Health system

For the hospital health care system organization, see Hospital network.

Health care systems can be distinguished by what percentage of their financing comes from either public or private funds, and whether health care delivery is controlled privately or by the government.

A health care system is the organization and the method by which health care is provided. In practice, these systems vary widely from one country to another, and not all health care is delivered by way of a health care system. Comparing systems is the focus of health care politics and current research, but generally systems are compared by how they are financed and how they are managed.

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.

Financing

There are generally five primary methods of funding health care systems:

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.

Although some view health care from an economic perspective as being no different from other products or services, others believe it has many characteristics that encourage government intervention or regulation:

• 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.
• People often lack the information or understanding to be able to choose rationally between competing health care providers when they need treatment, particularly in the event of the need of urgent or emergency treatment.

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).

• The other major models are public insurance systems:
  • Social security health care model, where workers and their families are insured by the State.
  • Publicly funded health care model, where the residents of the country are insured by the State.
  • Social health insurance, where the whole population or most of the population is a member of a sickness insurance company.

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.

Examples

• 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.
• 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.
• Cuba has 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: 15.2%) (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 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 ot 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.
• 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.
• Germany has a universal multi-payer system with two main types of health insurance: "Compulsory health insurance" (Gesetzlich) and "Private" (Privat). 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 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 Hong Kong, both private and public clinics are common, while public hospitals account for the majority of the market.
• 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.
• In Israel, the publicly funded medical system is universal and compulsory. Payment for the services are shared by labor unions and the government.
• 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. Italy has one of the highest doctor per capita ratio's at 3.9 doctors per 1,000 patients.
• 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.
• In the Netherlands, a system of standardised and mandatory health insurance is in place, meant to encourage competition between healthcare providers and insurers. The insurance policies are paid for through a system of levies and subsidies as well as a premium paid by the insured, from which children under 18 are exempt. The system resembles the German system in some respets.
• 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.
• 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.
• 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 the United Kingdom there are three separate but co-operating National Health Services of Scotland, Northern Ireland and England and 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 are lower in Wales, and the administration there is committed to their eventual elimination.) 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, but it is used only by a small percentage of the population, and generally as a supplement to NHS services.

• The United States is alone among developed nations with the absence of a universal healthcare system. 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 the poor, 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. Eligibility is determined by Priority Groups. Retirees and those with service-connected injuries are within the higher priority groups, while non-injured veterans may become eligible based on financial need (reference eligibility Priority Groups). Current servicemen and women are provided care at military facilities while on active duty. Reservists also have access to care while on active duty. Family members of full-time active duty personnel are covered under CHAMPUS (Civilian Health and Medical Program of the Uniformed Services). Together, these tax-financed programs cover about 27% of the population 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. 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. 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. 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.

See also

• 1993 Clinton health care plan
• Consumer driven health care
• Health
• Health care in the United Kingdom
• Health care in the United States
• Health insurance
• Primary care
• Primary health care
• Publicly-funded health care
• Social insurance
• Universal health care

External links

• The Not So Short Introduction to Health Care in US (305 KiB PDF file) by Nainil Chheda.
• HRC/Eldis Health Systems Resource Guide provides access to free online research and other resources on health systems in developing countries
• Health Decisions Comprehensive health insurance resource; with news, a learning center, and original content.
• Harvard University: Longevity Gap: Who, Where And Why Americans Live Longer Or Die Sooner