The use of blockchain in healthcare is attracting growing interest due to its ability to guarantee the integrity, traceability, and transparency of sensitive data processing. However, its integration into a legal environment strictly regulated by the GDPR and French healthcare data law faces major tensions: immutability versus the right to erasure, decentralization versus legal responsibility, transparency versus medical confidentiality. After reviewing the legal obstacles, this article proposes a series of regulatory adjustments aimed at making the use of distributed ledgers in healthcare legally viable. It calls for dedicated governance, a functional interpretation of rights, and regulation by design in order to reconcile technological innovation with the protection of fundamental rights.
Blockchain Technology Applications and Security
Healthcare Systems and Practices
Legal, Health, Environmental and COVID-19 Challenges
Essossinam Pali, Coffi Cyprien Aholou, François Paul Yatta
Since 2019, Togo has been strengthening financial decentralization through municipalization and the election of municipal councilors. Municipal financial autonomy is a key driver of local governance, allowing municipalities to mobilize their own resources, manage tax and non-tax revenues, and implement development projects. However, despite a legal framework governing local taxation, Togolese municipalities continue to face chronic financial constraints that limit their ability to finance public services and infrastructure. This study examines the mechanisms of financial decentralization in Togo and their contribution to municipal budgets. Using a quantitative approach that combines documentary analysis and interviews with 188 experts and practitioners in local finance, the study identifies the following four primary financing mechanisms: local, national, community-based and international. Among these, own revenues, including tax revenues, non-tax revenues, and revenues from the provision of services, together with government transfers through the Local Authorities Support Fund (FACT) are the main sources of local government finance. However, the results show that several legally defined fiscal instruments remain underutilized or outdated in many municipalities, significantly limiting their effectiveness in mobilizing resources. These results highlight the need to optimize fiscal decentralization strategies in order to strengthen the financial autonomy of municipalities and support sustainable territorial development.
BACKGROUND: This article addresses how health institutions operate in Algeria. It deals with the problem of the management of health institutions in Algeria between centralization and decentralization. This means are there spaces for health institutions in the formulation of local health policies? Algeria seeks to establish local health institutions in response to current demographic growth. AIM: This study evaluates the Algerian legislatureâs success in developing a legal framework for the administrative organization of health care institutions. METHODS: This comparative study focuses on legal texts, using data from the national statistical office, the World Bank, and the official Algerian news agency. RESULTS: The study finds a close relationship between free health services and the dominance of central health authorities that finance all public health institutions, including residentsâ medical expenses, screening, surgery, and rehabilitation. Non-resident patients are compensated for treatment by state insurance funds (CNAS and CASNOS). There are no charitable hospitals. Therefore, civil society and humanitarian, charitable institutions are invited to launch initiatives regarding charitable hospitals, because they will contribute to relieving pressure in public health institutions and will also help in promoting public health in Algeria. The Ministry of Health controls central health services. CONCLUSION: Algerian health law mixes central and decentralized management but does not encourage local health institutions to seek funding and administrative independence. Algeriaâs health system needs to be reformed.
Abstract This chapter offers an in-depth look at health politics and the social health insurance-based system in Hungary. It traces the development of the Hungarian healthcare system, characterized by seismic shifts from a Bismarckian, solidarity-based social health insurance to centrally planned healthcare pledging universal access to health services as a citizenâs right. After the fall of state socialism, Hungary returned to a social health insurance model, and since then the main policy efforts have focused on decentralization, strengthening of private provision and entrepreneurship, and financial consolidation of the health system. After the highly contested and ultimately failed attempt to introduce managed competition and user fees between 2006 and 2008, there has been a shift back to an increasingly centralized system with tax-based financing. As noted in the chapter, the consequences of recentralization for the solidarity, accessibility, affordability, and quality of healthcare in Hungary are still to be seen.
Abstract This chapter offers an in-depth look at health politics and the universal health system in Poland, financed through social health insurance. It traces the development of the Polish healthcare system under communism, characterized by a complete shift from an insurance system to a state-run Soviet Semashko model of healthcare with some elements of private provision. Since 1989, Polish health policy went through systemic changes which included a shift to a decentralized social health insurance system in the late 1990s and re-centralization in 2001. Polish healthcare politics has been turbulent, marked by political instability matched by a dense network of veto points, including the President and the judiciary, that had an impact on the direction of health reforms. As the chapter highlights, some of the main issues have been high out-of-pocket payments, corruption, and privatization and commercialization of public hospitals.
