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Welfare Reform on the Web (May 2007): Healthcare - overseas

Advocacy coalitions and health politics in Korea

H.-J. Kwon

Social Policy and Administration, vol. 41, 2007, p. 148-161

After the Asian economic crisis of 1997-98 social policy in Korea changed direction. The developmentalist paradigm, which subordinated social protection to the goal of economic development, had been dominant since the 1960s. After the crisis, the Korean government placed a stronger emphasis on social protection than ever before. The health care reform integrated fragmented health funds within the National Health Insurance (NHI) system into one national fund in 2000. This change aims to widen the risk pool of health insurance and to enhance equity by redistributing financial responsibility for the NHI. These reforms were due not only to the economic crisis but to the work of an advocacy coalition which had evolved since the 1960s. This article looks at the evolution of the advocacy coalition for equity in health policy and how it developed the two attributes necessary for successful policy change: institutional strength and the elaboration of policy rationale for reform.

An analysis of the supplementary health sector in Brazil

E. Fernandes and others

Health Policy, vol.81, 2007, p. 242-257

Health services in Brazil are provided in two ways: publicly, through the Unified Health System and privately by operators which sell supplementary health insurance plans. This study presents an assessment of the performance of companies in the supplementary sector. Low levels of public investment in health care lead to people acquiring health plans, which they cannot afford, aimed solely at providing basic services which should be available to all citizens. The supplementary health sector is thus now making up for the deficiencies of the public health system. This is financially unsustainable and leads to market distortion.

Complementary health insurance in France. Who pays? Why? Who will suffer from public disengagement?

B. Saliba and B. Ventelou

Health Policy, vol.81, 2007, p. 166-182

Today in France just over 90% of the population is covered by complementary health insurance. The French National Health Insurance System is universal and compulsory, but it reimburses only 75% of overall individual healthcare costs. The remaining 25% consists of co-payments for medical goods and services that are covered not at all or very poorly by the public system and for provider charges in excess of the maximum allowable amounts. To deal with these gaps individuals and employers can buy complementary insurance policies. This study explored why people without employer coverage decide to buy complementary insurance and the factors related to choice of policy quality.

Factors affecting primary care physicians’ perceptions of health system reform in Israel: professional autonomy versus organizational affiliation

R. Gross, H. Tabenkin and S. Brammli-Greenberg

Social Science and Medicine, vol. 64, 2007, p. 1450-1462

Health care reform in Israel, implemented in January 1995 with the enactment of the National Health Insurance Law, created a regulated market that embodies many of the principles of managed competition. Since the implementation of the NHI Law, the health plans (which are managed care organizations) have taken administrative steps to improve efficiency and restrain spending. These have included cost containment programmes affecting the practice patterns and professional autonomy of primary care physicians, who are the health plans’ principal workforce. This paper examines primary care physicians’ perceptions of the NHI Law using data from a postal survey to which 800 responded. Findings indicate that most physicians support the Law and loss of professional autonomy following the reform did not significantly affect attitudes towards national health insurance.

Factors influencing implementation of the Community Health Fund in Tanzania

P. Kamuzora and L. Gilson

Health Policy and Planning, vol. 22, 2007, p. 95-102

The Community Health Fund was introduced in Tanzania in 1995. It is a district-level voluntary prepayment scheme, introduced in parallel with user fees at public health facilities, that targets the 85% of the population living in rural areas and/or employed in the informal sector. However, enrolment in the scheme by the target population has been very low due to a widespread inability to pay membership contributions, the poor quality of the available services, a failure among communities to see the rationale for protecting against the risk of illness, and a lack of trust in scheme managers. Findings also suggest that district managers’ actions influenced the way the scheme was implemented and contributed to generally low enrolment rates.

The fiscal crisis of national health insurance in the Republic of Korea: in search of a new paradigm

S. Kwon

Social Policy and Administration, vol. 41, 2007, p. 162-178

National Health Insurance (NHI) in Korea is a social insurance system with universal population coverage. In 2001 it experienced a serious financial crisis as its accumulated surplus was depleted. The system recovered fiscal balance temporarily thanks to a short term increase in government subsidy. However the fundamental problem remains: health care expenditure has increased more rapidly than has the revenue from insurance contributions. As well as raising insurance contributions, efficiency in health care delivery needs to be improved through reform of the payment system for providers. However, increasing insurance contributions is unpopular with the public and payment system reform will run into determined opposition from the medical establishment. Korea needs to empower consumers in the decision-making processes of the NHI to counteract the overwhelming influence of the medical profession.

