Carlos Centeno, S. Hernansanz, Luis Alberto Flores, Álvaro Sanz Rubiales · 5 authors
Abstract This chapter offers an in-depth look at health politics and the tax-financed, universal health system in Spain. It traces the development of the Spanish healthcare system, focusing in particular on its double transition in the 1980s and 1990s from a centralized social insurance system, mostly funded through workers’ and employers’ contributions, to a decentralized universal model financed by general taxation. The new national health system aimed at covering all residents and transferred healthcare competences to the regions, i.e. the seventeen Autonomous Communities, a process completed in 2001. Key issues include rationalization, harmonization, and territorial equity-building of the decentralized healthcare system; efficiency improvement through the introduction of private management elements; and cost containment to bolster the system’s financial sustainability in the context of growing demand and scarce resources. As the chapter argues, these challenges along with the remarkable changes in the political party system have increased the political salience of healthcare in public debate in the 2010s, but the prospects for developing consensual healthcare policies have worsened, such that structural problems are likely to persist.
CONTEXT: In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service. OBJECTIVE: To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia. DESIGN, SETTING, AND PARTICIPANTS: A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia. MAIN OUTCOME MEASURES: Reported health care utilization, out-of-pocket expenditures, and financing practices. RESULTS: Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance. CONCLUSIONS: Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.
This article presents the results from an evaluative longitudinal study with before-after design. The main objective was to determine the effects of health care decentralization on changes in health financing. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. Taking into account the changes implemented in the three countries, as well as the strengths and weaknesses of each country in financing and decentralization, a rule for decision-making is proposed that attempts to identify the main financial changes implemented in each country and the basic indicators that can be used in future years to direct the planning, assessment, adjustment and correction of health financing and decentralization.
Background: Health system in Indonesia is experiencing a reform due to decentralisation policy. This policy causes a big change on public and private sector's roles in health services. The great impact will be on the regional economy. In turn the regional economy change will influence local health system. This study aims to make a projection on the influence of decentralisation policy to the regional health system due to the change of regional economy.\nMethods: This study is a case study with 7 provinces in Indonesia, including their districts, as the subjects of the study. The simulation of change in district economic situational as the impact of decentralization in 7 provinces is shown by secondary data.The local government economic strength is determined based on Regional Original Revenue (PAD), General Allocation Fund (DAU), and the simulation of Local Shared Fund (Dana Bagian Daerah). The community economioc strength is determined by Gross Domestic Regional Income (PDRB).\nResults: This study shows that there will be 4 groups of region based on their economy strength. The results shows that there are four types of district government and community situation: (1) strong district government financial resources with strong community finance
OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.
In international development, paradigms shift about once every 10 years. An important shift that is now taking place is from economic development to poverty reduction. The link between health and poverty has been recognized for a long time. The traditional way of looking at this is in terms of ‘wealthier means healthier’ ( Figure 1). While nobody disputes this link, the poverty reduction focus raises the question whether investment in health is important for poverty reduction. Quantitative evidence to answer this question is now emerging and producing astonishing findings. Health and income (a) the traditional view and (b) a new paradigm. In an analysis of geography, health and other factors in relation to poverty, Gallup et al. (1998) found one of the strongest correlations between poverty and malaria. In a longitudinal analysis of health, health policy and economic performance, Jamison et al. (1998) detected important time-frame relations between investments in health, the nature of these investments and economic performance. Bloom et al. (1998) found evidence that a change between dependent and the productive part of a population, i.e. reduction in fertility and increased child survival, can lead to a spurt in economic development. This demographic gift may be one of the reasons for the economic miracle in Asia. This effect is temporary and will turn negative when the cohorts grow old. At the microeconomic level there is also strong evidence for a link. For example, the programme fighting river blindness has given a 20% return