contributions (Busse et al., 2004). In many cases, the rate (i.e., the percentage of salary that the worker is required to pay) is the same for all funds. ...
... The classic formula is a 50:50 division between employee and employer, which is what happens, for example, in Germany. However, there are countries where contributions are paid differently (Busse et al., 2004). ...
... Per stimolare la competizione, a ogni cassa viene concesso di determinare sia il pacchetto delle prestazioni offerte ai propri assistiti, sia l'ammontare dei contributi che questi devono ter affermare che più che un unico modello, l'ASM costituisce oggi una famiglia variamente assortita. Le differenze riguardano importanti dimensioni, quali il numero e la natura giuridica delle casse di malattia, la libertà di scelta della cassa da parte del paziente, le modalità di calcolo dei contributi sanitari (Fukawa 2002;Busse, Saltman, Dubois 2004). ...
... L'assegnazione alla rispettiva cassa di malattia avviene d'ufficio, in base alla categoria professionale o alla residenza. Le casse di malattia, che sono organizzazioni private no profit, non sono quindi in competizione tra loro e non hanno il potere di fissare il livello dei contributi che i loro iscritti devono versare: l'aliquota contributiva a carico dei lavoratori e delle imprese è uguale per tutti ed è fissata dal governo attorno al 13% del reddito lordo (Busse, Saltman, Dubois 2004). Le casse di malattia operanti a livello nazionale sono poco più di una quindicina: la principale è la CNAMTS (Caisse Nationale d'Assurance Maladie des Travailleurs Salariés), che copre oltre l'80% della popolazione (dipendenti del settore privato e rispettive famiglie). ...
Economico, equo, di buona qualità: ecco l’identikit del sistema sanitario ideale. La pratica però è un’altra cosa, e non solo in Italia. Federico Toth analizza in chiave comparativa i sistemi sanitari di venti paesi OCSE, ricostruendo i modelli di finanziamento e di erogazione, il percorso storico seguito, le riforme che sono intervenute negli ultimi venti anni.
Indice
Introduzione - 1. I modelli di finanziamento - 2. Dai modelli alla realtà: una varietà di sistemi di finanziamento misti - 3. La produzione dei servizi sanitari - 4. Medici e Stato - 5. Le riforme sanitarie degli anni Novanta e Duemila - 6. Quale sistema sanitario è il migliore?
... Public/ private mix Within a system of social insurance, healthcare providers are generally a mix of public, private not-for-profit and private for-profit; though almost all are separate from payers. However, this is not a necessary characteristic of social insurance since many funds originally started as institutions which combined the role of payer and provider ( Busse et al., 2004). Given the payer-provider split, contracts are a feature of social insurance systems, however, initially at least this was not intended as a means of instilling competition between providers of services (ibid.). ...
... Contributions The financial relationship between the individual and the sickness fund varies across countries along a number of domains including the ratio of contributions from employer and employee, the existence of an upper contribution ceiling, the existence of additional non- wage related revenues, and the role of general taxes in funding ( Busse et al., 2004). ...
... 51 Social health insurance is often offered by the government or social security organisations to target certain groups or segments of society. 52 While such programmes seek to encourage equitable access to healthcare, they may face obstacles due to coverage constraints, service quality or administrative concerns, which may have an influence on beneficiary satisfaction. Variations in reported levels of satisfaction may also be attributed to differences in the methodology, in which a comprehensive approach is presented by this meta-analysis, which compiles data from several research conducted in different nations; however, the primary study conducted in Nepal could have had scope limitations that may affect the estimated satisfaction levels. ...
Objective
Beneficiaries’ satisfaction with health insurance schemes is crucial for the success of these programmes, influencing their effective implementation and reducing dropout rates. This systematic review and meta-analysis aimed to assess the proportion of beneficiaries satisfied with health insurance and identify factors associated with their satisfaction in Sub-Saharan Africa (SSA).
Design
A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.
Data sources
PubMed/MEDLINE, African Journals Online, Cumulative Index to Nursing & Allied Health Literature and Google Scholar were searched up to 23 May 2024.
Eligibility criteria
Observational and quantitative studies conducted in SSA that reported the proportion of health insurance beneficiaries satisfied with the scheme and/or determined factors associated with satisfaction were included.
