Health systems in transition最新文献

This analysis of the Croatian health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Croatia has a mandatory social health insurance system with nearly universal population coverage and a generous benefits package. Although per capita spending is low when compared to other EU countries, the share of public spending as a proportion of current health expenditure is high and out-of-pocket payments are low. There are sufficient physical and human resources overall, but some more remote areas, such as the islands off the Adriatic coast and rural areas in central and eastern Croatia, face shortages. While the Croatian health system provides a high degree of financial protection, more can be achieved in terms of improving health outcomes. Several mortality rates are among the highest in the EU, including mortality from cancer, preventable causes (including lung cancer, alcohol-related causes and road traffic deaths) and air pollution. Quality monitoring systems are underdeveloped, but available indicators on quality of care suggest much scope for improvement. Another challenge is waiting times, which were already long in the years before 2020 and are bound to have increased as a result of the COVID-19 pandemic.

This analysis of the Slovene health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Slovenia has a statutory health insurance system with a single public insurer, providing almost universal coverage for a broad benefits package, though some services require relatively high levels of co-insurance (called co-payments in Slovenia). To cover these costs, about 95% of the population liable for cost-sharing purchases complementary, voluntary health insurance. Health expenditure per capita and as a share of GDP has increased slightly, but still trails behind the EU average. Among statutory health insurance countries, Slovenia is rather unique in that it relies almost exclusively on payroll contributions to fund its system, making health sector revenues vulnerable to economic and labour market fluctuations, and population ageing. Important organizational changes are underway or have been implemented, especially in prevention, primary, emergency and long-term care. Access to services is generally good, given wide coverage of statutory health insurance. Further, Slovenia has some of the lowest rates of out-of-pocket and catastrophic spending in the EU, due to extensive uptake of complementary voluntary health insurance. Yet long waiting times for some services are a persistent issue. Though population health has improved in the last decades, health inequalities due to gender, social and economic determinants and geography remain an important challenge. There is variation in health care performance indicators, but Slovenia performs comparatively well for its level of health spending overall. As such, there is clear scope to improve health and efficiency, including balancing population needs when planning health service volumes. Recently, the Slovene health care system was overwhelmed by the demand for COVID-19-related care. The pandemicâs longer-term effects are still unknown, but it has significantly impacted on life expectancy in the short-term and resulted in delayed or forgone consultations and treatments for other health issues, and longer waiting times. Additional challenges, which are necessary to address to ensure long-term sustainability, strengthen resiliency and improve the capacity for service delivery and quality of care of the health system include: 1) health workforce planning; 2) outdated facilities; 3) health system performance assessment; and 4) implementation of current LTC reform.

This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Germany's health care system is often regarded as one of the best health care systems in the world, offering its population universal health insurance coverage and a comprehensive benefits basket with comparably low cost-sharing requirements. It provides good access to care with free choice of provider and short waiting times, which is partly due to good infrastructure with a dense network of ambulatory care physicians and hospitals, and a quantitatively high level of service provision. With the largest economy in the EU it is not surprising that Germany spends more than other countries on health, with most financing coming from public funds. The country had the highest per capita spending in the EU in 2018. In relation to overall health expenditure and available resources, a very high number of services is provided across sectors, particularly in hospital and ambulatory care. This can be seen as achieving a considerable level of technical efficiency. Given the high volumes, however, there are questions about the oversupply of services, as well as some comparatively moderate health and quality outcomes; from this perspective, there are signs that there is room for improvement in how the system allocates resources. Additional challenges in the German health system may be identified in: (1) the strong separation of ambulatory and inpatient care in terms of organization and payment, which can hinder the coordination and continuity of patient treatment; (2) the coexistence of statutory health insurance (SHI) and substitutive private health insurance (PHI), which weakens the principle of solidarity; and (3) a complex stewardship framework which promotes incrementalism and makes it more difficult to implement reforms.

