Health systems in transition最新文献

This analysis of the Tajik health system reviews developments in its organization, governance, financing, provision of services, health reforms and health system performance. Tajikistan has made progress in reforming its health system away from the model inherited from the Soviet period, but challenges remain. In 2022 the country had the second lowest health spending per capita in the WHO European Region, and health spending is dominated by private out-of-pocket payments (both formal and informal) which undermines a range of health system goals, including financial protection. A basic benefits package was piloted for over 15 years but ended in 2023, and while a new package is in development it had not been introduced as of August 2024. Public financing depends primarily on regional and local authorities, which contributes to regional inequalities in funding. Health system efficiency is undermined by outdated provider payment mechanisms, although there have been efforts to introduce changes such as partial capitation-based payments. Quality of care is an ongoing concern, with challenges including insufficient health data, underinvestment in infrastructure and equipment, staff turnover, deficiencies in the training of health workers, and limited access to pharmaceuticals. The number of doctors and nurses per population in Tajikistan is lower than in other countries in Central Asia, although the number of nurses has increased in recent years. There is a particularly pronounced shortage of doctors in rural areas and a high rate of medical staff migration. Medical education has been a key area of reform, but family medicine continues to suffer from low prestige. Health reforms have aimed to strengthen primary health care, with other priorities including health financing, regulation and financial protection. Under its current national health strategy, the government is committed to promoting universal health coverage for the population by 2030, and has established strategic priorities for health system development in key areas such as governance, financing, workforce and health service quality. A substantial number of reforms and an increase in government spending will be required to deliver this vision.

The analysis of the Cyprus health care system reviews all developments related to the newly introduced General Healthcare System (GeSY), in particular in relation to its organization and governance, financing, physical and human resources, provision of service and its performance after 4 years of operation. The implementation of the GeSY created a completely new health care environment, bringing together the public and private sectors into a single and competitive quasi market. Major and fundamental changes are being recorded in all health system areas (including administration, financing and remuneration of providers, coverage, access, freedom of choice, benefits, and financial protection) compared to the old system. The main characteristics of the GeSY are the universality of coverage, funding from contributions levied on people's income and the state budget, the provision of an integrated benefits package, including personal and family care through the introduction of general practitioners (GPs)/personal doctors with a gatekeeping role and a referral system to access specialties and hospitals. The GeSY has improved coverage, the available benefits package, access, freedom of choice and financial protection of beneficiaries compared to the previous system. The population of Cyprus has a relatively good health status with high life expectancy, while few older people relative to the European Union (EU) average report having chronic conditions. There are also low levels of unmet need, and the indexes for both preventable and treatable mortality are well below the EU averages. Diabetes, obesity and smoking remain the main health risk factors. Main challenges and areas for development are: a) the reorganization and reform of public hospitals in order to compete with private ones; b) the introduction and use of e-health, including electronic health records, the regulation of data storage and use of bio information; c) the implementation of university clinics in public hospitals; d) the integration of quality and performance indicators into the compensation mechanisms of GeSY providers; and e) the introduction of medical and therapeutic protocols and guidelines. Finally, a major challenge is the financial sustainability of the system in the long term.

This analysis of North Macedonia's health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Life expectancy improved prior to the COVID-19 pandemic, but remains far below the EU average, and the country still struggles with comparatively high levels of morbidity and mor¬tality. The social health insurance system covers almost the entire population and progress has been achieved in providing access to publicly covered essential health services. However, challenges remain for patients in access¬ing health services and in financial protection. Geographical accessibility of services varies, with better access in the capital and major cities compared to smaller towns and rural areas. In terms of health financing, the health system offers universal population coverage for a wide range of benefits and services, which are free at the point of delivery or require only minimal co-payments to prevent overuse. Yet the share of private spending on health as a percentage of current health expenditure is high, which undermines the achievement of key health system goals, such as financial protection, equity and efficiency. The health workforce has been a focus of health reforms and efforts are underway to strengthen education and training to improve the skill mix and competences of the health workforce to respond to new challenges and an ageing population. The ratio of physicians per population has increased markedly in recent years, but remains below the EU average. The priorities for the country in the National Health Strategy 2021-2030 are restructuring the hospital system, continuing the country's primary care reform, and improving quality of care while increasing the efficiency of resource use. Access to medicines has improved, but further efforts are needed to ensure access to innovative medicines and treatments. Overall, the Macedonian health system has made important progress, especially in terms of digitalization of health care and access to e-services and telemedicine, but unmet needs remain an issue. The main outstanding challenges include increasing the responsiveness of the health system to population needs; redistributing resources and activities from hospitals to primary care; ensuring access to medicines; and safeguarding the financial sustainability of the health system.