Data extraction and synthesis
Data were extracted using Microsoft Excel and analysed with STATA V.17 software. The quality of studies was assessed using Joanna Briggs Institute checklists. A random-effects model was employed to estimate pooled outcomes. Publication bias was evaluated with a funnel plot and Egger’s regression test, while heterogeneity was assessed using the I² statistic.
Result
The study included 29 primary studies with a total of 11,488 participants. Among the included studies, 17 (58.62%) were found to have a low risk of bias, while the remaining studies exhibited a moderate risk of bias. The findings suggested publication bias among the included studies. To address this, a trim-and-fill analysis imputed 10 hypothetical missing studies, resulting in a more symmetrical funnel plot. The pooled finding showed that 61.84% of beneficiaries were satisfied with their health insurance (95% CI: 55.14 to 68.55, (I ² =98.6%, p<0.001)). Having a good knowledge of health insurance (OR=2.75, 95% CI: 1.42 to 5.34, (I ² =95.3%, p<0.001)), availability of prescribed drugs (OR=5.69, 95% CI: 3.04 to 10.62, (I ² =88.6%, p<0.001)) and availability of lab services (OR=4.20, 95% CI: 2.18 to 8.11, (I ² =88.4%, p<0.001)) were significantly associated to higher satisfaction with health insurance.
Conclusion
The results of this review show that a significant number of beneficiaries are satisfied with their health insurance. The findings highlight that beneficiaries’ satisfaction is significantly influenced by their knowledge of health insurance, as well as the availability of prescribed drugs and essential laboratory services. It is recommended that health insurance programmes in SSA focus on these factors to improve overall satisfaction among beneficiaries.
PROSPERO registration number
CRD42024496847.
... Sickness funds collect the premiums and use the revenues from these premiums to fund collective contracts with providers for the provision of healthcare services for insured patients. As regards funding, mandatory contributions or premiums are the main source of financing for social health insurance systems, which are usually income-related and, thus, based on income from gainful employment, pensions or unemployment benefits (Busse et al. 2004). National health systems, also called Beveridgean systems, are found in Greece, Italy, Spain and the UK and are more centralized than SHI in terms of organization. ...
... Commonly, the insurer reimburses health care providers, who are themselves independent. It is also common for the insurance institutions to be accountable to bi-or tripartite boards, comprising representatives of employers and employees, as well as possibly the state (Busse, Saltman and Dubois 2004;Saltman and Dubois 2004). ...
In summary, successful reforms are based on the right combination of key ingredients in a comprehensive and well-sequenced reform plan, but what exactly needs to (and can) be done depends on the cultural, political, economic and health care context of the actual countries concerned. The ability of a country to pay always determines the boundaries of the health sector, while the willingness of citizens to pay taxes limits the extent to which the financial burden of patients can be reduced. These characteristics also profoundly influence the efforts to increase the efficiency of the health care system. While Kyrgyzstan had a terribly inefficient system, which could have been improved substantially with the centralization of pooling and the downsizing of the hospital sector, Hungary started the reforms with centralized pooling and well-developed plans and pilots – for instance, for the adaptation of DRGs as the payment method for acute inpatient care. The essence of the challenge for Hungary was the same as for Kyrgyzstan, yet the tools used to approach the problem had to be different. Hungary had to combine into one reform model incentives for efficiency savings, the income of health workers and the experiences with patients’ willingness to pay as a potential source of private revenue. The reasons why Hungary – unlike Kyrgyzstan – eventually failed can probably be found in the wider fiscal and political context, and this should not be ignored by health policy-makers.
... As a social health insurance (SHI) system, one of the key challenges in the organisation of the Austrian healthcare system is the fragmentation of organisational and financial structures [6][7][8][9]. This applies particularly for people with multimorbidities and/or chronic conditions (ibid.), even if recent reforms have attempted to tackle fragmentation and to shift service provision away from the inpatient sector while expanding outpatient care in the context of target-based governance reforms [7,10]. ...
Background
There is a growing interest in redesigning healthcare systems to increase access to and coordination across care settings for people with chronic conditions. We aim to gain a better understanding of the barriers faced by (1) children with chronic bronchial asthma, (2) adults with non-specific chronic back pain, and (3) older people with pre-existing mental illness/es in Austria’s fragmented social health insurance system.
Methods
Using a qualitative design, we conducted semi-structured interviews face-to-face and by telephone with health service providers, researchers, experts by experience (persons with lived/ personal experience, i.e., service users, patient advocates or family members/carers), and employees in public health administration between July and October 2019. The analysis and interpretation of data were guided by Levesque’s model of access, a conceptual framework used to evaluate access broadly according to different dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability, and appropriateness.
