The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
[Excerpt] It is not surprising that most theories of human capital treat the firm as the key unit of analysis, given the deep imprint that Becker (1964 [1993]) left with his early efforts to distinguish between general and specific human capital. It is especially understandable for research that focuses on American institutions and practices. Ever since the passage of the New Deal employment policies of the 1930s, firms have been assigned central roles in the delivery and financing of a variety of labor-market services, including the provision of workforce training and development (Osterman et al, 2001). Most of the chapters in this volume reflect this emphasis by exploring how individuals and firms allocate the costs and share the benefits of human capital, incorporating human capital development into alternative theories of the firm (such as transaction cost, resource-based, agency, entrepreneurial, and knowledge-based perspectives), and how human capital plays into emerging research on social capital, organizational capabilities, learning, and human resource strategies and architectures. But, as Chapters 12, 22, and 23 each suggest, firm-centric theories, particularly those founded upon the neoclassical economics framework, need to more fully take into account how firm boundaries, strategies, and practices relate to other institutions in society. This is particularly important given the changes in employment relationships that are acting to reduce the labor-market functions served by individual employers. In short, the central argument of this chapter is that a more up-to-date theory of the changing nature of employment relationships is needed to understand whether and how human capital is to serve as a source of competitive advantage in a modern economyâeven one as decentralized as that of the US.
The present study describes and explains the changing role of the state in the Italian healthcare system since the beginning of the 1970s, with a particular focus on developments following 1978 when the healthcare system was transformed from a social insurance system into a national health service. In order to address these changes in a systematic way, we track healthcare system development along three dimensions: regulation, financing, and service provision. With regard to regulation, we observe a relative retreat of the state due to decentralization processes and internal market mechanisms. Quantitative measures for the financing and service provision dimension also indicate a modest relative retreat of the state. Taking regional data into account, we identify a clear North-South-divide in the public/private mix of financing and service provision. Although the focus of the paper is to describe the changing role of the state in the Italian healthcare system, we also offer preliminary explanations. We seek to identify the role of exogenous shocks such as economic crises versus endogenous stressors specific to the healthcare system itself (i.e. inherent inefficiencies) on healthcare system change. Therefore, the paper aims to provide a tentative, yet dynamic account of healthcare system change that is both descriptive and explanatory.
David E. Bloom, Ajay Mahal, Larry Rosenberg, Jaypee Sevilla
Abstract The rapid ageing of India's population, in conjunction with migration out of rural areas and the continued concentration of the working population in the informal sector, has highlighted the need for better economic security arrangements for the elderly. Traditional family ties that have been key to ensuring a modicum of such security are beginning to fray, and increased longevity is making care of the elderly more expensive. As a result, the elderly are at increased risk of being poor or falling into poverty. In parallel with its efforts to address this issue, the Government of India and some of the Indian states have initiated an array of programmes for providing some level of access to health care or health insurance to the great majority of Indians who lack sufficient access. Formalâsector workers have greater social security than those in the informal sector, but they only represent a small share of the workforce. Women are particularly vulnerable to economic insecurity. India's experience offers some lessons for other countries. Although there is space for private initiatives in the social security arena, it is clear that most such efforts will need to be taxâfinanced. The role that private providers can play is substantial, even when most funding comes from public sources, but such activity will face greater challenges as more individuals seek benefits. India has also shown that implementation can often be carried out well by states using central government funds, with a set of advantages and disadvantages that such decentralization brings. Finally, India's experience with implementation can offer guidance on issues such as targeting, the use of information technology in social security systems, and human resource management.
The regional organization of the Spanish national health system offers a âunique fieldâ for exploring the sources of health inequalities as well as for testing the effects of political decentralization on health and healthcare inequalities. Drawing from the results of an empirical analysis where inequalities in three dimensions of health (outcome), healthcare (access) and healthcare payments (financing) are estimated, this article first explores the association between three such inequality dimensions alongside other system and socio-economic controls. Second, we examine whether the first wave of asymmetric healthcare devolution which took place in Spain between (1980â2001) â whereby health policy responsibilities were transferred to a few region states (autonomous communities [ACs]) â correlates with higher inequalities in health, healthcare and health financing. Our findings suggest that inequalities in health and healthcare appear to be driven by income inequalities and inequalities in use but not by inequalities in financing and health expenditure. Region states politically responsible for the organization of healthcare did not exhibit significant differences in health and healthcare inequalities and tend to exhibit a better equity performance.