The Belgian health system covers almost the entire population for a large range of services. The main source of financing is social contributions, proportional to income. The provision of care is based on the principles of independent medical practice, free choice of physician and care facility, and predominantly fee-for-service payment. The Belgian population enjoys good health and long life expectancy. This is partly due to the population's good access to many high-quality health services. However, some challenges remain in terms of appropriateness of pharmaceutical care (overuse of antibiotics and psychotropic drugs), reduced accessibility for mental health and dental care due to higher user charges, socioeconomic inequalities in health status and the need for further strengthening of prevention policies. The system must also continue to evolve to cope with an ageing population, an increase of chronic diseases and the development of new technologies. This Belgian HiT profile (2020) presents the evolution of the health system since 2014, including detailed information on new policies. The most important reforms concern the transfer of additional health competences from the Federal State to the Federated entities and the plan to redesign the landscape of hospital care. Policy-makers have also pursued the goals of further improving access to high-quality services, while maintaining the financial sustainability and efficiency of the system, resulting in the implementation of several measures promoting multidisciplinary and integrated care, the concentration of medical expertise, patient care trajectories, patient empowerment, evidence-based medicine, outcome-based care and the so-called one health approach. Cooperation with neighbouring countries on pricing and reimbursement policies to improve access to (very high price) innovative medicines are also underway. Looking ahead, because additional challenges will be highlighted by the COVID-19 crisis, a focus on the resilience of the system is expected.

This analysis of the US health system reviews the developments in organization and governance, health financing, healthcare provision, health reforms and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce and a wide range of high-quality medical specialists, as well as secondary and tertiary institutions, a robust health sector research programme and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor measures on many objective and subjective measures of quality and outcomes, and an unequal distribution of resources and outcomes across the country and among different population groups. It is difficult to determine the extent to which deficiencies are health-system related, though it is clear that at least some of the problems are a result of poor access to care. The adoption of the Affordable Care Act in 2010 resulted in greatly improved coverage through subsidies for the uninsured to purchase private insurance, expanded eligibility for Medicaid (in some states), and greater protection for insured persons. Furthermore, primary care and public health received increased funding, and quality and expenditures were addressed through a range of measures such as financial rewards for providing higher-value care. At the same time, a change in political administration resulted in subsequent efforts to scale back the legislation. Many key issues remain, including further reducing the number of uninsured people, alleviating some of the burdensome patient cost-sharing requirements, and considering some new cost-containment methods such as allowing the government to negotiate drug prices with pharmaceutical manufacturers. The direction of future health policy will almost certainly depend on which political party is in power.

This analysis of the Canadian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Life expectancy is high, but it plateaued between 2016 and 2017 due to the opioid crisis. Socioeconomic inequalities in health are significant, and the large and persistent gaps in health outcomes between Indigenous peoples and the rest of Canadians represent a major challenge facing the health system, and society more generally. Canada is a federation: the provinces and territories administer health coverage systems for their residents (‎referred to as "medicare")‎, while the federal government sets national standards, such as through the Canada Health Act, and is responsible for health coverage for specific subpopulations. Health care is predominantly publicly financed, with approximately 70% of health expenditures financed through the general tax revenues. Yet there are major gaps in medicare, such as prescription drugs outside hospital, long-term care, mental health care, dental and vision care, which explains the significant role of employer-based private health insurance and out-of-pocket payments. The supply of physicians and nurses is uneven across the country with chronic shortages in rural and remote areas. Recent reforms include a move towards consolidating health regions into more centralized governance structures at the provincial/ territorial level, and gradually moving towards Indigenous self-governance in health care. There has also been some momentum towards introducing a national programme of prescription drug coverage (‎Pharmacare)‎, though the COVID-19 pandemic of 2020 may shift priorities towards addressing other major health system challenges such as the poor quality and regulatory oversight of the long-term care sector. Health system performance has improved in recent years as measured by in-hospital mortality rates, cancer survival and avoidable hospitalizations. Yet major challenges such as access to non-medicare services, wait times for specialist and elective surgical care, and fragmented and poorly coordinated care will continue to preoccupy governments in pursuit of improved health system performance.

This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employment-based social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution - the Mexican Social Insurance Institute (IMSS) - is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico's health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements. Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.

This analysis of the Norwegian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Norway is among the wealthiest nations in the world, with low levels of income inequality. Norwegians enjoy long and healthy lives, with substantial improvement made due to effective and high-quality medical care and the impact of broader public health policies. However, this comes at a high cost, as the Norwegian health system is among the most expensive in Europe, with most financing coming from public funds. Yet there are several areas requiring substantial co-payments, such as adult dental care, outpatient pharmaceuticals, and institutional care for older or disabled people. Recent and ongoing reforms have focused on aligning provision of care to changing population health needs, including adapting medical education, strengthening primary care and improving coordination between primary and specialist care sectors. There has been an increasing use of e-health solutions, and information and communication technologies. Improvements in measuring performance and a more effective use of indicators is expected to play a larger role in informing policy and planning of health services.