This review of Luxembourg's health system analyses the country's health organization and governance, financing, health care provision, recent developments and reforms, as well as the system's performance. Luxembourg's statutory health insurance system ensures a comprehensive benefits basket for a large share of the population. Although health care accessibility is high in Luxembourg, administrative considerations, such as the requirement to possess an official address or the lack of automatic third-party payment mechanisms for several services, still constitute significant barriers for vulnerable populations to access care. Overall, Luxembourg performs well on health outcomes, although indicators on behavioural risk factors and socioeconomic disparities remain sources of concern given their adverse impact on population health. Historically, Luxembourg's health system legislation has been fragmented but the recent merger in 2023 of two ministries to compose the Ministry of Health and Social Security (known by the abbreviation M3S) sets a path towards more cohesive health care planning, legislation and financing. Nevertheless, elements of accountability and transparency in health policy-making still pose important challenges. Considering its small size, Luxembourg's health care system is highly centralized and the health infrastructure is well distributed. However, the country relies heavily on a foreign-trained health workforce, which raises concerns about the accessibility of care and may undermine the maintenance of high standards of quality of care for complex medical procedures if the retention of skilled medical professionals is not safeguarded. Hence, Luxembourg has been focusing on developing further initial education programmes for its health professionals, as well as developing a digital health care workforce registry and legal framework to encourage multiprofessional collaboration and task-shifting opportunities. Finally, despite efforts to enhance the sustainability of the health system via reforms for better cost containment, increased investments in preventive services and refinement of hospital services, overall efficiency could be improved. Luxembourg has one of the highest per capita expenditures on health compared with other countries with similar health system and population health outcomes and lacks a mechanism for priority setting in budget allocation, incentives for efficiency improvements, and an enhanced focus on prevention.

This analysis of the health system of the Caribbean Netherlands reviews developments in governance, organization, financing and delivery of care, health reforms and health system performance on the islands of Bonaire, St Eustatius and Saba (the BES islands). Since the dissolution of the Netherlands Antilles in 2010, residents of the BES islands live in special municipalities of the Netherlands, each with its own government (public entity). The Ministry of Health, Welfare, and Sport (VWS) in The Hague, through the Department of Care and Youth Caribbean Netherlands (ZJCN), oversees the health system and the mandatory, centrally financed health insurance scheme. The publicly funded system had per capita spending on health (US$ 6 471) below that of the European Netherlands (US$ 6 729) in 2022; without logistical costs of referrals (accommodation and ground transportation, flight tickets, per diem allowances), per capita health spending on the BES islands was US$ 5 895, though these levels have not been adjusted for purchasing power parity. Cost-sharing within the public system is low, but voluntary insurance for uncovered services is unavailable, and data on out-of-pocket payments are unknown. Limited on-island care capacity necessitates many off-island referrals to cross-border contracted providers, which are fully covered by insurance. Challenges include recruiting and retaining qualified staff, although an agreement with Amsterdam University Medical Center helps to provide specialist care in the hospital on Bonaire. Besides primary and secondary care, there are long-term, dental and mental care facilities. Each island has at least one pharmacy, and protocols are in place for off-island care needs. The next development stage aims for an "equivalent" level of services as in the European Netherlands, improving from the "acceptable" standard set post-2010. Poverty is higher on the BES islands than in the European Netherlands. Health risks include limited access to fresh foods, physical inactivity and behaviours like alcohol and tobacco use, highlighting the need for better disease prevention and health promotion. Although life expectancy at birth was higher on the BES islands in 2019 than in the European Netherlands, data on health outcomes and system performance indicators are lacking. Enhancing evidence-based interventions and comparisons with the European Netherlands, other Dutch Caribbean islands and the wider Caribbean region can support future planning and health system assessments.

This review of the Spanish health system analyses recent developments in health organization and governance, financing, health care provision, recent reforms and health system performance. Overall health status continues to improve in Spain, which presents the highest life expectancy in the European Union - although some socioeconomic inequalities in health persist and risk factors such as overweight, tobacco and alcohol consumption and illegal drug use remain a concern. The Spanish national health system (SNS) provides universal coverage, and it is mainly funded by taxes. Health competences are transferred to the regions, while the Ministry of Health is responsible for the overall coordination of the SNS. Health spending has seen a large increase as a percentage of GDP, following the COVID-19 pandemic in 2020, remaining high in 2021 (10.8% of GDP). While the benefits package is comprehensive, cost-sharing is required for pharmaceuticals and some prostheses; nonetheless, out-of-pocket (OOP) payments do not result in catastrophic spending for households. Co-payments have been largely reformed with further exemptions in place since 2020. Primary care remains at the centre of the SNS, with the Family Doctor 1 acting as the gatekeeper to specialized and hospital care. The 2019 Strategic Framework for Primary and Community Care aims for primary care to adapt to and address new epidemiological, societal and technological challenges that have emerged over the last decade. Regarding provision of care, there is a shortage of physicians in some specialties and problems in covering vacancies in some rural areas of the country, particularly for primary care physicians. Health system reforms since 2018 have focused on widening the population covered by the health system, reducing co-payments, improving the scope of coverage in terms of increasing provided services, and the reinforcement of primary care. Future challenges for the health system include addressing access gaps, such as the limited coverage of some services (such as dental and optical care), and large waiting lists for some services. Some gaps in efficiency remain, such as the low numbers of qualified personnel in some medical specialties, the shortage of mental health resources, the underuse of effective treatments, and the overuse of non-appropriate or ineffective procedures.

This analysis of the Danish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Population health in Denmark is good and improving, with life expectancy above the European Union (EU) average but is, however, lagging behind the other Nordic countries. Denmark has a universal and tax-financed health system, providing coverage for a comprehensive package of health services. Notable exclusions to the benefits package include outpatient prescription drugs and adult dental care, which require co-payment and are the main causes of out-of-pocket spending. The hospital sector has been transformed during the past 15 years through a process of consolidating hospitals and the centralization of medical specialties. However, in recent years, there has been a move towards decentralization to increase the volume and quality of care provided outside hospitals in primary and local care settings. The Danish health care system is, to a very high degree, based on digital solutions that health care providers, citizens and institutions all use. Ensuring the availability of health care in all parts of Denmark is increasingly seen as a priority issue. Ensuring sufficient health workers, especially nurses, poses a significant challenge to the Danish health system's sustainability and resilience. While a comprehensive package of policies has been put in place to increase the number of nurses being trained and retain those already working in the system, such measures need time to work. Addressing staffing shortages requires long-term action. Profound changes in working practices and working environments will be required to ensure the sustainability of the health workforce and, by extension, the health system into the future.

This analysis of the Estonian health system illustrates recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In general, Estonia spends less per capita on health than the European Union average, although public expenditure has been growing steadily, with an increasing role of government budget transfers towards the social health insurance model. Despite these efforts, more than a fifth of current health expenditure comes from out-of-pocket payments, creating pressure to develop new and strengthen existing financial protection instruments. Life expectancy in Estonia has increased rapidly over the past decade, but not fast enough to meet the targets set in strategic documents. The first years of the COVID-19 pandemic were marked by a decline in life expectancy and high excess mortality, which set back progress. Despite this, Estonia's gains in population health were more pronounced in 2022. Overall, health inequalities between socioeconomic groups remain high, prompting policymakers to take steps to increase equity in access to care. The outstanding challenges for the Estonian health system include: addressing the shortage of primary and mental health experts, especially given the growing burden of chronic conditions and other needs of the ageing population; minimizing stark socioeconomic inequalities in health outcomes; renewing the outdated public health framework; and further improving integration and coordination of care and clinical decision-making.

The Health Systems in Transition (‎HiT)‎ country reports provide an analytical description of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiTs are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This analysis of the Swedish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. This series is an ongoing initiative and material is updated at regular intervals.

An indispensable prerequisite for answering research questions in health services research is the availability and accessibility of comprehensive, high-quality data. It can be assumed that health services research in the coming years will be increasingly based on data linkage, i.e., the linking, or connecting, of several data sources based on suitable common key variables. A range of approaches to data collection, storage, linkage and availability exists across countries, particularly for secondary research purposes (i.e., the use of data initially collected for other purposes), such as health systems research. The main goal of this review is to develop an overview of, and gain insights into, current approaches to linking data sources in the context of health services research, with the view to inform policy, based on existing practices in high-income countries in Europe and beyond. In doing so, another objective is to provide lessons for countries looking for possible or alternative approaches to data linkage. Thirteen country case studies of data linkage approaches were selected and analysed. Rather than being comprehensive, this review aimed to identify varied and potentially useful case studies to showcase different approaches to data linkage worldwide. A conceptual framework was developed to guide the selection and description of case studies. Information was first identified and collected from publicly available sources and a profile was then created for each country and each case study; these profiles were forwarded to appropriate country experts for validation and completion. The report presents an overview of the included countries and their case studies (Chapter 2), with key data per country and case study in the appendices. This is followed by a closer look at the possibilities of using routine data (Chapter 3); the different approaches to linkage (Chapter 4); the different access routes for researchers (Chapter 5); the use of data for research from electronic patient or health records (Chapter 6); foundational considerations related to data safety, privacy and governance (Chapter 7); recent developments in cross-border data sharing and the European Health Data Space (Chapter 8); and considerations of changes and responses catalysed by the COVID-19 pandemic as related to the generation and secondary use of data (Chapter 9). The review ends with overall conclusions on the necessary characteristics of data to inform research relevant for policy and highlights some insights to inspire possible future solutions - less or more disruptive - for countries looking to expand their use of data (Chapter 10). It emphasises that investing in data linkage for secondary use will not only contribute to the strengthening of national health systems, but also promote international cooperation and contribute to the international visibility of scientific excellence.