on investment ( World Bank 1993). Moreover, families with river blindness spend twice as much on health as others, and their children are twice as likely to drop out of school, girls more often than boys. In a related chronic disease, lymphatic filariasis, patients produced 30% less material per hour than healthy cotton weaver coworkers ( TDR 1996a). Thus diseases and their underlying causes can affect the economies of families in a number of ways: Reduced productivity, impediment of education or retained high dependency ratios. The emerging conclusion is that the right investment in health is at least as important as education. While further quantitative research is needed to substantiate findings, leading decision-makers are are already convinced, as illustrated by the G8 resolutions at Cologne relating to debt relief for for highly indebted poor countries (HIPC). As the communique said, ‘The central objective of this initiative is to provide a greater focus on poverty reduction by releasing resources for investment in health, education and social needs’. The resources that could be available through the new debt relief initiative if not drained away in other directions are significant. According to estimates provided by Jeffrey Sachs (1999), the amounts are about 5 billion dollars annually for over 40 countries with a population of about 750 million. Thus we are considering about $7 per capita or $120 million per country. If health were allocated half of this, health spending could amount to $60 million per country. This has come at just the right time to accelerate our development of concepts and policies. In May a meeting between WHO and international development agencies dealt with the role of specific strategies in health to achieve poverty reduction ( WHO 1999a). In education the simple notion is that poor people are illiterate, so to secure basic schooling for the poor is paramount, and indeed much evidence supports that view. Similarly, the basic assumption in health is that the first priority in is to fight diseases from which the poor suffer most, i.e. their excess burden. Further analyses of what these conditions are, their quantitative relation to poverty country by country and relative importance as targets for investment to reduce poverty have been initiated. This has now become a priority for WHO (1999b). The major conditions linked to excess burden among the poor and their global importance in terms of mortality are set out in Table 1. According to ongoing work by Gakidou and Jamison (personal communication), they all show a strong excess in poor populations. Tuberculosis is 10 times more prevalent in people earning < $1 a day; maternal mortality about eight times, and childhood mortality (< 5 years) four to five times more common in children of poor families. One effect of this poverty reduction perspective is prioritizing and focusing. Thus we are faced with a limited set of predominantly infectious diseases. The question is, then, how to address them most effectively. What are the relative merits of the available tools in addressing disease burden? How cost-effective are they and what is their potential for reaching the populations in need? Clearly we need modules of different sets of interventions and need to look for synergies. From an immunization perspective we believe that with the pneumococcal vaccine soon becoming available, about 3.5 million deaths can potentially be prevented by immunization ( Table 2). Three and a half of 12.7 million (and let us add 2.3 million equivalents for family planning) would suggest that immunization could justify use of more than 20% of the resources on this basis alone, without taking into account cost effectiveness or capacity to reach the poor. In both these parameters immunization would, of course, score very high ( Miller & Hinman 1999). Based on the HIPC calculations with about $60 million per country where on average one million children are born every year, $12 would be available per child for immunization services. One of the advantages of investing in excess burden for poor people is that the investments become self-targeting, i.e. one does not need to consider specialized services for the poor, as they are notorious for becoming ‘poor’ services. While this does not exclude the possiblity of using vouchers and other mechanisms where payments are required for systems reasons, services for those conditions could be free or almost free in a poverty reduction programme. Moreover, if one focuses on outcomes, one does not necessarily have to target investments at specific disease categories. A very good example of this comes from Ghana ( Adjei 1999). Ghana has undertaken profound health sector reforms by adopting and implementing a sector-wide approach. The government agreed with international agencies and bilateral donors that resources would be pooled and and used towards an agreed strategic framework. During 1997, &, 1998, immunization coverage has increased by about 20% (from approximately 50%–70% for measles). What are the reasons? There appear to be several: Vaccine procurement was protected in a general procurement mechanism. There was a shift in resources from tertiary care to district care. District support increased from 22% in 1996 to 39% in 1998 in national health budgets. Private healthworkers including midwives have become involved