Results
The findings from the 25 expert interviews were organised within Levesque’s conceptual framework. They highlight a lack of coordination and defined patient pathways, particularly at the onset of the condition, when seeking a diagnosis, and throughout the care process. On the supply side, patterns of poor patient-provider communication, lack of a holistic therapeutic approach, an urban-rural divide, strict separation between social care and the healthcare system and limited consultation time were among the barriers identified. On the demand side, patients’ ability to perceive a need and to subsequently seek and reach healthcare services was an important barrier, closely linked to a patient’s socio-economic status, health literacy and ability to pay.
Conclusions
While studies on unmet needs suggest a very low level of barriers to accessing health care in the Austrian context, our study highlights potential ‘invisible’ barriers. Barriers to healthcare access are of concern for patients with chronic conditions, underlining existing findings about the need to improve health services according to patients’ specific needs. Research on how to structure timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care would be paramount.
... In der gleichen Sendung kritisierte aber auch der Geschäf tsf ührer aus den Städtischen Kliniken in Dortmund Rudolf Mintrop die pauschalierende DRG-Finanzierung der Krankenhäuser: "Wir sagen ausdrücklich hier im Hause, am Bett des Patienten wird nicht gerechnet. Wa- [15]. rum müssen wir das ausdrücklich sagen? ...
Medizinethik und Wirtschaftsethik sind nicht dasselbe
Teil III der Serie „Ethik, Gesundheitsversorgung und Ökonomie“
Aus Sicht der Ökonomen ist jeder Mensch mit seiner Berufstätigkeit primär Teil der Wirtschaft. Aus der Perspektive der meisten Ärztinnen und Ärzte sowie Pflegefachkräfte und sonstigen Heilberufe entspricht Gesundheitsversorgung aber keinem primär wirtschaftlichen Handeln. Zu- nächst stehen für diese immer die bestmögliche Diagnose und Therapie im Vordergrund – im Idealfall also koste es, was es wolle. Schnell stellen wir allerdings fest, dass das oft nicht möglich ist und wir sparen müssen, weil unsere Mittel und Möglichkeiten begrenzt sind.
„Chrematistik“ – das Gift der Gewinnmaximierung
Eines der Grundprinzipien in der Wirtschaft ist es, Gewinne zu generieren (so- genanntes legitimes Gewinnstreben) – was durchaus auch wirtschaftsethisch richtig sein kann, solange hier die Gier bzw. die Gewinn„maximierung“ nicht im Vordergrund steht. Dafür wurde der Be-griff „Chrematistik“ von Aristoteles geprägt und der „Oikonomia“ (Beschaffung von lebensnotwendigen Dingen) gegenübergestellt. [12]. Denn Löhne und Gehälter der Beschäftigten inklusive der Sozialversicherungsbeiträge und Steuern müssen bezahlt werden, es müssen Betriebsgebäude saniert oder neu erbaut und es muss in die Entwicklung innovativer Produkte und Dienstleistungen investiert werden und vieles anderes mehr.
...
Symbiose von Medizin- und Wirtschafts- ethik?
Medizinethik und Wirtschaftsethik lassen sich aus medizinischer Sicht nicht „grundsätzlich“ deckungsgleich bringen, auch wenn unzweifelhaft ist, dass sie einander bedingen bzw. eine Schnittmenge haben. Eine Art von Symbiose ist also gefragt. Denn ohne Regeln einer ordentlichen Haushaltung in Gesundheitseinrichtungen und Praxen und einer ausreichenden wirtschaftlichen Finanzierung hätten wir auch heute noch eine Verelendung der Gesundheitsversorgung für die meisten Menschen. Also so, wie das vor Bismarcks Zeiten und damit vor der Einführung der Sozialversicherungen bei uns der Fall war. Sparsamkeit wurde dabei stets als eines der Grundprinzipien verankert. So, wie es auch das Wirtschaftlichkeitsgebot nach § 12 SGB V verlangt, also bei gleicher Wirksamkeit die günstigere Alternative zu verschreiben (WANZ = wirtschaftlich, ausreichend, notwendig, zweckmäßig). Eine Gleichsetzung der Gesundheitsversorgung mit Gesundheitswirtschaft und die Betrachtung von Patienten als Kunden verführen aber zu einer fehlgeleiteten Denkweise, sowohl auf der medizinisch-pflegerischen als auch auf der ökonomischen Seite. Dieses wird leider durch wirtschaftliche Fehlanreize im Gesundheitssystem gefördert. Daher lohnt es sich, über andere Wege des Miteinanders und der Finanzierung nachzudenken. Hierbei hilft es, sich andere Gesundheitssysteme anzuschauen.