The health financing schemes is the foundation for the nationâs health care system, and the health insurance is a main one of some options for financing health care. This article compares two health care financing schemes in urban areas before and after the health reform, and targets at the impacts facing coverage groups, the financing methods, decision-making power or financial management (i.e. the distribution of responsibility and rights between the central government and local governments), payment arrangement and cost containment of health care financing mechanisms. Prior to reform, the equal access and universal coverage of health care services were implemented through the employment-based health insurance in a state-controlled economy with guaranteed full employment and central control in general. The decentralization reforms of fiscal system and tax sharing reforms disrupts the past economic foundation, the rebuilding health insurance system which still benefits the employed bring the limited coverage. The next trend is to make transition from health insurance covering only part of the employed population to what are in effect national health services covering the whole population in urban areas.
Introduction In 1981, the Reagan administration in the US, the Thatcher administration in the UK, and their allies compelled the International Monetary Fund (IMF) and World Bank Group (known as the âInternational Financial Institutionsâ [IFIs]) to launch an ideological assault against the state and promote a shift in power from the state to the market. From 1981 to the present, the IFIs have financed structural adjustment agreements (SAAs) in developing and transition countries to achieve that goal. Structural adjustment agreements call upon recipient governments to liberalize and privatize economies in the context of strict budget discipline. Adjustment lending facilitates economic integration â the hallmark of globalization â on terms that are advantageous to corporate and finance capital. The policy conditions associated with adjustment loans have accelerated transnational corporate penetration and expansion of markets in developing countries and lowered risks of portfolio investment and foreign direct investment. The role of the state has been reshaped to serve market liberalization, as governments have downsized, decentralized, and privatized (or âcontracted outâ) their functions. Such measures were intended to jump-start economic growth and free up resources for debt service. However, in most countries, public investment in critical areas (health care, education, infrastructure) foundered, growth rates were disappointing, and debts mounted to unsustainable levels (Pettifor 2001). This volume explores the relationship between adjustment and respect for human rights. Importantly, as governments in developing countries implemented World Bank and IMF-financed structural adjustment programs (SAPs), respect for human rights diminished.
The government dominates health care in Britain, France and Germany, but there are a number of significant differences between the three countries. In Britain, health care is financed by general taxation, whereas the French and German systems are both insurance-based. Spending on health is higher, and the health systems are more decentralized, in France and Germany than in Britain. These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Latin American social medicine (LASM) emerged as a movement in the 1970s and played an important role in the Brazilian health care reform of the 1980s, both of which focused on decentralization and on health care as a social right. The dominant health care reform model in Latin America has included a market-driven, private subsystem for the insured and a public subsystem for the uninsured and the poor. In contrast, the Mexico City government has launched a comprehensive policy based on social rights and redistribution of resources. A universal pension for senior citizens and free medical services are financed by grants, eliminating routine government corruption and waste. The Mexico City policy reflects the influence of Latin American social medicine. In this article, I outline the basic traits of LASM and those of the prevailing health care reform model in Latin America and describe the Mexico City social and health policy, emphasizing the influence of LASM in values, principles, and concrete programs.
Decentralization looms large in any analysis of Canadian economic and social policy. This trend has been especially pronounced in the area of unemployment insurance (UI) and social assistance (SA) programmes. Provinces now manage SA programmes and retain 100% of any cost savings that they achieve, while the Federal government maintains full responsibility for the passive component of UI. Under a series of provincial-federal Labour Market Development Agreements, since 1997 most of Canada's provinces have taken over administrative responsibility for the employment benefit and support measures (EBSMs) targeted on UI beneficiaries. A number of articles have examined the implications for provincial SA systems of restrictive measures in the UI programme. This paper examines the possibility that provinces may shift actual and potential SA clients onto the insurance system (now called employment insurance, EI). It concludes that within the context of EBSMs, any cost-shifting of this ...
Social assistance as the technique providing means-tested income guaranteed financed by general taxation in Spain is composed by different benefits. There is not a only one policy, but different measures oriented to different groups of population and organised by different public administrations. During the last two decades, the different levels of public administration have implemented a set of benefits, which observed together can considered as the Spanish âsafety netâ. The main lines of this development has been: a) fragmented in different protection systems (unemployment, pensions, social services), b) subsidiary of the development of these systems and c) decentralized in different levels of public administration (mainly in regional level, i.e. Autonomous Communities).
In the course of the present transition in Russian society, a new system of social security has been developed. The previous Soviet system has been replaced by a system of four more or less independent social funds, covering the main branches of social security. These funds are supposed to be run according to insurance principles and to be financed by contributions, mainly from employers. Given the difficult economic and social situation of the country, there have been increasing demands for effectiveness in the management of the different funds and also in the management of the whole social security system. The results of this study show that the social funds have developed different organizational structures with different degrees of centralization and decentralization. Only one of the funds seems to be relatively wellâfunctioning and effective, while the others have experienced more or less serious problems in fulfilling their main tasks and functions. The most serious problems, however, seem to stem from the structure of the social security system as a whole, which is perceived as fragmented and badly coordinated. In order to improve the coordination of the system, there have been proposals to merge two or more funds into a unified social security organization. This strategy is open to question, however, since it would increase the bureaucracy of the system. There are other ways in which the structure of the social security system might be advanced. Such developments should be based on an analysis of the system from the perspective of the individual client or patient.
We model the links between skills and changes in work organization. As the proportion of skilled workers increases, the economy travels through a sequence of organizational equilibria. We show that as the relative supply of skills increases the organization of work becomes more decentralized. Both skilled and unskilled workers become more autonomous and perform a wider range of tasks: decentralization spreads across firms at the expense of the old centralized organization based on a strict division of labor. Moreover, as firms switch to decentralization, their employment structure becomes more homogeneous and wage inequality stops decreasing. These predictions are compared with empirical evidence based on French establishmentâlevel data and we find support for both of them. This suggests that the longâterm increase in the skill level of the workforce may have been one important factor driving the recent introduction of new work practices by a large number of firms.
AIM: To evaluate the results of current reforms in Macedonian health sector. METHOD: Description and situation analysis, covering the period 1991-1997, are focused on demographic and vital indicators, morbidity and mortality data, elements of health care system, legislation, health insurance, health care financing, and elements of health care reforms. RESULTS: The Republic of Macedonia experienced changes in the social and economic situation, similar to those in other countries in transition. The growing number of dependents (young and old persons) impact high health expenditures. High priority health problems were infant and premature adult mortality. As an inheritance of the former political system, the development of different parts of health care services was unbalanced and insurance and local network of health facilities were highly decentralized. The reforms addressed health financing and reimbursement, organization and management of health services, and pharmaceutical policies and supply. The legislation was revised, but new revision is needed. CONCLUSIONS: Health care reforms were needed in Republic of Macedonia in order to overcome the problems associated with early phase of transition. The disadvantages of the current reforms are: lack of proper political will for the implementation of activities according to the planned schedule, initial over-utilization of hospital care, and no significant changes in financing of the public sector facilities. The advantages are that the health system did not disintegrate, universal access to health services was maintained, free choice of physician was promoted, and public/private mix of services was established and financed by the Health Insurance Fund.
In continental Europe, the unemployment rate has risen continuously from a low level of below 3 percent in the early 1970s to more than 10 percent in the late 1990s. If those who are in governmental employment schemes and in early retirement are included, the unemployment rate runs as high as 20 percent in quite a few European countries, including France and Spain. The basic rule for a stable employment situation in an economy is: nominal wages should stay in line with labor productivity growth plus the increase in producer prices. In a situation of high unemployment, however, when the unemployed are to be integrated into the labor market, the productivity rule has to be modified: the increase in real wages should stay below the productivity growth rate until a satisfactory level of employment has been obtained. The most elegant approach to creating more employment is to improve labor productivity. If an economy succeeds in raising labor productivity, there is more scope for real wage increases or for more employment. We should, however, not overestimate the potential of an economy to increase labor productivity. If we want to integrate the unemployed, average labor productivity in the economy is likely to decrease. We should be realistic enough as to expect trends in Europe to be similar to those in the United States, where labor productivity per hour has increased by less than 1 percent per year since 1980. The task for Europe is to change the institutional setup of labor relations, to move wage formation closer to the market process, and to allow greater wage differentiation. It is unlikely that the "social partners", i.e., the trade unions and employers' associations, will be able to change the rule system sufficiently. Therefore, it is necessary to change the legal rules, especially those in favor of the unemployed, for instance, by introducing a legal right for each individual to enter the labor market at a wage of his or her choice. If continental Europe wants to reduce unemployment, it will have to change the impact of the welfare state. With respect to the level of benefits provided by unemployment and health insurance, a distinction should be made between large risks and small risks for the individual. Such a distinction between large and small risks would allow the costs of the social security system to be reduced, thus lowering the tax on labor. Insurance against large risks would be mandatory, small risk coverage would be optional. With respect to financing the welfare state, more choice should be given to the individual as concerns the insurance coverage that he/she desires. One serious issue concerning social welfare payments is determining the extent to which the level of social welfare benefits should be scaled down for those who are able to work in order to increase the incentive to work and the intensity of the search for work. A related issue is whether unemployment benefits should be reduced in their level or in the length of time they are paid in order to intensify the job search and reduce the reservation wage. âą Shifting the employment issue to the EL) level would take attention away from the need to decentralize wage formation, i.e., to negotiate wages at the level of firms. It would be an incentive not to undertake the necessary steps to solve national unemployment problems and it would shift the financial burden to those countries that are successful in reducing unemployment. It would elevate the national labor market cartels to the EU level and it would blur the lines of responsibility. National governments would shift their responsibility to the EU level. This would be an extremely dangerous development for European integration because the European cause would become the scapegoat of failed national policies.