Abstract This chapter offers an in-depth look at health politics and the decentralized, tax-financed health system in Italy. It traces the development of the Italian healthcare system, including the processes leading to hospital reform and regionalization in the 1960s and 1970s and the creation of the national health service in 1978. Since the late 1980s, health policy has been shaped by the transformation of the Italian political system, further transfer of powers to the regions, and public expenditure constraints due to public debt. Policies inspired by the New Public Management approach that aimed to increase the health systemâs cost-effectiveness through steps towards fiscal federalism were introduced and reversed. Over the course of the 2000s, agreements between the central state and regional governments have become the main tool for coordinating health policy and trying to settle recurring disputes regarding health expenditure responsibilities. Ongoing debates on healthcare concern measures to ensure the national health serviceâs sustainability, typically the control and containment of its costs, and to reduce the territorial gap and other gaps that clash with the systemâs universalist design.
Healthcare Systems and Practices
Healthcare Quality and Management
Health Systems, Economic Evaluations, Quality of Life
Abstract This chapter offers an in-depth look at health politics and the tax-financed, universal health system in Denmark. It traces the development of the Danish healthcare system, characterized by an evolving division of labor between central authorities and decentralized municipal and regional governments. Since the late 1980s, Danish health policy has seen a number of gradual changes and a major structural reform passed in 2005 that amalgamated municipalities and regions and changed healthcare financing rules, thus shifting the balance of shared power toward the center. Other healthcare issues have been cost containment, patient rights, and promotion of local integrated health services. A negotiated policy style contributes to efficient implementation of reforms once a decision has been made.
Healthcare Systems and Practices
Health Systems, Economic Evaluations, Quality of Life
Ciara Brennan, James Rice, Rannveig TraustadĂłttir, Peter Anderberg
Article 19 of the United Nations (UN) Convention on the Rights of Persons with Disabilities requires states to ensure that persons with disabilities have access to a range of support services, including personal assistance. The Convention is an agreement between state parties and the UN. However, in practice, disability services are often implemented at the local level. Drawing on the findings of qualitative research in Iceland, Norway and Sweden, this paper examines a paradox whereby states commit to ensure access to support services, but decentralize responsibility to autonomous and independent local governments. A multi-level governance framework is applied to analyse the findings of qualitative inquiry with policy-makers, local government officials and leaders of independent living organizations in all three Nordic countries. A multi-level analysis highlights the tensions and contradictions between decentralization and human rights commitments.
Carlo De Pietro, Paul Camenzind, Isabelle Sturny, Luca Crivelli · 8 authors
This analysis of the Swiss health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Swiss health system is highly complex, combining aspects of managed competition and corporatism (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy. The health system performs very well with regard to a broad range of indicators. Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland, and healthy life expectancy is several years above the European Union (EU) average. Coverage is ensured through mandatory health insurance (MHI), with subsidies for people on low incomes. The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times, though managed care type insurance plans that include gatekeeping restrictions are becoming increasingly important. Public satisfaction with the system is high and quality is generally viewed to be good or very good. Reforms since the year 2000 have improved the MHI system, changed the financing of hospitals, strengthened regulations in the area of pharmaceuticals and the control of epidemics, and harmonized regulation of human resources across the country. In addition, there has been a slow (and not always linear) process towards more centralization of national health policy-making. Nevertheless, a number of challenges remain. The costs of the health care system are well above the EU average, in particular in absolute terms but also as a percentage of gross domestic product (GDP) (11.5%). MHI premiums have increased more quickly than incomes since 2003. By European standards, the share of out-of-pocket payments is exceptionally high at 26% of total health expenditure (compared to the EU average of 16%). Low and middle-income households contribute a greater share of their income to the financing of the health system than higher-income households. Flawed financial incentives exist at different levels of the health system, potentially distorting the allocation of resources to different providers. Furthermore, the system remains highly fragmented as regards both organization and planning as well as health care provision.