... etc.
Goldschmidt AJW: Medizinethik und Wirtschaftsethik sind nicht dasselbe.
Hessisches Ärzteblatt 11 (81) 2020: 606-609 (ISSN 0171–9661)
Original Download: https://www.laekh.de/heftarchiv/ausgabe/2020/november-2020 -> https://www.laekh.de/fileadmin/user_upload/Heftarchiv/Einzelartikel/2020/11_2020/Medizinethik_Wirtschaftsethik_nicht_dasselbe.pdf
... This, in turn, intensified the debate on the failure of the existing healthcare systems and the need for reforms. Examples of the studies on healthcare reforms can be found in the works of Freeman (1998); Saltman -Figueras (1998); Lameire et al. (1999); Busse et al. (2004); Nemec -Kolisnichenko (2006); Kutzin et al. (2010). ...
This paper examines the Bismarckian and Beveridgean-style healthcare systems in 25 OECD countries to identify the relationship between the efficiency of the country's healthcare delivery arrangement and its economic wealth. The Data Envelopment Analysis (DEA) is applied as a quantitative tool. I examine three models using infant mortality and potential years of life lost as output indicators. These models differ only in the way of expressing healthcare inputs. The DEA computations show that neither the Bismarckian nor the Beveridgean healthcare system has a clear advantage over the other when inputs are expressed by health expenditure as a percentage of GDP. The model which uses USD per head expenditure data at purchasing power parity shows a slight advantage of the Beveridge-style systems. This confirms the common opinion that the Bismarck-style systems perform worse in controlling the costs. When inputs are expressed using physical units (medical staff and equipment), DEA shows that the Beveridge system is significantly more efficient than the Bismarckian ones. I analyse the relationship between the DEA scores and the country's GDP per capita, as well. This analysis shows that more developed economies are technically less efficient. These findings are consistent with the belief that technical efficiency is only one of the many criteria that determine the quality of the healthcare system and patient satisfaction.
... Despite consensus about the objective of solidarity arrangements, there is no single way of translating solidarity into concrete arrangements. Significant variations in the set-up of Impact of Dutch Social Policy Reforms on Solidarity 3 social arrangements are a testimony to that fact (Busse et al. 2004). Analyzing and comparing developments of solidarity therefore requires a framework bringing together all dimensions of solidaritymeaning those which are relevant in formal social insurance arrangements. ...
Solidarity is the “moral infrastructure” of social insurance arrangements that protect citizens against financial risks of illness: costs of medical care (health insurance) and loss of income (disability insurance). Although these arrangements have both met reforms, the effects of these reforms on the two forms of insurance have not yet been compared. This article presents a comparative analysis of these reforms’ impact on solidarity since the 1980s in the Netherlands. It develops an analytical framework, distinguishing coverage and financing dimensions, and concludes that the reforms affected several solidarity dimensions and that the effects were partly different in health insurance and disability insurance.
... In case the size of the pooling fund is not sufficiently large, and insurance premiums cannot be allocated over time, costs of the insurance scheme tend to rise and the scheme operates under higher unpredictability of risk. The premiums and operating costs associated with the scheme may vary significantly from one period to another [5]. ...
... While it is commonly assumed that in countries where entitlement to health coverage has been linked to employment, wage-based contributions (payroll taxes) many of these countries combine these with general budget funding, and several have increased reliance on the latter in recent years (Busse et al., 2004; Sheiman et al., 2010). As noted previously, this has been driven in part by the shift toward UHC as the underlying rationale for public policy on health coverage , with entitlement for each person in society rather than only for those in the labor force, and in part by the practical realities of different tax instruments in each country. ...