in immunization activities. This has dramatically increased the number of sites at which immunizations take place. Outreach points have increased from 7 to 11 per health facility. Immunization coverage has become an outcome measure used in the negotiation between central government and districts regarding resource allocation. The impact of health reforms on immunization in other countries appears to be mixed, but hard data is difficult to come by. Decentralization appears to have had a negative effect in many countries because central functions such as procurement suffered. In Latin America at least these effects were temporary (Ciro de Quadros, personal communication). In Uganda the reform process apparently led to the cutting of all resources of outreach services, which had a dramatic effect on coverage ( Ngoma 1999). A detailed review of the impact of sector-wide reforms is in preparation by the WHO. It is important in this context to conclude that reforms do not necessarily have a negative impact. The issue is therefore not whether the investments go into one pot or not – this will depend on the stage of reform in each country. Strategies for investments in health in relation to poverty reduction may with appropriate know-how be used to promote reforms to achieve better services rather than inhibit them. We should be able to overcome vertical in favour of horizontal entrenchment. To reach out to poor populations represents a great challenge. This is where the biggest gains of poverty reduction are likely to be achieved, as illustrated by the striking differences in coverage between routine polio 3 immunization and national vaccination days ( Table 3). Similarly high coverage has been achieved with ivermectin distribution in Africa, where quantitative randomized trials showed that a community-driven approach resulted in better coverage than health centre-driven ones ( TDR 1996b). Thus it would appear that we now have several successful models: Polio national immunization days with community mobilization; Ivermectin distribution directed by communities; Health sector reforms shifting resources from tertiary to primary care; Contracting of privately practicing midwives and other health personnel; Securing resources for mobile services including transport. The optimal mix of these would of course depend on geography and other local factors. The costing of outreach services is a priority in this perspective. They may bring up the cost of services severalfold, depending on the circumstances. Over the last 1½ years, kick-started by a meeting in the World Bank, an analysis of immunization services has taken place. The analysis showed: stagnation of immunization services globally with a decline of EPI coverage for certain countries as well as marked regional discrepancies ( WHO 1999c); newly developed, efficacious vaccines against major killers are not being introduced into poorer countries, the gap between the number of vaccines used in the ‘North’vs. the ‘South’ is widening; limited investment into vaccine research for diseases that predominate in the poorest developing countries. As a result of this analysis the major partners in the field decided to strengthen their global effort in this field, leading to the formation of the Global Alliance for Vaccines and Immunization (GAVI) in July 1999 ( GAVI 1999a). GAVI has the following strategic objectives: Improve access to sustainable immunization services; Expand use of all existing, safe and cost-effective vaccines where they address a public health problem; Accelerate development and introduction of new vaccines and technologies; Accelerate R & D efforts for vaccines needed primarily in developing countries; Make immunization coverage a centrepiece of international development efforts. The main instruments created for GAVI to advance these objectives ( GAVI 1999a) are; A Global Fund for Children's Vaccines (GFCV) with the aims of purchasing vaccines and safe injection materials, financing access, infrastructure and R & D. The fund's first priority is to secure availability of newer vaccines (Hepatitis B, Haemophilus influenza b, yellow fever) ( Figure 2); A Governing Board comprising 11 members from partner constituencies. Dr Gro Harlem Brundtland, Director General of WHO, will chair for the first two years followed by Ms Carol Belamy, Executive Director of UNICEF, for the following two years; A small secretariat to implement the directions of the Board and ensure the involvement and representation of the broader immunization community; A Partners' Working Group to ensure Board decisions are translated into operational actions appropriate to each lead agency; Task forces of limited duration to address specific issues; A biannual meeting to bring together the broader immunization community. Structure of the Global Fund for Children's Vaccines. The intention of GAVI's modus operandi is to ensure that the partners do the work and that the secretariat remains small to avoid duplication of efforts. The working group with its weekly teleconferences appears to be an important mechanism for coordination with strongly dedicated people of the main partners. The Fund became reality before the end of the year 1999 with a contribution of $150 million per year for five years from the Bill and Melinda Gates Foundation. This needs to be matched by a 30% contribution from