In Burkina Faso, as in most developing countries, the operational level of the health system is made up of Health Districts (HDs), the activities of which are typically coordinated by the District Team (DT). Assessing the the core functions of DTs, as described by WHO, shows two important weaknesses. Firstly, instructions from "above" are often implemented rather passively: DTs tend not to display much leadership. Secondly, the current organisation, based on input financing and centralised planning, does not sufficiently promote either the vision or research functions of DTs. In this article, we report our experience in the Orodora HD in Burkina Faso, where the DT's leadership and vision proved to be essential ingredients for effective health action in the district. Our description of six interventions implemented between 2004 and 2008 shows how DT leadership and vision have improved outputs at the HD level. Until 2004, the district applied static health planning. The health system was insufficiently financed and performed poorly. Faced with this situation, the DT decided to set up several priority interventions based on health care access criteria and patient concerns, while respecting and contextualizing national norms and objectives. Six interventions were then implemented. The first was ensure that quality blood (meeting transfusion security norms) was available at the District Hospital (DH), by picking blood up from the regional blood transfusion center weekly. This speeded up care at the DH, reduced the number of cases referred to the regional hospital for transfusion, and reduced neonatal and maternal mortality. The second intervention sought to improve the skills of health workers in managing emergency cases and to improve relationships with the referral hospital through the reintroduction of counter-referral procedures. This led to a decrease in unnecessary referrals and also reduced the mortality rates of serious cases. The third intervention, by implementing a decentralized approach to tuberculosis detection, succeeded in improving access to care and enabled us to quantify the rate of tuberculosis-HIV co-infection in the HD. The fourth intervention improved financial access to emergency obstetric care by providing essential drugs and consumables for emergency obstetric surgery free of charge. The fifth intervention boosted the motivation of health workers by an annual 'competition of excellence', organised for workers and teams in the HD. Finally, our sixth intervention was the introduction of a "culture" of evaluation and transparency, by means of a local health journal, used to interact with stakeholders both at the local level and in the health sector more broadly. We also present our experiences regularly during national health science symposia. Although the DT operates with limited resources, it has over time managed to improve care and services in the HD, through its dynamic management and strategic planning. It has reduced inpatient mortality and improved access to care, particularly for vulnerable groups, in line with the Primary Health Care and Bamako Initiative principles. This case study would have benefited from a stronger methodology. However, it shows that in a context of limited resources it is still possible to strengthen the local health system by improving management practices. To progress towards universal health coverage, all core functions of a DT are worth implementing, including leadership and vision. National and international health strategies should thus include a plan to provide for and train local health system managers who can provide both leadership and strategic vision.
The implementation of decentralization policies in the health sector of many developing countries has been a major issue in international health. The objectives were to focus on health sector reform, health financing system, and human resource development. However, less attention has been paid to the institutional capacity development of health systems. In this paper, institutional capacity refers to the abilities of organizations to make effective management in order to build local capacity and to achieve goals with local ownership. The aims of this paper were to explore the developmental process of districts institutional capacity by assistance of an NGO in Cambodia, and to identify the key factors influencing this development. We chose five operational districts (ODs) and two of them were contracted to NGO for management assistance. We conducted semi-structured in-depth interview to 17 managers and 16 key informant interviews. For analysis, we used qualitative analysis based on a grounded theory approach to clarify a conceptual framework for understanding management practices at district health institutions. There is a 4-stage capacity developmental process at the district-level institution. Supportive supervision and widening of decision-making authority were identified as key factors for sustainable institutional capacity development. They have complementary function each other. External agencies such as NGOs can use these key factors to develop local management capacities, and also this capacity development can be done internally within institutions such as OD health offices and by upper authorities such as the PHD.
Seen from France, this report underlines how far we still have to go in our country to reduce social inequalities in health. France is not one of the partner countries of the Commission1 and the conceptions of health determinants which are developed in the report appear far removed from the paradigm which predominates in our country. We can no longer say that France is at the âpre-contemplativeâ stage:2 data exist, the phenomenon of social inequalities in health is known and well documented for numerous states of health. But these efforts, which issue largely from the world of research, have not resulted in a system of routine statistical surveillance. Furthermore, at this âcontemplativeâ stage, there is no explicit public policy and no objective written down in law. In the law on public health policy of 2004, objective 34 touches on this question, but restricts it to the state of health of the most precarious populations. As stated in the report, reduction of social inequalities in health is above all a political problem, but it is essential to provide evidence. In this respect, the report lends support to those who, in France, think that it is important to continue to increase our knowledge of the subject, but that the most pressing question is how we can move on to the active stage. It is strange to see how our country, always ready to give others lessons on human rights, tolerates a problem as well documented as social inequalities in health. Although the right to optimal health is laid down in a number of texts, this question of social justice and ethics does not mobilize opinion. This is so in France, but also throughout the world. The question thus remains to find out on what basis opinion and the decision makers can be mobilized. Though today it is unfortunately a fragile argument, it seems to us that the ethical imperative put forward in the report must remain central. The fact that the reduction of social inequalities can be a source of economic gain, as shown in a Canadian report,1 is an argument to be developed in order to remove economic objections, but it cannot be the central argument for mobilization. This report may well enjoy less popularity in France than a previous WHO report.3 In its World Health Report 2000, the World Health Organisation had no hesitation in describing the French health system as one of the best in the world. In that report, the conception of health determinants was in line with the prevailing conception in France. The health system was described as being the essential factor of the good health of a country. âIf Sweden enjoys better health than Ugandaâlife expectancy is almost exactly twice as longâit is in large part because it spends exactly 35 times as much per capita in its health systems.â3 On the basis of this analysis, since 1945 France has enjoyed a system of social protection which proclaims, among its objectives, the improvement of the population's level of health. Within this system of social protection, the general health insurance system, completed by specific schemes for the poorest among the population, should allow widespread access to health care. The number of French people who have the benefit of insurance against ill health has constantly increased over the years and now almost the entire population is covered. In 2002, according to the Health and Social Protection survey, 91% of residents in France also had complementary coverage.4 At the same time, the mortality statistics remind us that in this country social inequalities in health are particularly marked in comparison with our European neighbours. This apparent paradox calls into question such a conception of health. The 2008 report puts the determinants back into perspective in a most useful way. On a world-wide scale, access to drinking water, to a diet which prevents malnutrition, protection against the vagaries of the climate are the major decisive factors in social inequalities in health. In line with this analysis, the report emphasizes actions which target determinants outside the health system and the need for a coherent policy in order to achieve health equity. A large number of spheres are involved, some of which seem a priori far removed from health: these are not only education, but also access to employment, working conditions, the age of retirement, the housing policy and lastly policies of redistribution, through taxation and direct financial aid. These are all relevant to social inequalities in health in France. The impact of investments concerning children at the very start of life and young people, in particular relating to education and training, is strongly pertinent to social inequalities in health, especially because of the links between education, qualification and health later in life. The role of unemployment and working conditions1 and of housing and transports are emphasized. In agreement with studies which have shown the protective influence of social networks and social support, and the role that a sense of control over one's life can play, citizens are encouraged to participate actively in decisions related to healthâand this theme is a far-reaching one. Behaviour change is not mediated only by individual approaches to health education. The prices of food products, the industrial processing of foods, institutional catering, advertising, legislative measures and regulations are all paths to be explored. We must thus be delighted that the report stresses the intersectoral aspect of the fight against social inequalities in health, as this is a key issue. For example, the report points out the contradictions which were observed in certain Northern European countries when the common agricultural policy of the European Union came to thwart the efforts of the health authorities, themselves supported by the government.5 It thus will help to promote an intersectoral approach to health, at a national and at a European level, a choice which involves fundamental policy choices. For example, the increase in precarious employment, obligatorily part-time work, poorly paid jobs and their detrimental effects clearly shows that what is at stake here is the choice between a potential political determination and the predominantly economic (and short term) approach which is that of the liberal ideology. Just as for the issue of climate change, the fight against social inequalities in health is clearly revealed here as a global combat implying a choice of development strategy. Measurement and surveillance are one dimension of the solution. With the partial exception of death certificates and of a longitudinal survey of mortality based on the Permanent Demographic Sample, in France social characteristics are ignored by nearly all routine statistics, whether hospital information systems, health insurance data or registers of specific diseases. The data produced by research studies, generally based on one-off surveys or at best surveys repeated every few years, do not allow us to grasp changes in inequalities over time. The proposals for a minimum statistic system and a system which covers social determinants are important and should be developed in France. The information systems of healthcare institutions, starting with those of hospitals, are silent as to the social situation of those who use them, and this evidently restricts their ability to adapt their services to the needs of these persons. Naturally, the report does not elude the question of healthcare and advocates universal access to quality care. At a time when health expenditure is strictly limited, it is important to examine the question of patientsâ share in these expenses and its effects on care consumption and health in the light of health inequalities. The Rand Corporation study,6 carried out in the 1970s in a sample of American families, followed for 3â5 years and randomly assigned to health insurance plans which differed by levels of reimbursement and the share to be paid by the household, is still topical. The conclusions of this randomized study showed that the amount of care consumed decreased markedly as soon as >25% of the cost was borne by the patient. No difference in state of health was observed in the population as a whole. But the impact of the cost to be borne made itself felt as soon as the poor population was concerned. It is interesting to point out that the share borne by the patient in France has been around 25% during the last 20 years, a proportion which has tended to increase. But the tendency in France is to increase the participation of households in health expenses, including (particularly) persons who are in a precarious situation because of their state of health, with in due course an impact on social inequalities in health. The report stresses the need for health systems to be proactive. Taking the need for proactivity into account is particularly pertinent in France, where the system is still widely based on a logic of offer. Issues related to secondary access to care are somewhat briefly dealt with in the report, which is strongly centred on primary access. But to ensure that this first phase is well organized is not sufficient if the system is ineffective in other respects, or if its malfunctions concern mainly the most disadvantaged patients.7 The report suggests that the role of the healthcare system goes beyond the treatment of diseases. Physicians and the other health professionals are leaders of opinion, who influence conceptions and representations of health. Finally, this is where analysis of health determinants is put together and where the directions taken by public health and research are given value. This last remark underlines the importance of giving professionals training on social determinants of health. Their commitment is undoubtedly essential to negotiate the turn towards less biological or medicinal concepts of health. The way in which behaviours are conceptualized in fact determines the way in which they will be taken into account by public health. In agreement with what we have said above, the presentation in the report of the aims of research in public health is particularly pertinent: research on the causes of social inequalities in health, on interventions aiming to reduce them, analysis of public policies and lastly statistical measurement and surveillance. In view of the issues at stake and of the nature of the determinants, research on health should be more interdisciplinary and should integrate social determinants. Redressing the balance towards these objectives should enhance their value, unlike a primarily biological or disease-oriented approach. The complexity of the interventions and so of the methods used to evaluate them justifies not only the interdisciplinary approach, but also a reflection on the notion of proof. Going beyond randomized trials, the question is how to make use of qualitative as well as quantitative data. Evaluation of interventions and strategies to reduce social inequalities in health raises a difficult problem, particularly when these are interventions of a structural type or which aim at long-term modifications. Assessing a research programme carried out in the Netherlands on social inequalities in health, it was found that the interventions subsidized by the programme had been specific, targeted interventions that were easy to evaluate. The projects evaluated were all of this type, to the exclusion of any wide ranging, far-reaching public policy.8 The causes of inequalities are multiple, and several levels of explanation coexist, proximal and fundamental causes. We pay tribute to the very ambitious nature of this report, which runs counter to the policies of international bodies (WTO) and so underlines the most fundamental causes of health inequalities. The main messages of the report are all the more essential as the financial and economic crisis may worsen inequalities by affecting the weakest first. Can health be the theme to mobilize us towards humane objectives, not only economic ones? The report stresses that the sector of health and healthcare professionals, including the minister or ministers responsible, could take position as defenders of wide societal objectives giving health and health equality their rightful place as a marker of progress. This supposes that professionals and politicians become aware of the importance of social determinants of health. This task is a particularly important one in France, and it is without doubt one of our primary challenges.
This article proposes a secondary analysis of data collected on four French cities as part of an European research project, entitled "Rescaling Social Welfare Policies. A Comparative Study on the Path towards Multi-level Governance in Europe". The field-work provided a profusion of data on the so-called "2nd wave of decentralization" (2004-2005) that hardly fit into the standardized frame designed for international comparisons. It appears that this territorial re-organization combines opposite movements depending on the point of view adopted (bottom-up or top-down) and the type of public action considered (planning, funding, defining eligibility criteria etc.). The rescaling processes that occurred within the four field-sites have ambiguous effects as regards regulation. On the one hand, theoretically speaking, they turn market competition into an attractive model. But, on the other hand, they have practical implications (limited market size and lack of expertise within local governments for example) which prevent this autonomous mechanism of regulation from achieving efficiency. This finally induces constant bargaining which leads case managers to using informal procedures in the selection of beneficiaries within the official target population and give rise to disparities in access to welfare programs across the four field-sites but also within each site depending on the institutional entry point.
The French health-care system is almost totally under the supervision of the government, which defines the general orientation of health policy. For example, a health-care policy for cancer treatment will be developed in France within the next 5 years. The government organizes the initial formation of all categories of health professionals and so controls the number of professionals in each category. In France, 4500 medical students graduate each year. Demographic problems at the present time are caused by the quota for all medical professions. The government also ensures that the number and location of hospitals are adequate for the needs of the French population. It supervises public hospitals and the management of private clinics, with the objective of providing a consistent standard of care in all health-care structures. The government also proposes the health budget for parliament's approval. In 1996, in line with the concept of decentralization, which means âto think globally but act locallyâ, regional agencies for hospital care were created in each administrative region. They are responsible for the strategic and economic supervision of hospitals, and for the organization of regional health care. However, they have no authority with regard to ambulatory care, thus creating a gap between hospital and ambulatory care in France, which represents a great obstacle to the coordination of care for disabled and elderly people. The French health-care system is a mixed system, being both etatic and liberal. There is a collective health insurance program in place based on incomes; the premium payments are automatically deducted from salaries. The rate is determined each year by the government for an equilibrated budget. Patients have completely free access to all medical care, including hospitals and choice of practitioners. They can have as many consultations and hospitalizations as they want. Furthermore, public and private health structures coexist. Sixty-five percent of hospitals are public and 35% are private. Ambulatory care structures are mainly private (95%). Therefore, although the French system is complex, comprising etatic and private organizations, it functions well. Furthermore, freedom and heterogeneity are probably the main guarantees of quality of health care in France, even if the cost is high and constantly increasing. In France, the number of available hospital beds for acute care (short-stay units), rehabilitation, long-term care and psychiatry is high (Table 1). The rates per 1000 people are the highest in Europe. However, the number of beds for disabled geriatric patients is low: 400 000 beds in retirement homes and 68 000 beds in long-term care units. There is a very long queue to get into such establishments. For psychiatric institutions, there are a total of 6430 beds. The number of health professionals is quite high (Table 2), but they are growing older and demographic problems will arise in the next 10 years. To finance the health-care system, including ambulatory and hospital care, a budget is approved by parliament annually. Ten percent of the gross domestic product (GDP) is devoted to the health-care system (130bn euros), including public hospitals, private hospitals, ambulatory care organizations and pharmacies (Table 3). The budget is being constantly increased. Patients can get a refund of the total cost of health care. For example, refunds for hospitalization costs are between 80% and 100%. For ambulatory care, refunds are between 70% and 100% and for drugs, between 35% and 100%. Health care is free for the homeless and poor people (100% refund). There is a list of 30 severe diseases, including Alzheimer's disease (AD), for which patients are entitled to a 100% refund. Last year, the treatment of AD was listed as a national priority and the government established a care program for the disease. Two main initiatives were proposed. The first one is diagnosis, particularly early diagnosis, as only half of the patients are diagnosed in France. In regard to this, the program proposed the development of memory clinics and regional expert centers. The second initiative is to provide better care for people with AD. This covers ethical issues, the possibility of family caregivers benefiting from some help, financial aid, and the creation of social day-care centers. Hospital care for people with AD is totally paid for by the social security system. Various options are available: short-stay units, rehabilitation units, and day hospitals (of which there are too few) for diagnosis and rehabilitation. Furthermore, people with AD are generally not very welcome in traditional short-stay and rehabilitation units, and it is very difficult to get them a place in such units. Memory clinics are being developed and regional expert centers will be created next year to assist in the early diagnosis of the disease. An expert center must meet specific defined criteria. It must have a multidisciplinary team (neurologists, geriatricians, psychiatrists, and neuropsychologists) and a day hospital for disease diagnosis (capable of handling at least 100 new patients a year). It must also be a source of expertise in research, possess postgraduate knowledge about dementia, and be the centre of a network including general practitioners, ambulatory neurologists and memory clinics of the first degree. Ambulatory care for people with AD is provided by neurologists and psychiatrists (both in insufficient numbers), and by general practitioners, who are not accurately trained for dementia care. Very few geriatricians are included in ambulatory care. Nurses, orthophonists, and physiotherapists are also involved, but again, they are insufficient in number. In other words, social day-care centers should be developed. Social support for patients is financed by a new prestation, the âAPAâ (personalized prestation for the promotion of autonomy). This prestation was defined in 2002. The amount of the prestation is calculated according to the loss of autonomy. Patients are classified into six groups upon evaluation of their autonomy. It is possible for patients to buy the time of professional social workers and caregivers. The highest level of financial aid they can obtain is 1200 euros per month. Today, 50% of patients are being looked after only by family caregivers. Nursing homes are currently evolving in France. Retirement homes and long-term care units now belong to a single category. The total living expenses comprise three parts: food and housing costs are borne by the patients (through family or social aid); nursing costs are covered by the APA prestation and patients (or their families); and the total cost of medical care is covered by social security (100%). In conclusion, the French health-care system is quite unique since it involves both etatic and liberal organizations. It is an excellent system for patients because of low medical costs, but it requires a high cost of maintenance.
Carlos Centeno, S. Hernansanz, Luis Alberto Flores, Ălvaro 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 workersâ and employersâ 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 systemâs 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.