Many countries have identified Universal Health Coverage (UHC) as the goal for their health systems, and health financing reforms are at the core of strategies to move in this direction. While there is no one “best” financing strategy that applies in every context, this chapter synthesizes both theory and practice into principles that can be used to guide country progress with their financing reforms, while also highlighting pitfalls to avoid on the path to UHC. It begins with the conceptual underpinnings of both UHC and health financing policy, arguing that the emergence of UHC after the Second World War had profound implications for public policy on health coverage, particularly with regard to the role of general government revenues and the weakening of contributory-based entitlement. This is followed by a synthesis of lessons with a particular focus on low- and middle-income countries (LMICs), including the importance of increasing reliance on compulsory revenue sources raised through diverse mechanisms, reducing fragmentation in pooling arrangements and addressing inefficiencies through strategic purchasing and effective provider payment methods (PPMs). We then address a key challenge facing LMICs — extending effective access and financial protection to the informal sector who comprise the majority of the population.
... In addition, these schemes allow contributions to be collected relatively easily through salary deductions, making it easier for organizations to identify subscribers and also restrict benefits if contributions to the insurance plan are not made. In Germany and the Netherlands more than 60 percent of health spending is covered this way, whereas in other European countries such as Austria, Belgium, and Luxembourg the figure is much less, with less than half of total health spending coming via salary contributions to SHI (Busse, Saltman, & Dubois, 2004). ...
With recent world health reports focussing on health systems, there have been renewed calls for universal health-care coverage globally. Ensuring universal coverage requires a well-financed health system. However, the evidence guiding health system financing policy is equivocal. Health financing mechanisms need to be appropriate for the country with an emphasis on equity, income and risk subsidization, and a trend towards reducing out-of-pocket payments. Innovative financing mechanisms have great potential to meet the funding demand without generating unsustainable pressure on public resources. As such, innovative financing has the potential to fill the funding gap critical to the transition to more equitable models of health-care financing in many low- and middle-income countries.
... Lediglich Deutschland und die Niederlande bestreiten über 60% ihrer gesamten Gesundheitsausgaben auf diese Weise. In Österreich, Luxemburg und Belgien machen die lohnabhängigen Einnahmen weniger als die Hälfte dieser Ausgaben aus (29). Somit hat der Prozess der Diversifizierung bereits begonnen. ...
... Only Germany and the Netherlands cover more than 60% of total health spending in this way. In Austria, Luxembourg and Belgium, less than half of total spending is funded from payroll taxes (29). Hence, the diversification process has already begun. ...
... In SHI countries, the role of third-party payers has been delegated to " sickness funds, " which are separate from providers – be they public (typically owned by regional or local governments ), private not-for-profit or for-profit. To a varying degree, national (and partly regional) governments regulate and supervise sickness funds and providers, both of which are organizationally separate from the regulating level government (Busse et al. 2004). As to the question of whether the separation of purchasing and providing will bring net gains, at least in terms of economic efficiency, organization theory highlights a number of important factors. ...
Health is one of the fundamental human rights that is necessary for the realization of many other rights, in particular, the right to development, it is also necessary for a
decent life. An essential element of everyone's right to health is the right to access
quality medical technology, including medicines. Essential medicines meet the priority health needs of the population. Existing health systems must ensure that necessary medicines can be obtained at any time, in sufficient quantities, in appropriate dosages, of guaranteed quality, and at a price that is acceptable to both the individual patient and the community as a whole. In this context, the main goal of the article is to study and understand the features of drug insurance financing in developed and developing countries, presenting different models of health insurance and their implementation mechanisms. The authors have also studied the main sources and directions of financing global healthcare costs.
Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.
This book uses a revised version of Kingdon’s multiple-streams framework to examine health financing reforms in China, Hong Kong, Taiwan, and the Republic of Korea (ROK) as well as long-term care insurance (LTCI) reforms in Japan and Singapore. It shows that the explanatory power of the multiple-streams framework can be strengthened through enriching the concepts of policy entrepreneurs, ideas, and windows of opportunity in the original framework as well as bringing the theoretical lens of historical institutionalism into the framework.
Napjainkban a kormányzattól és a biztosítóktól kezdve a szolgáltatókig és a fogyasztókig mindenki az egészségügyi piaci versenyrõl beszél. De mit is értenek piaci versenyen? Vajon azonos dolgokról beszélnek-e? Mivel az egészségpolitika alakításá ban az egészségügy különbözõ szereplõi is részt vesznek, ez a kérdés alapvetõ fontosságú. Kevés szó esik arról is, hogy az egészségügy kulcsszereplõi hogyan képzelik el a versenyt a saját szempontjukból. Röviden áttekintjük a fejlett országok tapasztalatait, különös tekintettel az Egyesült Államok, Egyesült Királyság, Hollandia, valamint Ausztria és Németország példáján. Elemzésünk alapján elmondható, hogy a verseny az egészségügy területén valamennyi vizsgált országban korlátozott, az eredmények értékelése pedig nagyfokú óvatosságot igényel.