other sources to become a charity with tax-free status. The UNICEF national committee of the US has taken on that challenge. Initially the Fund will be used to supply HEP B, HIB and yellow fever vaccines to the poorest countries with a per capita GNP < $1000. China, Indonesia and India are considered special cases because of their purchasing power and vaccine production capacity. Thus GAVI will discuss with these countries how best to support them through mechanisms other than external purchase. Countries are invited to submit proposals which will be reviewed on the basis of clearly defined eligibility criteria ( Unicef 1999b), giving considerable scope for synergy with HIPC-based investments. With an estimated $1 billion potentially available over the next five years, Figure 3 illustrates the possible disbursement of funds to sets of countries in $50 million increments. These countries would receive fully funded vaccines for three years; support would then be tapered off by 25% per year with the last 25% continuing for three years, giving a total support period of eight years. $1 Billion distributed in 4 separate $250 million trunches each starting with $50 million for 3 years. Different shaded areas relate to different cohorts of countries with different implementation rates. The cost of vaccines and safe injection material for a fully immunized child is approximtely $10. Thus $200 million will cover 20 million children, i.e. about half of the total child cohort in eligible countries. Assuming that many countries would need to strengthen their immunization services first, both in terms of infrastructure and access to qualify, the programme is being phased in to reach maximum capacity in the third year. With the Fund, GAVI has extraordinary new opportunities in relation to immunization, but if they are to materialize fully, some problems need to be resolved. Many countries targeted for this programme have low coverage of DPT3, often < 60%. Their infrastructure was eroded in the 1990s and coverage capability is limited. A substantial proportion of children may not receive a full immunization schedule. However, the polio eradication initiative greatly strengthened infrastructure in recent years. As outlined above, clear successes have been achieved in sector and community-based research. Strengthening current services is a challenge to GAVI partners already involved in supporting health and immunization services, notably the countries themselves, UNICEF, WHO, bilateral agencies and the development banks. We do not consider it likely that the GFCV will play an instrumental role here initially. GAVI will support the strengthening of existing mechanisms. HEP B and HIB vaccines will be required for newborns every year in the poorest countries. Thus their continued financing must be secured. While the costs of the vaccines is likely to continue to fall, substantial investments will be required on a continuing basis, necessitating collaboration of all parties concerned. The governments of eligible countries have a particularly important role to play: Only if it is a priority to them can bilateral agencies provide assistance and development banks concessionary loans. New vaccines, such as one agains pneumococcal pneumonia, are in the pipeline. This vaccine alone could save more than a million children from dying of acute respiratory infection. Unless we can secure the funding of currently available vaccines, we cannot ensure funding of new ones. On the other hand, if we are successful with the former, we will have a good chance to raise the resources required to introduce new vaccines. This is illustrated in Figure 4. The need to secure sustainable financing to secure funding for new vaccines. Since the last biotechnological revolution, we have seen a continuos trend towards a sharper distinction between public and private sector, which has accelerated after the collapse of the communist system. Within R & D the roles have also become more distinct: The public sector plays a key role in supporting basic, clinical, epidemiological and operational research while the private sector tends to be responsible for product development. Product development is, in part due to rules and regulations imposed by the public sector, a complex operation spanning intellectual rights related to discovery, preclinical and clinical development, production, marketing and post marketing surveillance. The driving force for the private sector is profit. Through a century of competitive development, the R & D industry has become the most effective actor in this field, and continues to undergo change to retain that competitive edge especially in a globalized market. A problem arises for unprofitable products; so far, the public sector has had to take a responsibility for these. Most who have been involved in public sector product development realize that it is difficult to match the range of expertise and competence required. Thus, if the public sector could guarantee a market that would engage the private sector, many obstacles would be overcome. This is what is called the ‘pull’ mechanism. For some products, such as the pneumoccocal vaccine which has a market in the industrialized countries, the pull mechanism does not need to be very substantial. Potential availability of $100–200 million for the poorest countries is expected to be