A gendered analysis of labour market informalization and access to health in Chile

J. Gideon

Global Social Policy, vol. 7, 2007, p. 75-94

In Latin America an increasing number of women combine low paid, insecure work in the informal sector of the economy with caring for children and elderly relatives. Declining employment conditions and an increased burden of caring are leading to greater health risks for these women. These developments have occurred alongside trends towards privatisation of health care and individualised health insurance programmes. For many workers in the informal sector, contributing to a health insurance scheme is not feasible.

The German patient

G. Bousfield

Public Finance, Apr. 20th-26th 2007, p. 24-25

The German government has introduced NHS-style central funding into the German healthcare system. The reform has provoked furious opposition from the public, the medical profession, and the country’s 252 public health insurance companies. The government is persisting as it argues that the present social insurance based funding system is unsustainable.

Globalisation, rural restructuring and health service delivery in Australia: policy failure and the role of social work?

M. Alston

Health and Social Care in the Community, vol.15, 2007, p. 195-202

Inland rural areas of Australia are besieged by problems of rapid population ageing, poorer health and education standards than urban dwellers, increasing indigenisation, loss of employment opportunities and declining community cohesion. Governments at both Commonwealth and state level have responded to global pressures by pursuing neoliberal policies, introducing a market-driven approach to service delivery, and championing the need for self-reliance among citizens. The result for rural Australia has been a withdrawal of services at a time of increased need. This paper addresses the social work response to these challenges.

Health human resources policy in the 21st century: addressing the complexities of who does what in a Canadian context

S. Birch and I.L. Bourg Ault (editors)

Canadian Public Policy, vol. 33, Jan. 2007, supplement, 99p.

This special issue presents a wide range of contributions to some of the key problems associated with health human resource management in Canada, covering:

  • Limitations of approaches currently used to determine future requirements for health human resources
  • Job satisfaction and future job intentions among nurses
  • Challenges presented by collaborative models of health care delivery
  • Workforce implications of marketisation of home care services
  • Growing need for formal home care services to support disabled elderly people
  • Productivity of physicians

Human resource development in the public sector: the case of health and social care

S. Sambrook and J. Stewart (editors)

London: Routledge, 2007

Across Europe and the world, countries are attempting to develop their health and social care policies and practices to address the global challenge of increasing demand and pressurized supply, created by ageing populations, emerging technologies and finite financial and human resources. This book provides examples of attempts to develop HRD practices in health and social care contexts in Ireland, the Netherlands, Romania, Russia, the UK and the USA, providing a comprehensive survey of human resource development research and practice in public and voluntary health and social care organizations around the world. The book explores workplace learning, management development, evaluation of learning and development and wider organizational issues including organizational learning, culture and values and organizational commitment.

Impact of a generic substitution reform on patients’ and society’s expenditure on pharmaceuticals

K. Andersson and others

Health Policy, vol.81, 2007, p. 376-384

The total expenditure on prescription drugs more than doubled in Sweden between 1990 and 2000. In order to contain costs mandatory generic substitution was introduced on October 1st 2002. This study investigated whether the implementation of generic substitution was associated with changes in patients’ expenses and reimbursed cost of prescribed drugs included in the Swedish Pharmaceutical Benefits Scheme. Results showed that the introduction of generic substitution was associated with a shift in trend from an increase into a decrease for both patients’ and public expenditure, indicating that the reform has had an impact on the growth in costs of pharmaceuticals.

Incorporation of public hospitals: a “silver bullet” against overcapacity, managerial bottlenecks and resource constraints? Case studies from Austria and Estonia

A.H. Fidler and others

Health Policy, vol.81, 2007, p. 328-338

This paper presents a decade of experience in Austria and Estonia of restructuring and reorganising hospitals. It demonstrates in two case studies that hospital incorporation and market incentives combined with public ownership have the potential to introduce more cost-efficient and flexible management into hospitals while offering at the same time a politically acceptable solution to stakeholders. In both Austria and Estonia the hospital sectors have undergone fundamental restructuring and face further organisational change to reduce costs, achieve efficiencies and improve service quality. In Austria, the primary focus was on horizontal integration of municipal hospitals through the establishment of holding companies in most of the nine states. In Estonia all hospitals (public or private) were incorporated under company or foundation (trust) law and several hospitals were merged into larger integrated organisations.

Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala

T.J. Bossert, D.M. Bowser, and J.K. Amenyah

Health Policy and Planning, vol.22, 2007, p. 73-82

There is no consensus on whether centralised or decentralised logistics systems are more efficient and effective in moving essential medicines down the supply chain to service delivery points and end users. This study analysed “decision space” (degree of choice) of local officials and found that less choice (ie more centralised) was associated with better management of two key functions, inventory control and information systems, while more choice over planning and budgeting (ie more decentralised) was associated with better performance. It was also found that the procurement process in Guatemala, where firms and prices were fixed by national tender, was associated with positive performance, while the “cash and carry” cost-recovery procurement process in Ghana was associated with negative indicators. The study suggests that logistics systems can be effectively decentralised for some functions while others should remain centralised.

Is the new health-care executive an entrepreneur?

W. van der Scheer

Public Management Review, vol. 9, 2007, p. 49-65

The need to contain costs has caused the Dutch government introduce market mechanisms into the health sector. In consequence the role of health care managers is changing and they are increasingly addressed as entrepreneurs. This article presents the results of a survey of health care executives that was designed to elicit their understanding of entrepreneurship in health care and to find out how they coped with the new ideal. The study also explored the relationship between the discourse and actual practice of entrepreneurship.

Negotiating antiretroviral drug prices: the experience of the Andean countries

E. S. Vazquez and R. Rodriguez-Monguio

Health Policy and Planning, vol. 22, 2007, p. 63-72

This study analyses the effect of the Andean countries’ June 2003 negotiation of antiretroviral drug prices. Results show that the negotiation did achieve lower prices and higher quality and bioequivalence standards for these drugs. However, in general the public healthcare programmes of the six countries analysed did not purchase from companies that participated in the negotiation, nor did they base purchases on the prices or quality and bioequivalence criteria established in the negotiation. It is concluded that successful multinational price negotiations require the implementation of common technical standards, the coordination of procurement processes of participant programmes, and the negotiation of final acquisition prices resulting in contractual obligations to the participants.

Pathways of influence on equity in health

B. Starfield

Social Science and Medicine, vol. 64, 2007, p. 1355-1362

An increasing number of studies are documenting the existence of inequities in health, and attention is now turning to the pathways through which they are generated and might be attacked. This commentary briefly reviews past research which may have relevance to pathways, considers what those pathways might include, and concludes with suggestions for future research.

(For responses see Social Science and Medicine, vol. 64, 2007, p. 1363-1372)

A pricing policy towards the sourcing of cheaper drugs in Cyprus

S. Merkur and E. Mossialos

Health Policy, vol. 81, 2007, p. 368-375

In contrast to other EU member states, 43% of the population in Cyprus are not insured for pharmaceutical care and pay out of pocket for all medicines. Due to the small size of the country and the small indigenous pharmaceutical industry, most drugs are imported. Prices in the private sector are based on the ex-factory price from the country of origin. Distribution margins are calculated as a percentage of the import price, which creates perverse incentives for wholesalers to import drugs from high price countries in order to maximise their profits. This article compares drug prices in Cyprus to those in other EU countries and finds them to be high. It then proposes a new pricing system to change wholesaler incentives and encourage them to shop around for the best buy in Europe.

Rethinking prevention in primary care: applying the chronic care model to address health risk behaviours

D.Y. Hung and others

Milbank Quarterly, vol. 85, 2007, p. 69-91

The Chronic Care Model (CCM) was originally developed as a comprehensive framework for managing chronic illness with support from the Robert Wood Johnson Foundation in the USA. The CCM identifies six essential elements of a system that facilitates high quality care: community resources and policies, good organisation of care, self-management support, effective delivery system design, decision support and clinical information systems. This study offers an empirical analysis of whether the CCM can be expanded beyond chronic disease management to serve also as a framework for primary care practices to address health risk behaviours.

SA HealthPlus: a controlled trial of a statewide application of a generic model of chronic illness care

M. Battersby and others

Milbank Quarterly, vol. 85, 2007, p. 37-67

In 1997 Australia’s governments began trials of coordinated care to develop and test models of service delivery for chronic conditions. The SA HealthPlus trial of coordinated care demonstrated that the health and well-being of some patients with chronic and complex conditions can be improved through patient-centred care involving GPs working with a service coordinator and using a 'problems and goals' approach and a structured evidence-based care plan. The two-year trial was unable to demonstrate a sufficient reduction in hospital admissions to pay for the costs of coordinated care. A longitudinal study is required to better assess individual health changes and the effects of service substitution on costs and hospitalisation rates when multiple strategies at the individual and system levels are introduced in a short time frame.

Unaffordable healthcare amid phenomenal growth: the case of healthcare protection reform in China

C.-K. Wong, K.-L. Tang and V.I. Lo

International Journal of Social Welfare, vol. 16, 2007, p. 140-149

In 1998 the Chinese government introduced a new Basic Health Insurance scheme for urban residents. This scheme covers only very basic health care costs, while expensive diagnostic procedures and medicines have to be paid for out-of-pocket by patients. This research shows that the reformed urban health care system is financially sustainable, but that individual citizens contribute the largest share of expenses, while the state has reduced its input in spite of strong economic growth. This has made healthcare unaffordable for large sections of the population.

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