As presented in the first chapter, the economic order is a dynamic phe- nomenon with governments alternately moving to the left or to the right side of a continuum between two theoretical extremes. Since 1975, the gov- ernments of the countries of the European Union have pursued policies of moving to the right side of the continuum, increasingly giving power to the market, based on economic arguments (globalization)as well as on ideo- logical arguments (neo-liberalism and the theory of “public choice”). These policies also affect the production and consumption of health care goods and services. This is the theme of the second part of this book.
Health care reform has been a perpetual issue in German politics since
reunification. Reform initially focused on restructuring the health care system of the
former East Germany. It has subsequently focused on questioning whether the financing
of the German social health insurance (SHI) system is sustainable, in light of
economic malaise that characterized the 1990s and heightened global competition. In
this article, we document twelve significant attempts to reform health care financing
in Germany and critically appraise them according to the principles of solidarity and
subsidiarity on which SHI systems were built. While the reforms in the aggregate
offered the prospect of addressing the challenges faced by the system, the modest
results of the reforms and remaining deficiencies of the system underscore the limitations
of the evolutionary approach to reforms. This suggests that reformers should
consider a more revolutionary approach.
This article addresses the issue of the classification of healthcare systems, with the intent to take a step further than the previously analysed models of healthcare organisation. As concerns the financing of healthcare services, the standard tripartite classification (according to which healthcare systems are divided into three groups: voluntary insurance, social health insurance and universal coverage) is enriched with two additional types: compulsory national health insurance and residual programs. With respect to the provision of services and the relationship between insurers and providers, it is important to distinguish between vertically integrated and separated systems. What differentiates this analysis from the majority of previous studies is its underlying logic. Assuming that all systems are hybrid, the article proposes to put aside the classic logic for classifying healthcare systems (according to which individual countries are pigeonholed into different classes depending on the prevailing system) in favour of the identikit logic. The concept of segmentation (of healthcare services or population) proves to be remarkably useful to this purpose.
This chapter focuses on two of the key functions of a health sector financing system: revenue collection and fund pooling. It uses as its starting point the World Health Organization resolution calling for health care financing systems to provide universal coverage and financial protection for citizens. Revenue collection concerns the sources of funds, contribution structures, and the means by which they are collected, while fund pooling addresses the need to spread the risk of incurring unexpected health care costs over as broad a population group as possible. In terms of revenue collection, the chapter reviews the equity, sustainability, and feasibility of alternative financing mechanisms (e.g., donor and tax funding, a range of health insurance mechanisms, and out-of-pocket payments) and highlights key lessons from recent research in low- and middle-income countries on these mechanisms. It also highlights the importance of carefully considering who the most appropriate revenue collection organization may be in different political contexts. The main focus of the section on fund pooling is on alternative strategies for reducing fragmentation in health care financing in order to maximize both income and risk cross-subsidies in the overall health care financing system. Such cross subsidies are critical to achieving universal coverage and adequate financial protection.
This book provides a critical assessment of developments in health and healthcare policy. Primarily focusing on the UK, the chapters cover issues such as the policy-making process; the development of the NHS; health care governance; health promotion; and the comparative analysis of health care systems within the EU and US. Each chapter brings together social and political themes to offers a unique combination of theory, historical detail, and wider social commentary.
Kiszolgáltatottság és ösztönző erő a kiskereskedelmi láncok és beszállítóik kapcsolatában Oksági elemzés beszállítói szemszögből A kiskereskedelem koncentrációja a nagyméretű kereskedelmi láncok alkupozíciójá nak erősödéséhez vezetett, amelyeknek ezáltal egyre több lehetőségük nyílik szállító ikkal kötött szerződéseiket a maguk számára kedvezően alakítani. A kemény feltételek beszállítókra gyakorolt hatása ugyanakkor nem egyértelmű: egyes vélekedések sze rint ezek a beszállítókat hatékonyabb termelésre ösztönzik, ami végső soron verseny képességüket növeli. Mások szerint azonban egyes szerződéskötési módok, amelyek a magyar gyakorlatban annak ellenére jelen vannak, hogy a 2006. június elsején ha tályba lépett új kereskedelmi törvény is tiltja őket, torzítják a kiskereskedelmi láncok versenyét, és korlátozzák a beszállítók fejlődési lehetőségeit. Tanulmányunkban a Magyarországon jelen lévő kiskereskedelmi láncok és beszállítóik kapcsolatát, szer ződéskötési gyakorlatát vizsgáljuk empirikus módszerekkel. Az adatbázis 392 élelmi szer-ipari termelő-és nagykereskedő vállalat vezetőivel készített 2007. évi kérdőíves vizsgálatból származik. Eredményeink szerint a nagyobb méretű, nagyobb árbevételű, dinamikusan fejlődő vállalatok gyakrabban szembesülnek a kiskereskedők erejével, ugyanakkor nem igazolható, hogy a kiskereskedelmi láncok inkább ösztönöznék in novációra szállítóikat, mint más típusú kereskedők.* Journal of Economics Literature (JEL) kódok: L14, L22, F14. Az elmúlt két évtizedben Magyarországon is megfigyelhető a kiskereskedelem koncent rációjának folyamata, amely Nyugat-Európában és Észak-Amerikában már korábban nyilvánvalóvá vált. A vállalatméret és a bolti alapterület növekedése hatékonyabb műkö dést tesz lehetővé a hiper-és szupermarketek, a diszkontok és más, láncba szerveződött üzletek számára. Ezek a változások átalakítják az értékesítési lánc szereplőinek kapcsolatát is. A fogyasz tók élvezik az alacsonyabb árak, a széles választék és a hosszabb nyitvatartási idő előnyeit, és ennek megfelelően egyre nagyobb arányban szerzik be a szükséges fogyasztási cikkeket hipermarketekben, heti-kétheti nagybevásárlások alkalmával. A kiskereskedelmi láncok vonzó ajánlataikat azonban csak úgy képesek folyamatosan fenntartani, hogy kemény fel * Jelen tanulmány a szerzőknek az MKIK Gazdaság-és Vállalkozáselemző Intézet Gazdasági Versenyhivatal (GVH) megbízásából 2008 áprilisában készített elemzésének rövidített és átdolgozott változata. Az eredeti tanul mány és a kutatás kérdőíve elérhető a Gazdaság-és Vállalkozáselemző Intézet honlapján (http://www.gvi.hu/index. php/hu/papers/show.html?id=34). A szerzők ezúton szeretnének köszönetet mondani Tóth István Jánosnak a tanul mány elkészítéséhez nyújtott segítségéért, az adatbázis rendelkezésre bocsátásáért és értékes észrevételeiért.
The Korean health care system is under great controversy. Over the last 30 years, main goal of health policies was to pursue equal access of health care services. However, another goal of health policies laid on efficiency and Quality of care, it had lower priorities. Superficially, controversy stems from priority setting among goals of health care system, equity, efficiency and quality. At a deeper level, arguments arise from disagreement and confusion about the values of Korean health care system. One of the value spectrums believes that health care is the basic right of human beings, therefore it should be produced and distributed on need approach, and needs are known to be decided by professionals. If we accept need approach, health care is a pubic good. Another value of spectrums considers that health care should be distributed on demand approach. Demand approach means that health care is a consumption good on the positive economics, while normative judgement believes that health care is a public good. In equity aspect, health care is considered as a public good. Over the last several years, some of scholars proposed health care reform based on the principle of competition which is based on demand approach. Others argue that the competition principle based on demand approach is not appropriate for the reform proposal, because health care has to be approached on need base. If we do not make explicit values we should adopt, consensus building for reform is nearly impossible. From this perspective, this article will review an ideology and reality in health policies in Korea.
The aim of this paper is to explore the scale and scope of economisation and commercialisation processes in OECD health systems. At first I will develop the basic premise of a proliferating hegemonic strategy in national health policy making in OECD countries that is termed competitive cost-containment policy. After that the possible impact of economisation and commercialisation processes will be discussed. Firstly, processes of monetarisation regulating the basic medical social relation of physicians and patients as well as the privatisation of health care provision are described as effects of widespread economisation and commercialisation pressures. Secondly, the double transformation of the physician-patient relationship is understood as a contradictory process of its democratisation and economisation. Thirdly, tendencies of healthism and consumerism in OECD health systems are shown both to have socially exclusive effects while constituting a new culture of health. Finally, based on these explorative considerations I will sketch the framework of a comprehensive research program that integrates descriptive, analytical and normative research interests. Its basic thrust is to explore the dimensions, causes and effects of economisation and commercialisation tendencies in OECD-health (care) systems.
This article discusses the main hypotheses generated within the strand of research that focuses on health politics. These hypotheses are subjected to a brief empirical test, presenting data from 15 OECD countries. There seems to be a correspondence between the healthcare models adopted in different national contexts and the ideological orientation of the governments that have instituted them. Most laws instituting a system of social health insurance have been advanced by conservative governments, while those instituting a national health service have been passed – in the majority of cases – by social-democratic governments. The resulting clashes between governments and competing interest groups are largely attributable to the institutional setting. Thus, in the period from 1945 to 2000, most of those countries where political power was more concentrated implemented a national health service. Conversely, those countries where political power was more dispersed tended to maintain a system of voluntary or social health insurance.
This article investigates different modes of public policy in health care and their impact on health care financing and health service provision. In order to investigate the relationship between health expenditure and health service provision, we construct an “index of health care providers”. The empirical analysis of expenditure and this index demonstrates that there is only a weak correspondence between the level of total health expenditure and the number of health service providers in OECD countries. Different modes of health policy can help to explain why some countries are more successful in translating monetary inputs into health care personnel than other countries. Our results indicate that policies which favor self-regulation by non-governmental actors (as in Germany) lead in general to high levels of health care providers at above OECD average health expenditure. Policies which favor direct state control (as in the United Kingdom), on the other hand, are characterized by lower levels of health care providers and below average health expenditure. Policies which favor market elements are more difficult to categorize. However, it is noteworthy that especially countries that give market mechanisms higher priority than other countries (as the United States) offer below average numbers of health care providers at comparatively high total health care costs.
The welfare state is at the heart of the institutional structure of all European societies. Yet there are major variations
across countries due to different historical developments. The origins of social policy date back more than 120 years, but
the real expansion of the welfare state did not take place until the end of World War II. In the 1950s, social programmes
in most western European countries entered into a historically unique period of growth, which lasted until the 1970s (Flora
1986–1988). Since the early 1980s, however, the dominating issues of the welfare state debate have been crisis and retrenchment
(Pierson 2001). Today, the expansion of state welfare has come to an end in most countries, but the core institutions and
features of the welfare state have survived (Kuhnle 2000) and even been stabilized and consolidated. After more than 20 years
of crisis debates and retrenchment policies, the welfare state has successfully adapted to domestic as well as international
pressures (Castles 2004) and is supported by the vast majority of citizens in all European nations. The role of the state
in social security, on the other hand, has changed during this time.
Health care reform has been a perpetual issue in German politics since reunification. Reform initially focused on restructuring the health care system of the former East Germany. It has subsequently focused on questioning whether the financing of the German social health insurance (SHI) system is sustainable, in light of economic malaise that characterized the 1990s and heightened global competition. In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.
Up to the 1990s German health care legislation was dominated by measures regulating the supply side. Measures, such as budgets, aimed at volume control and sought to confine the increase of health care spending to the growth of the national income. To curb costs more effectively, competitive elements were introduced in the 1990s with free choice of sickness funds (open enrollment). To balance competition and solidarity, a risk compensation scheme (RCS) was implemented two years prior to open enrollment. Since then, balancing competition and solidarity has been a key feature of all consecutive health care reforms. The implementation of disease management programs in the statutory health insurance (SHI) served the dual purpose to promote quality of care and to foster competition. Preliminary experiences suggest, that the aligning of disease management programs with a RCS can greatly aid its implementation and benefit solidarity and competition.
This study provides an overview of funding mechanisms in Croatian health care and analyses them in terms of sustainability, efficiency and equity. The study presents an in depth investigation of problems facing funding health care in Croatia: high expenditure, inadequate financial resources, continuous deficits of the state insurance fund, lack of transparency in funding, an aging population, etc. Furthermore, the study provides a critical overview of reforms that have been implemented to counter those issues from 1990 to 2002. The study argues that the implemented reforms over relied on shifting health expenditure from public to private sources in addressing financial deficits in the system. The study argues that, instead, the reforms should have focused more on curbing rising expenditure in health care providers. Emphasis has been put on the extent to which the reforms affected the conceptual-social foundations of the system. Finally, the paper provides recommendations for policy makers in Croatia and presents an overview of Croatian experiences that might be of interest to researchers and policy makers internationally.
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