sufficient. On the other hand, vaccines that are of greater use to poor populations and countries, such as vaccines against malaria, HIV/AIDS or tuberculosis, would require a stronger pull, on the order of magnitude of a billion dollars or more per year for at least five years. We are awaiting private sector assessments. There is considerable interest in pursuing this mechanism by the World Bank, by Jeffrey Sachs and colleagues at Harvard, and the US government. If the GFCV were to become a vehicle for such a pull mechanism, it would need to be substantially strengthened. If increased investments in vaccine R & D can be achieved, many resent discoveries and tools provided by basic science would become part of a development effort. These include identification of protective antigens selectively synthesized in vivo where tissue damage occurs; functional and structural characterization of antigens derived from genomics efforts; rationalization of the immunization process itself through improved methods for introduction and expression of vaccine DNA and selective targeting to the presentation mechanisms of the immune system ( Hoffman & Liu 1999); and simpler The most important challenge for GAVI is to that all whether in the or in the field, will as part of this effort to and health, through the use of safe
Like many developing countries, the Philippines has decentralized its public health system. Despite its supposed advantages, however, the decentralization, has not led to widespread improvements in local provision. This is partly because many local government units are found financially inadequate since the current revenue-sharing scheme does not factor in the distribution of the devolved expenditure responsibilities across LGU. Moreover, this particular flaw in the present revenue-sharing scheme has made corrective policy measures more difficult to undertake since it is no longer sufficient to compensate those LGUs originally with financing difficulties. More crucially, it has also become politically necessary to compensate those adversely affected by the corrective policy measure. If only to avoid the added cost of further adjustments, the experience of the Philippines underscores the importance of a well-designed and carefully implemented decentralization program.
Setting risk-adjusted capitation rates in health systems with centralized financing and decentralized delivery is one of the most intriguing policy issues. The common practice to set capitation group rates is based on individual data collected from either population surveys or medical records, using a single-and in most cases arbitrary-set of relative unit costs of services. This paper presents a method for estimating group-specific mean costs and capitation rates using a panel of aggregate cost data of the competing health plans and the composition of their populations. This method is used to estimate mean costs and capitation rates for the Israeli health care system. The limited data available severely constrains the range of estimable models, however, the results evoke some questions with regards to reimbursement and rates presently used, as well as to the methodology used to estimate them.
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.
The introduction of health insurance system has been the core of the Russian health care reform. It has coincided with the decentralization of the state administration. The reform has thus been decentralized, and the transition has been fragmentary and incomplete. As a result, the existing health financing system is eclectic and contradictory. Meanwhile, the reform has had a positive stabilizing influence on financing of health care under conditions of continued economic crisis. The new priorities of the reform should be to balance the financial flows and the state's obligations, and to increase the efficiency of the use of resources through encouragement of competition, assurance of transparency of public funding, development of health care planning, and shift from inpatient to outpatient care.
The focus of this article is changes in Slovak health-care policy 1990-7. To place these changes in a comparative perspective we also examine recent Czech, Polish and Hungarian experiences. In the Slovak case we show that although there has been official support for privatization, decentralization, mixed sources of provision, accountability and individual choice, in practice progress towards these goals has been very slow. This relative immo bility has been caused by public preferences; chronic political instability; the legacy of plan ning; a policy-making process dominated by a small number of politicians and a politicized bureaucracy. In addition we argue that the variety of health-care policies we observe in Central Europe reflects the general lack of a clear vision of social policy during transition. The article has six main sections. In the first we use public choice theory to explain why the results have occurred. In the second we sketch the health-care system under communism. There follows a description of policy changes since 1989. This topic is split into three parts. First the political background to change is de scribed, then the finance of health care is discussed, and finally issues of organization, control and delivery are raised. A concluding section has a summary and discussion of the arguments.
espanolLa evolucion de la prestacion sanitaria media parece moverse a impulsos de dos grandes factores: los tecnologicos, en gran medida exogenos a las autoridades sanitarias, y los politicos, o endogenos en respuesta a las expectativas y preferencias sociales sobre las posibilidades de la medicina en las sociedades occidentales. Como resultado, las capacidades de tratamiento sanitario se expanden, de la mano de la presion ciudadana, en sociedades cada vez mas medicalizadas y en las que la industria sanitaria tiene un gran peso mediatico. En Espana, el incremento de la prestacion sanitaria media registrada en los ultimos anos aparece como coetanea a la descentralizacion sanitaria. Asi, existe diversidad no solo en razon del contenido de algunas prestaciones sanitarias, sino tambien de su utilizacion por parte de la poblacion. Nos interrogaremos en este trabajo acerca de la influencia de la descentralizacion sanitaria como inductor del crecimiento del gasto sanitario. A dicho fenomeno se asociaran aspectos relativos aprocesos de financiera, o de emulacion de politicas con falta de corresponsabilizacion en el gasto por parte de sus gestores. La tesis que deseamos mantener es que la devolucion de responsabilidades fiscales a las comunidades autonomas puede ser un buen antidoto para el control del gasto sanitario y, en particular, de los diferenciales de utilizacion. Con el nuevo sistema de financiacion autonomica, la integracion de la financiacion sanitaria en la general permite introducir los mecanismos necesarios para el autocontrol del gasto que aseguren una efectiva sostenibilidad de la financiacion de la sanidad publica en el proximo futuro. EnglishTechnological and social factors are beyond the increasing share of health expenditure on GDP. This implies that a mix of exogenous and endogenous factors influence health care delivery. Professional aims and social expectations on the production possibility frontier of health, on cure and care treatments, make for a rather difficult control of public health expenditure in OECD countries if reforms are not undertaken in the near future. In Spain, the rise in public health expenditure seems to go hand by hand, with an important decentralization power of health care delivery to Regional Authorities. Whether this is just a coetaneous or a relevant explanatory factor is examined in this paper.The lack of accountability and some fiscal ilusion aspects may undoubtedly influence, overall, public expenditure. But the absence of a rational distribution formula of regional health expenditure at he national level is an important factor too. The argument of the paper focusses on the need of devolution of full responsabilities on health expenditure to the Spanish Autonomous Communities. A fiscal room process is proposed as a result of some technical adjustments on a capitative finance basis. Cross-boundary flows of patients, age structure of the population, teaching and research externalities
Health reforms have been implemented in Russia for nearly a decade now. The first reform sought to improve the budgetary system for funding medical expenditures. In 1991, a health insurance system was set up. The major characteristics of Russian reform are: the complexity of the system of compulsory health insurance, which was introduced in bits and pieces ; the decentralization of reforms and regional differences in transitional models; and the attempts to oppose reforms and re-establish the former system for financing health care. The budget crisis has made it even more necessary to go on with reforms: a new phase was announced in 1997. The main tasks are to strike a balance between guarantees for access to free health care and public funds for such care; to correct financial flows to medical expenditures so as to overcome the piecemeal nature of health insurance; and to develop democratic procedures for administering and controlling the health system.
Public responsibility for health care can be justified by ambitious egalitarian objectives, as it is commonly believed that the private sector generates greater disparities than the public sector. Government institutions can be designed to achieve equality in provision of health services. The article addresses the geographical distribution of primary care physicians in Norway, where primary physician services are the responsibility of local governments, primarily financed by general taxation. The authors analyze the allocation of physicians using a local government demand model, a synthesis of consumers' demand and local government resource allocation. Analyses were performed on a panel data set of all Norwegian municipalities covering the period 1986-1992. The results are encouraging. A decentralized system of primary physician services does seem to be fairly effective in securing equity in access to these services for the municipal population. In particular, local governments seem to respond well to the health care needs of their populations. Distribution of physicians is only to a very small extent dependent on the wealth of the municipality.
Through the recent National Health Insurance Act (NHIA), the Philippines have committed themselves to introducing a social health insurance with universal coverage within 15 years. Germany was the first country to introduce a social health insurance system more than 100 years ago. Its system is based on the principles of corporatism, federalism and a mandate for equity. Based on a long-term German experience with equity, quality, cost and efficiency issues, the Philippines' NHIA is analysed concerning the entitlement to benefits and the benefit package, the organization of the health insurance programme, health insurance financing, and provider payment mechanisms. It is suggested that the Philippines could profit from including preventive and promotive services as well as pharmaceuticals in the benefits package. The organization of the health insurance system could be decentralized using the 13 regions as its principal units. To achieve financial equity between regions and health funds, a contribution compensation scheme is proposed. To prevent over-utilization in over-served areas and to promote utilization in under-served areas, a relative value scale for fee-for-service payments seem advisable.
The cutbacks in Medicare and Medicaid reimbursement, and the Republican takeover of Capitol Hill and the state legislatures as a result of recent elections, suggest that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of America's health services. These "voluntary" alliances that are now being forged as an amalgam of health providers and insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies throughout the United States. As the Department of Justice and the Federal Trade Commission are unable to appropriately analyze the efficacy of most prospective mergers, the American health field increasingly can expect monopolistic environments. In this process, the public eventually may demand the formation of state health services commissions. Within this framework, the German decentralized, multipayer, multitier approach, which historically is self-governing and allows for negotiating reimbursement rates between insurers and providers, offers a preferred option to the traditional American public utility model.
The paper reviews the theoretical basis for the application of user fees in the public health sector in low-income countries with particular reference to the special characteristics of medical care as a commodity. The general equilibrium efficiency result of the market mechanism is shown to be the theoretical justification for the financing of health services via a system of user charges. If markets for all goods and services exist, and are perfect in a very strict sense, the welfare outcome of the price mechanism cannot be improved upon by any other resource allocation device. Furthermore, the decentralized and impersonal nature of this mechanism renders it more convenient to use in the allocation of commodities, health care included, than its alternatives such as a system of centrally administered prices or a system of administrative controls and directives. However, since many of the assumptions of the price system are rarely met in actual situations, especially in the health sector, it should be applied with caution. In particular, problems of information asymmetry and consumption externalities in health care markets necessitate a simultaneous use of fees with government interventions in order for fees to achieve their often intended aim of efficiency and equity improvement in health care provision. The most important intervention of the government here is the enactment and enforcement of institutions that reduce costs of transacting in health care markets and that in addition facilitate the emergence of new markets such as the markets for medical insurance. A striking finding of the paper is that health services in low-income countries are best financed primarily by revenue from general taxation, supplemented by a system of moderate user fees. Since medical insurance markets are generally non-existent in low-income areas, it is argued that financing health services primarily through user fees in such areas would be inefficient and inequitable. However, to mitigate the moral hazard problem as well as the problem of the commons, both of which characterize publicly financed health care, imposition of modest user fees is required. The importance of fees in this proposal increases with economic growth and with evolution of institutions that facilitate market transactions. Strategic interaction among economic agents is shown to affect the structure and implementation of user fees. A game-theoretic analysis of the general problem of health care financing shows that this problem is best tackled by harnessing the efforts of households, private health care providers, the government and civil society. These entities form what might be called a winning coalition in health care financing game of society. It is argued that the government is better placed to provide an institutional framework for coordinating the efforts of the various players to the desired end.
Drawing from the public finance literature on expenditure assignment, this paper analyzes how devolution in the health sector is being operationalized in the Philippines. A central issue is how the central government can ensure that national and local objectives coincide. The pattern of health spending after devolution is described, and the financing of national health priorities at the local level through the Comprehensive Health Care Agreements is examined. The paper concludes by suggesting some guidelines for a financing mechanism for locally implemented health projects.
OBJECTIVES: This paper reviews Russia's health crisis, financing, and organization and public health reform needs. METHODS: The structure, policy, supply of services, and health status indicators of Russia's health system are examined. RESULTS: Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic. CONCLUSIONS: The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to noninfectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended.