Snapshots of Health Systems

European Observatory on Health Systems and Policies

The state of affairs in 16 countries in summer 2004 edited by Susanne Grosse-Tebbe and Josep Figueras Document number: WHO/EURO:2004-850-40585-54563

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2 Contents

Acknowledgements ...... 4 Austria...... 6 Belgium...... 11 Denmark ...... 15 Finland...... 18 France ...... 21 Germany ...... 25 Greece ...... 29 Ireland ...... 33 Israel ...... 37 Italy ...... 41 Luxembourg ...... 44 The Netherlands...... 47 Portugal ...... 50 Spain ...... 53 Sweden ...... 56 The United Kingdom of Great Britain and Northern Ireland...... 59

3 European Observatory on Health Systems and Policies Acknowledgements

The Snapshots of health systems - the state of affairs in 16 countries in summer 2004 provide very brief overviews of the organization and ﬁ nancing of the health systems, the provision of health care as well as developments prior to 1 May 2004 in 15 European Union Member States and Israel. The reports have been written by staff of the European Observatory on Health Systems and Poli- cies, with much appreciated contributions of national experts:

Austria: Annette Riesberg with contributions of Reinhard Busse (European Observatory on Health Systems and Policies), Maria Hofmarcher (Institute for Advanced Studies, Vienna) and the Austri- an Federal Institute for Health Care; Belgium: Nadia Jemiai with contributions of Dirk Corens (Centre for Health Economics and Hos- pital Policy, VUB, Brussels); Denmark: Susanne Grosse-Tebbe with contributions of Signild Vallgarda (University of Copenhagen, Copenhagen); Finland: Vaida Bankauskaite with contributions of Jutta Jaervelin (STAKES, Helsinki); France: Sara Allin with contributions of the Ministry of Health and Social Protection, Paris; Germany: Annette Riesberg with contributions of Reinhard Busse (European Observatory on Health Systems and Policies); Greece: Christina Golna with contributions of the Ministry of Health and Social Solidarity, Athens; Ireland: David McDaid with contributions of Eamon O’Shea (National University of Ireland); Israel: Sara Allin and Sarah Thomson with contributions of Bruce Rosen (Brookdale Institute, Je- rusalem); Italy: Susanne Grosse-Tebbe with contributions of Francesco Taroni (Agenzia Sanitaria Regionale, Bologna) and the Ministry of Health, Rome; Luxembourg: Nadia Jemiai with contributions of Michele Wolter (Ministry of Health, Luxem- bourg), Marianne Scholl (Inspection générale de la securité sociale, Luxembourg) and Jean-Paul Juchem (Union of Sickness Funds, Luxembourg); Netherlands: Jonas Schreyoegg with contributions of Peter Achterberg (RIVM, Centre for Public Health Forecasting, Bilthoven) and Lejo van der Heiden (Ministry of Health, Welfare and Sport, The Hague); Portugal: Susanne Grosse-Tebbe and Josep Figueras with contributions of Vaida Bankauskaite (Eu- ropean Observatory on Health Systems and Policies); Spain: Susanne Grosse-Tebbe and Hans Dubois with contributions of Rosa Urbanos (Spanish Ob- servatory on Health Systems, Madrid); Sweden: Hans Dubois with contributions of Catharina Hjortsberg (Swedish Institute for Health Economics, Lund); 4 European Observatory on Health Systems and Policies Acknowledgements

United Kingdom: Nadia Jemiai with contributions of David McDaid (European Observatory on Health Systems and Policies and the departments responsible for health of England, Wales and Scotland. The reports were edited by Susanne Grosse-Tebbe and Josep Figueras. The summaries presented also form part of WHO Regional Offi ce for Europe’s Highlights’ series 2004. The European Observatory on Health Systems and Policies is very grateful to the Highlights team of the Division of Evidence and Communication, WHO Regional Offi ce for Europe, especially Anca Dumitrescu and Barbara Legowski for the opportunity to contribute to the project. The snapshots of health systems draw on the Observatory’s Health Care Systems in Transi- tion (HiT) series of published profi les and summaries as well as drafts underway. The HiTs are country based reports providing a comprehensive analytical description of a country’s health system and of reform initiatives in progress or under development. The HiTs form a key ele- ment of the work of the European Observatory on Health Systems and Policies. The Observa- tory is a unique undertaking that brings together the World Health Organization Regional Of- fi ce for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the European Investment Bank, the Open Society Institute, the World Bank as well as the Lon- don School of Economics and Political Science and the London School of Hygiene and Trop- ical Medicine. This partnership supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe. The Observatory team is led by Josep Figueras, head of the Secretariat, and the research direc- tors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination and produc- tion of the reports was managed by Susanne Grosse-Tebbe, with the support of Jo Woodhead and Mary Stewart Burgher (copy editing) and Jesper Rossings (lay out). The reports refl ect the information available in summer 2004.

European Observatory on Health Systems and Policies Snapshots of health systems Austria The Federal Ministry of Health and Women is the main policy- maker in health care, responsible for supervising the statuto- groups of unemployed as well as ry health insurance actors and is- asylum seekers). The 26 statuto- suing nationwide regulations for ry health insurance funds are or- example on drug licensing and ganized in the Federation of Aus- pricing. The nine Länder govern- Organizational structure trian Social Security Institutions ments deliver public health serv- of the health system and do not compete with each ices and have strong competenc- The Austrian health system is other since membership is main- es to ﬁ nance and regulate inpa- shaped by statutory health in- ly mandatory and based on occu- tient care. Capacity planning insurance that covers about 95% pation or domicile. Since 2001 creasingly has been undertak- of the population on a manda- family coinsurance has required en by a structural commission at tory and 2% on a voluntary ba- a (reduced) contribution but federal level and nine commis- sis. Of the 3.1% of the popula- many household members re- sions at Länder level and is gradu- tion not covered in 2003, 0.7% main exempt for example chil- ally being extended to all sectors had taken out voluntary substi- dren, child-raising spouses or in- and types of care. tutive insurance, while 2.4% had dividuals in need of substantial no cover at all (for example some nursing care.

Fig. 1. Public and private expenditure on health as percentage of the gross domestic product (GDP) in the prior to May 2004 15 European Union Member States (EU-15) and Israel Israel 6,1 2,6 Luxembourg 4,9 1,1 Ireland 4,9 1,6 Finland 5,3 1,7 Spain 5,4 2,1 United Kingdom 6,2 1,4 Austria 5,3 2,7 Italy 6,3 2,1 Public Denmark 7,1 1,3 Private Sweden 7,4 1,3 The Netherlands 5,7 3,2 Belgium 6,4 2,5 Portugal 6,3 2,9 Greece 5,2 4,2 France 7,2 2,4 Germany 8 2,8

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

7 Snapshots of health systems Austria 2004

Health care fi nancing In 2000, 43% of total expend- Sickness funds contract with and expenditure iture was fi nanced from social individual physicians on the ba- In 2002 Austria spent 7.7% of its security schemes, 27% from sis of negotiations between the gross domestic product (GDP) government, 19% were paid via funds and medical associations on health and ranked below the user charges or direct payments, at Länder level. Contracted phy- prior to May 2004 15 Europe- 4% from other private funds and sicians in private practice are re- an Union Member States aver- 7% from voluntary health in- imbursed by per capita fl at rates age (fi gure 1).Total health ex- surance. Financing of statutory for basic services and fee-for- penditure remained stable be- health insurance differs among service remuneration for services tween 1997 and 2002; the sickness funds but is always beyond these. The split between share of public expenditures de- based on contributions repre- these components and possi- creased from 5.8% in 1995 to senting equal shares from em- ble volume restrictions may vary 5.4 % of GDP in 2002, account- ployers and employees, account- by speciality and Land and part- ing for 67% of the total expend- ing for 7.4% of salary in 2004. ly by the type of health insurance iture in that year. The rise in pri- Ceilings for maximum income fund. For visits to non-contracted vate expenditures was attributa- and contributions apply. Blue- physicians the health insurance ble mainly to an increase in di- collar workers paid higher con- funds reimburse their SHI-in- rect payments and co-payments. tribution rates than white-col- sured at 80% of the regular con- Calculated in US$ PPP (pur- lar workers until 2003. Rates for tracted rate per billed service. chasing power parity in US dol- civil servants, the self-employed Since 1978, hospital care has lars) expenditure per capita was and farmers still differ from the been fi nanced from funds at US$ 2220 (table 1). main contribution rate. Länder level with separate divisions for recurrent and invest- Table 1. Total expenditure on health per capita US$ ment expenditures. Since 1997 PPP (Public and Private) hospital care has been fi nanced from funds at Länder level with 2001 2002 separate divisions for recurring Austria 2 174 2 220 and investment expenditures. Belgium 2 441 2 515 The funds are fi nanced by federal, Länder and district govern- Denmark 2 523 2 580 ments and, most importantly, by Finland 1 841 1 943 lump sums from health insurance funds. France 2 588 2 736 Public and not-for-profi t hospi- Germany 2 735 2 817 tals that are accredited in hospital Greece 1 670 1 814 plans for acute care at Länder level (“fund hospitals”) are eligible 2 059 2 367 Ireland for investments and reimburse- Israel 1 623 1 531 ment of services for individu- Italy 2 107 2 166 als covered by SHI. Introduced in 1997, the performance-orient- Luxembourg 2 900 3 065 ed payment scheme consists of a Netherlands 2 455 2 643 core component of national uni- Portugal 1 662 1 702 form diagnosis-related groups (DRG) and a steering system to Spain 1 567 1 646 account for hospital characteris- Sweden 2 370 2 517 tics. The latter may vary consid- erably between Länder. Fund hos- United Kingdom 2 012 2 160 pitals derive additional income US $ PPP: purchasing power parity in US dollars from co-payments, supplementa- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional ry insurance or their owners. Pri- Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

8 Snapshots of health systems Austria 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 vate for-profi t hospitals may con- tory health insurance funds de- by fund hospitals accredited in tract selectively with health in- liver secondary outpatient and hospital plans or by private for- surance funds and then be reim- dental care. General practition- profi t hospitals. In 2001, 28% bursed according to DRGs. ers coordinate care and referrals of beds were provided by pri- Long-term nursing care ben- and serve as formal gatekeepers vate hospitals and 73% by fund efi ts are fi nanced mainly from to inpatient care, except in emer- hospitals owned by municipali- federal taxes. They are granted to gency cases. In practice, howev- ties, the Länder and religious or about 4% of the population, re- er, patients often access outpa- other not-for profi t organiza- gardless of income, on the basis tient clinics directly. A co-pay- tions. While the numbers of hos- of seven categories of need that ment for this type of service did pital beds have been reduced to depend on the hours of nursing not impact substantially on fund 6.1 beds per 1000 population in care required per month. Pooling revenues and care-seeking behav- 2002, the density of beds in Aus- and allocation of benefi ts is car- iour and was abolished in 2003. tria remains high compared with ried out by the statutory pension The number of outpatient con- the EU 15 average (table 2). Ad- funds. tacts was 6.8 per person in 2002. mission rates have increased fur- Public health authorities deliver ther and reached the highest Health care provision antenatal care, child health care share in Europe at 29 cases per Self-employed providers in sin- and screening services, many of 100 population in 2002. This gle practice deliver most pri- which are fi nanced by statutory may be attributable in part to mary and secondary outpatient health insurance. the introduction of the new DRG care. Outpatient clinics owned Acute secondary and terti- system that attracted surgery cas- by hospital providers or statu- ary inpatient care is provided es, which previously had been

9 Snapshots of health systems Austria 2004 dealt with in ambulatory care, to ly in urban areas. Major political inpatient care. At the same time, debates also are concerned with average length of stay was re- strategies to curb the (growing) duced from 13 days in 1990 to 6 defi cits of health insurance funds days in 2002 when the occupan- and to secure the revenue basis cy rate was 76%. of the statutory health insurance The number of physicians in- system. creased continuously to 3.3 per 1000 population in 2002, similar The Austrian summary was written to Germany but below the EU-15 by Annette Riesberg (European Ob- average. The ratio of nurses to in- servatory on Health Systems and Pol- habitants also increased to 5.9 per icies) with contributions of Rein- 1000 but ranks substantially be- hard Busse (European Observatory on low neighbouring countries or Health Systems and Policies), Maria the EU-15 average (table 2). Hofmarcher (Institute for Advanced Studies, Vienna) and the Austrian Fed- Developments & issues eral Institute for Health Care. The vast majority of the Austrian The text draws on the HiT for Austria population has access to a com- of 2001 and work in progress. prehensive set of statutory benefi ts in preventive, curative, pal- liative and long-term care, based on the principles of solidarity and risk pooling. The Minis- try of Health and Women aims to expand the HI coverage of asylum-seeking immigrants. Qual- ity management initiatives have been intensifi ed and patient om- budsmen have been introduced in all nine Länder to handle and report complaints in all sectors of care in order to increase the responsiveness of services. Recently cost-containment has targeted rising pharmaceutical expenditures by introducing price cuts, new price categorization schemes, margins for wholesal- ers and pharmacists and measures to increase the low rate of generic prescribing. Despite substantial achievements in downsizing hospital beds and shifting acute capacities to nursing, geriatric and pallia- tive care, acute bed capacities and utilization remain high by Eu- ropean comparisons, particular-

10 European Observatory on Health Systems and Policies Snapshots of health systems Belgium Substitutive health insurance covers 80.2% of the self-employed for minor risks. Sick- managed sickness funds. Patients ness funds offer complementa- have free choice of provider, hos- ry health insurance to their in- pital and sickness fund. sured. Private for-profi t insur- A comprehensive benefi t pack- ance remains very small in terms Organizational structure age is available to 99% of the of market volume but has risen of the health system population through compulsory steadily as compulsory insurance Belgium has a health care system health insurance. Reimbursement coverage has decreased. based on a compulsory social by individual sickness funds de- The federal government reg- health insurance model. Health pends on the nature of the serv- ulates and supervises all sec- care is publicly funded and main- ice, the legal status of the provid- tors of the social security sys- ly privately provided. The Nation- er and the status of the insured. tem, including health insur- al Institute for Sickness and Disa- There is a distinction between ance. However, responsibility bility Insurance oversees the gen- those who receive standard reim- for almost all preventive care eral organization of the health bursements and those who ben- and health promotion has been care system, transferring funds efi t from higher reimbursements transferred to the communities to the not-for-profi t and privately (vulnerable social groups). and regions.

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

11 Snapshots of health systems Belgium 2004

Health care fi nancing through voluntary health insur- tween the National Committee and expenditure ance premiums. of Sickness Funds and providers’ Statutory health insurance is fi - In 2002, total health expendi- representatives. Other health care nanced mainly through income ture was above the prior to May professionals are mainly salaried. contributions from employers 2004 EU 15 average and account- Hospitals obtain most of their fi - and employees. There are differ- ed for 9.1% of its gross domes- nance through a dual structure: a ent schemes for salaried workers tic product (GDP), 71,4% came fi xed prospective lump sum for and the self-employed although from public sources (fi gure 1). accommodation services and a these will merge by July 2006. Calculated in US$ PPP (purchas- fee-for-service payment for med- Currently, these two schemes ing power parity in US $), health ical and technical services. receive extra funding in parts care expenditure amounted to of the value added tax revenue. US$ 2515 per capita (table 1). Health care provision Sickness funds are funded partly A fi xed annual budget for com- Private sole general practitioners through a risk adjusted prospec- pulsory health insurance and sec- and specialists deliver most pri- tive budget, partly retrospective- toral target budgets are set at fed- mary care. There is no referral sys- ly on the basis of their individu- eral and community level. Health tem. In 2002 the average number al share of total expenditure. Fur- care delivery in Belgium is main- of physician contacts per person ther state subsidies are allocat- ly private: most doctors, dentists, was relatively high at 7.3, com- ed for administrative costs. Pa- pharmacists and physiotherapists pared to an EU 15 average of 6.2. tients fi nance 19.1% of health are self-employed and paid on a In 2002 Belgium had 4.6 acute expenditure mostly through fee-for-service basis. The fees are hospital beds per 1000 popula- out-of-pocket payments but also negotiated at national level be- tion, above the EU 15 average of 3.8 (table 2). In 2003 there were Table 1. Total expenditure on health per capita US$ 218 not-for-profi t hospitals, 149 PPP (Public and Private) general and 69 psychiatric. The majority of hospitals (147) are 2001 2002 private. The hospital legislation Austria 2 174 2 220 and the fi nancing mechanism are Belgium 2 441 2 515 the same in both the public and private sector. Between 1980 and Denmark 2 523 2 580 2003 the number of hospitals Finland 1 841 1 943 dropped from 521 to 218 and the average capacity of a hospi- France 2 588 2 736 tal rose from 177 to 325 beds. Of Germany 2 735 2 817 the 218 hospitals, 55% were lo- Greece 1 670 1 814 cated in the Flemish region, 30% in the Walloon region and 15% 2 059 2 367 Ireland in the Brussels region. Israel 1 623 1 531 The communities are respon- Italy 2 107 2 166 sible for health promotion and preventive services, except for Luxembourg 2 900 3 065 national preventive measures. For Netherlands 2 455 2 643 this reason public health policies Portugal 1 662 1 702 and services differ between the French and Flemish Community. Spain 1 567 1 646 In 2002 there were 4.5 physi- Sweden 2 370 2 517 cians per 1000 population (table 2). In the last 30 years staff num- United Kingdom 2 012 2 160 bers in most health care profes- US $ PPP: purchasing power parity in US dollars sions have doubled (or even tre- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional bled) mainly due to a lack of sup- Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

12 Snapshots of health systems Belgium 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 ply-side control. Until recently diem rates to a prospective diag- The effi ciency gains from giv- there was no limit on the number nosis-related groups (DRG) paying greater fi nancial responsibil- of trainees entering these pro- ment scheme has been quite suc- ity to sickness funds have been fessions, resulting in very high cessful in controlling costs. Previ- constrained: since the latter are doctor/population and nurse/ ously based on structural features not allowed to selectively con- population ratios compared with such as the number of accredited tract with providers they only the rest of western Europe. beds, fi nancing now takes account have limited infl uence over pro- of the ‘justifi ed activity of the viders’ behaviour. Developments and is- hospital’. This justifi ed activity is Other measures introduced sues based upon the hospital’s case-mix have aimed at tariff cuts, supply The Belgian health system pro- and the average national length of restrictions and increases in co- vides comprehensive health care stay per DRG. To stimulate day care, payments but these have not yet coverage to almost all the popula- one-day hospitalization is integrat- succeeded in curbing public ex- tion while maintaining a wide de- ed into this calculation. penditures. In this context the di- gree of choice for the insured and In the fi eld of pharmaceutical vision of power between the fed- the providers. Since the 1980s the policy the reimbursement pro- eral and regional government is Belgium Government’s two main cedures were simplifi ed, the revi- regarded as an additional chal- objectives have been cost con- sion process for new and existing lenge. tainment and improving access to medicines was improved and a A system of preferential reim- health care services. reference reimbursement system bursement and social and fi s- In the hospital sector fi nanc- introduced to promote the use of cal exemptions was introduced ing system, the change from per generics. to improve access to health care.

13 Snapshots of health systems Belgium 2004

As the social exemption applies to only certain social categories, and the ﬁ scal exemption provides only for a reimbursement after an average of two years, the system of a ‘maximum invoice’ was introduced. This aims to improve access by limiting payments for health care to a maximum amount for example a family’s out-of pocket expenses. The amount varies according to family income and other socioeco- nomic factors.

The Belgium summary was written by Nadia Jemiai (European Observa- tory on Health Systems and Policies) with contributions of Dirk Corens (Centre for Health Economics and Hospital Policy, VUB, Brussels). The text draws on the HiT on Bel- gium 2000 as well as work in progress on its update to be published in 2005.

14 European Observatory on Health Systems and Policies Snapshots of health systems Denmark well as control the number and location of the privately practising general practitioners. The ly limited role in health care. Its municipalities are responsible for main responsibilities include es- providing services such as nurs- tablishing the goals for national ing homes, health visitors, home health policy; preparing health nurses and school health servic- Organizational structure legislation and regulation in- es. of the health system cluding the supervision of health Denmark has a tax-based, decen- personnel; promoting coopera- Health care fi nancing tralized health system that pro- tion between the different health and expenditure vides universal coverage for all care actors; and providing health In 2002 Denmark spent 8.8% of Danish residents. Hospital care, information. The Ministry of Fi- its gross domestic product (GDP) general practicioners’ (GP) and nance plays a key role in setting on health (fi gure 1), calculated in public health services are free at the overall economic framework US $ PPP (purchasing power par- the point of use. for the health sector. ity in US dollars) this amounted Central government, in the Most health care is funded and to US$ 2580 per capita (table 1). form of the Ministry of the Inte- provided by the counties. These A combination of state, coun- rior and Health, plays a relative- own and run most hospitals as ty and municipal taxes fi nanced

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

15 Snapshots of health systems Denmark 2004

ance schemes. About 30% of the ed group (DRG) payments for 83% of the total expenditure on population purchases VHI in or- patients treated in hospitals out- health care. Central government der to cover the costs of the stat- side their own counties have holds overall fi nancial responsi- utory co-payments. been introduced. DRG payments bility for the health service: local The most signifi cant resource are being introduced gradually in taxes are supplemented by annu- allocation mechanism in Den- all county hospitals and now ac- al state subsidies calculated ac- mark is the annual national budg- count for 20% of expenses. cording to the size of these local et negotiation between the Min- General practitioners’ remu- revenues. In addition, resourc- istry of the Interior and Health, neration is a mixture of quarterly es are transferred between coun- the Ministry of Finance, the As- capitation payments (30% of re- ties and municipalities according sociation of County Councils and muneration) and fees for service. to a formula that takes account of the National Association of Lo- County-licensed specialists are age structures and socioeconom- cal Authorities. This sets overall paid on a fee-for-service basis. ic indicators. limits for the average growth of Public hospital staff receive sala- Private payments accounted county and municipal budgets ries. for 17% of total expenditure on and the levels of funding. health and can be attributed to Public hospital resources are Health care provision out-of-pocket expenses such as allocated mainly through pro- Self-employed health care pro- co-payments for physiotherapy, spective global budgets set by fessionals and municipal health dental care, spectacles and phar- the counties in negotiation with services provide primary health maceuticals as well as contribu- hospital administrators. In addi- care. Privately practising gener- tions to voluntary health insur- tion, since 2000 diagnosis-relat- al practitioners play a key role in the Danish health care system: as Table 1. Total expenditure on health per capita US$ the patient’s fi rst point of con- PPP (Public and Private) tact and as gatekeepers to specialists, physiotherapists and hos- 2001 2002 pitals. Danish residents over 16 Austria 2 174 2 220 have been able to choose from Belgium 2 441 2 515 two general options: Group 1 patients may access a GP free of Denmark 2 523 2 580 charge at the point of use if they Finland 1 841 1 943 accept that this GP acts as a gatekeeper; Group 2 patients may France 2 588 2 736 visit any GP or specialist with- Germany 2 735 2 817 out referral but must pay part of Greece 1 670 1 814 the treatment/ consultation costs then. In 2002 only 1.7% of the 2 059 2 367 Ireland population opted for Group 2, Israel 1 623 1 531 partly due to the extra costs in- Italy 2 107 2 166 volved and partly due to general satisfaction with the GP refer- Luxembourg 2 900 3 065 ral system. Netherlands 2 455 2 643 The counties own and fi nance Portugal 1 662 1 702 the majority of hospitals. Excep- tions include hospitals in the Co- Spain 1 567 1 646 penhagen area and private for- Sweden 2 370 2 517 profi t hospitals, the latter accounted for less than 1% of the United Kingdom 2 012 2 160 total number of hospital beds in US $ PPP: purchasing power parity in US dollars 2002. The number of beds per Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional 1000 population fell from 7.6 in Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002). 1980 to 3.4 in 2001. The general

16 Snapshots of health systems Denmark 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 decline in the number of beds in ment in 1993, contracts and tar- with general political consensus. both general and psychiatric hos- get-based management in hos- The Government has proposed pitals has been associated with a pitals, restructuring delivery on a radical change to the regional large increase in the number of the basis of functional units, administrative structure of Den- outpatient visits. DRG classifi cation, in parts ac- mark to reduce the numbers of In 2002 there were 3.7 phy- tivity-based hospital fi nancing, municipalities and counties/ sicians and 9.7 nurses per 1000 the development of quality indi- regions. The reform is being ne- population (table 2). It is felt that cators and waiting-time guaran- gotiated with the political parties the recruitment of nurses may tees. Most current reform initia- in parliament (June 2004). become increasingly problemat- tives focus on hospitals and inpa- ic as the profession is associat- tient care. ed with low salary levels, a heavy Primary care continues to be a The Danish summary was written workload and poor working con- key strength of the Danish health by Susanne Grosse-Tebbe (European ditions. care system and a source of high- Observatory on Health Systems and level satisfaction for the popula- Policies) with contributions of Sig- Developments & issues tion. Further structural changes, nild Vallgarda (University of Copen- National and local reforms initi- possibly associated with a great- hagen). ated during the last decade have er role for the private sector, are The text draws on the HiT for Den- focused on increasing produc- being considered but the Danish mark of 2001, the HiT summary 2002 tivity and quality and reducing system will remain committed to and work in progress. waiting lists for non-acute care. the welfare ideals of tax fi nanc- These include the introduction ing and universal access to high of a free choice for hospital treat- quality health care, in accord

17 European Observatory on Health Systems and Policies Snapshots of health systems Finland

Health care fi nancing and expenditure issues framework legislation on The Finnish health care system health and social care policy and is mainly tax fi nanced. Both the monitors its implementation. Mu- state and municipalities have the nicipal health committees, coun- right to levy taxes. In 2002 about Organizational structure cils and executive boards plan and 43% of total health care costs of the health system organize health care at local level. were fi nanced by the municipal- Finland has a compulsory tax- Municipalities (444 in 2004) also ities, 17% by the state (mainly based health care system that have responsibility for health pro- through state subsidies), 16% by provides comprehensive cov- motion and prevention, prima- National Health Insurance (NHI) er for the entire resident popu- ry medical care, medical rehabil- and about 24% by private sourc- lation. itation and dental care. The coun- es. Central government and the mu- try is divided into 20 hospital dis- In both absolute and relative nicipalities are the main players in tricts, federations of municipali- terms there has been an over- the organization of health care in ties are responsible for arranging all increase in private fi nancing, Finland. At national level the Min- and coordinating specialized care from 20.4% of total health ex- istry of Social Affairs and Health within their area. penditure in 1980 to 24.3% in

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

18 Snapshots of health systems Finland 2004

Municipalities pay hospitals for ferent levels of care. The personal 2002. This is accounted for by in- the services used by their inhab- doctor system introduced in the creased user charges for munici- itants. Hospital physicians and 1980s includes the requirement pal services, the abolition of tax most doctors in municipal health that doctors see their patients deductions for drugs and other centres are salaried employees. within three days and made sala- medical treatment costs and re- Under the personal doctor sys- ries more workload-related. This ductions in the NHI reimburse- tem, physicians are paid a com- has improved access to GPs and ments for pharmaceuticals. bination of basic salary (approxi- reduced waiting times. Public Total health expenditure (THE) mately 60%), capitation payment health policy has been particular- accounted for 7.3% of Finland’s (20%), fee for service (15%) and ly successful in reducing mortal- gross domestic product (GDP) local allowances (5%). ity and risk factors related to car- in 2002 – for that year the low- diovascular diseases. est among the Nordic countries Health care provision Outpatient and inpatient depart- and lower than the average of the Primary curative care, preven- ments provide secondary and ter- prior to May 2004 15 Europe- tive care and public health serv- tiary care in public hospitals. Acute an Union Member States. In the ices are provided by multidisci- hospitals had 2.3 beds per 1000 same year health expenditure in plinary teams working in pri- population in 2002 (table 2). US $ PPP (purchasing power par- mary health care (PHC) centres. In 2002 there were 3.2 phy- ity in US dollars) was US$ 1943 These publicly owned centres are sicians per 1000 population, per capita (table 1). Public ex- the responsibility of municipali- matching the EU 15 average. At penditure on health was 75.3% ties and play an important role in 21.7 per 1000 population the ra- of THE. guiding patients through the dif- tio of nurses was the highest in western Europe (table 2). The Table 1. Total expenditure on health per capita US$ ageing population is expected PPP (Public and Private) to increase demand on the existing shortage of doctors and other 2001 2002 health personnel. Austria 2 174 2 220 Belgium 2 441 2 515 Developments & issues During the last decades Finland’s Denmark 2 523 2 580 health care system has been very Finland 1 841 1 943 successful in many ways: it provides generally good quality France 2 588 2 736 care, is fairly effi cient compared Germany 2 735 2 817 to other countries and, in overall Greece 1 670 1 814 terms, the Finns are satisfi ed with their system. Reforms are intend- 2 059 2 367 Ireland ed to solve specifi c problems Israel 1 623 1 531 rather than promote major struc- Italy 2 107 2 166 tural changes. The introduction of the personal doctor system in Luxembourg 2 900 3 065 the 1980s was an attempt to ad- Netherlands 2 455 2 643 dress increasing waiting times Portugal 1 662 1 702 for health centre doctors. Since 1997 cost-containment Spain 1 567 1 646 measures have been implement- Sweden 2 370 2 517 ed in response to rising pharmaceutical costs. In 2001 qual- United Kingdom 2 012 2 160 ity guidelines for mental health US $ PPP: purchasing power parity in US dollars care services were negotiated and Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional approved in order to facilitate the Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

19 Snapshots of health systems Finland 2004

20 European Observatory on Health Systems and Policies Snapshots of health systems France 5% of the population. In 2004 an insurance fund was established specifi cally for dependent elderly statutory health insurance funds. people. In 1999 universal health The state sets the ceiling for insurance coverage (CMU) was health insurance spending, ap- established on the basis of res- proves a report on health and so- idence in France (99.9% cover- Organizational structure cial security trends and amends age). of the health system benefi ts and regulation. Complementary VHI has ex- The French health system is There are three main schemes panded signifi cantly over recent based on a national social insur- within the statutory health insur- decades and since the introduc- ance system complemented by ance system. The general scheme tion of CMU in 2000 has been elements of tax-based fi nancing covers about 84% of the popu- available free to those on low in- (especially the General Social Tax lation (employees in commerce comes. VHI covered about 85% - CSG) and complementary vol- and industry and their families). of the population in 2000 and untary health insurance (VHI). The agricultural scheme covers now covers over 95%. The health system is regulated farmers and their families (7.2% The French health system is by the state (parliament, the gov- of the population). The scheme gradually decentralizing from ernment and ministries) and the for self-employed people covers national to regional level. At the

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

21 Snapshots of health systems France 2004

fi xed rate covering all costs ex- same time, power has shifted ion Member States. In 2002 so- cept doctors, these are paid on a from the health insurance funds cial health insurance constitut- fee-for-service basis. Private not- to the state. ed 73.3% of total health expend- for-profi t hospitals can choose iture, the remainder consisted of between the two systems of pay- Health care fi nancing VHI (13.2%), out-of-pocket payment (public or for-profi t). A re- and expenditure ments (9.8%) and national taxes form currently underway aims to In 2002, total expenditure on (3.7%). introduce an activity-linked re- health care in France was esti- Since 1996 parliament has ap- imbursement system and to har- mated at 9.7% of gross domes- proved a national ceiling for monize the fi nancing of the pub- tic product (GDP) and amount- health insurance expenditure lic and private sectors. ed to US $ 2736 per capita when (ONDAM) annually. Once the Self-employed physicians pro- calculated in US $ PPP (pur- overall ceiling is set, the budg- vide the majority of outpatient chasing power parity in US dol- et is divided between four sub- and private hospital services. Pa- lars) (fi gure 1; table 1). Pub- groups: private practice, pub- tients pay direct fees for service lic expenditure constituted 76% lic hospitals, the regions, pri- and are then partially reimbursed of total health expenditure in vate for-profi t hospitals and so- by the statutory health insurance the same year. As shown in fi g- cial care. system. The national agreement ure 1, as a proportion of GDP The main health insurance between doctors and the funds France spends the second high- scheme pays public hospitals specifi es a negotiated tariff. Alter- est amount on health in the pri- through prospective global budg- natively, from 1980 all doctors, or to May 2004 15 European Un- ets. For-profi t hospitals are paid a but since 1990 only those with specifi c qualifi cations, have been Table 1. Total expenditure on health per capita US$ able to join ‘Sector 2’ (currently PPP (Public and Private) about 24% of doctors) which al- lows them to charge higher tar- 2001 2002 iffs. Doctors in public hospitals Austria 2 174 2 220 are paid on a salary basis, since Belgium 2 441 2 515 1986 they have been permitted to engage in part-time pri- Denmark 2 523 2 580 vate practice within their hospi- Finland 1 841 1 943 tals as an incentive to remain in the public hospitals. France 2 588 2 736 Germany 2 735 2 817 Health care provision Greece 1 670 1 814 Self-employed doctors, dentists, medical auxiliaries, around 1000 2 059 2 367 Ireland health centres managed by local Israel 1 623 1 531 authorities and, to a lesser extent, Italy 2 107 2 166 salaried staff in hospitals deliver primary and secondary health Luxembourg 2 900 3 065 care. There is no gatekeeping and Netherlands 2 455 2 643 patients have free choice of doc- Portugal 1 662 1 702 tor. Recent attempts to introduce a gatekeeping system have not Spain 1 567 1 646 been particularly successful, de- Sweden 2 370 2 517 spite fi nancial incentives for both doctors and patients. United Kingdom 2 012 2 160 Hospitals in France are ei- US $ PPP: purchasing power parity in US dollars ther public (65% of all inpa- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional tient beds), private not-for-prof- Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

22 Snapshots of health systems France 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 it (15%) or private for-profi t tegic plans in designated priori- sion of health services, easy ac- (20%). Private for-profi t hospi- ty areas and established a frame- cess to health care for most peo- tals deal mainly with minor sur- work of objectives and targets. ple and, except for some special- gical procedures; public and pri- There are approximately 1.6 ties in certain parts of the coun- vate not-for-profi t hospitals fo- million health care professionals try, the absence of waiting lists cus more on emergency admis- in France, accounting for 6.2% of for treatment. In recent years a sions, rehabilitation, long-term the working population. In 2002 number of reforms have trans- care and psychiatric treatment. there were 3.3 physicians and formed its original characteris- With 8.4 beds per 1000 inhab- 6.9 nurses per 1000 population, tics by increasing parliament’s itants, half of which are acute both fi gures below the EU 15 av- role, replacing employees’ wage- beds, France is close to the EU15 erage (table 2). The distribution based contributions with a con- average. of doctors shows geographical tribution (tax) based on total in- The many actors and sources of disparities favouring Paris and come and basing universal cover- fi nance involved in public health the south of France and urban age on residence rather than em- policy and practice in France lead rather than rural areas. ployment. to a lack of cohesion among the Financial sustainability has been actors and diluted responsibili- Developments and is- a key issue for the French health ties. In March 2003 a new bill sues system since the 1970s. The sys- was proposed to tackle this prob- The French health system is not- tem’s organizational structure lem. It set out a comprehensive ed for its high level of freedom makes it diffi cult to control ex- legislative framework for a public for physicians and choice for penditure and, although relative- health policy that developed stra- patients, plurality in the provi- ly high levels of expenditure on

23 Snapshots of health systems France 2004 health have resulted in patient satisfaction and good health outcomes, cost containment remains a permanent policy goal. Howev- er, during the late 1990s con- cerns for equity led to a major reform (CMU) aimed at remov- ing ﬁ nancial barriers to access but which went against the general trend of cost containment. In May 2004 the conservative government proposed a series of reforms to raise revenue and reduce expenditure, purported- ly to save 15 billion by 2007. The government proposes the introduction of several changes: charge all patients 1 per visit to a doctor; oblige pensioners who can afford it to pay substantially more; raise health care levies on ﬁ rms; reduce waste and over- consumption (particularly of pharmaceuticals); reduce reimbursement of expensive pharmaceuticals; prevent national health insurance card fraud; establish a computerized, personal medical record accessible by any French health care professional to prevent patients from “shopping around”; and continue to move towards gatekeeping. The French health system is in- stitutionally complex leading to tensions between the state, the health insurance funds and providers. In future it will be important to improve relations by clari- fying the responsibilities of these key actors.

The French summary was written by Sara Allin (European Observato- ry on Health Systems and Policies) with contributions of the Ministry of Health and Social Protection, Paris. The text draws on the HiT for France and its summary of 2004.

24 European Observatory on Health Systems and Policies Snapshots of health systems Germany their associations on the purchasers’ side. Hospitals are not represented by any legal corporatist was mandatory for about 77% and institution, but by organizations voluntary for 10%. An addition- based on private law. The actors al 10% of the population took out are organized on the federal as private health insurance; 2% were well as the state (Land) level. Organizational structure covered by governmental schemes The Ministry of Health and So- of the health system and 0.2% were not covered by any cial Security proposes the health The roots of the German health third-party-payer scheme. acts that – when passed by par- system date back to 1883, when The health care system has a liament – defi ne the legislative nationwide health insurance be- decentralized organization, char- framework of the social health came compulsory. Today’s system acterized by federalism and dele- insurance system. It also super- is based on social health insurance gation to nongovernmental cor- vises the corporatist bodies and – and characterized by three co-ex- poratist bodies as the main actors with the assistance of a number isting schemes. In 2003, about in the social health insurance sys- of subordinate authorities – ful- 87% of the population were cov- tem: the physicians’ and dentists’ fi ls various licensing and super- ered by statutory health insurance; associations on the providers’ visory functions, performs scien- based on income, membership side and the sickness funds and tifi c consultancy work and pro-

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

25 Snapshots of health systems Germany 2004 vides information services. gross domestic product (GDP), ernment sources. Private health The 292 sickness funds col- and 79% was covered by pub- insurers fi nanced 8%, employers lect the contributions of the stat- lic funds, giving the country the 4% and non-profi t-making or- utory insurance for health and highest rank among those shown ganizations and households 12%. long-term care. They also negoti- in Fig. 1 and ranking it third Most out-of-pocket payments ate contracts with the health care among countries in the Organ- were spent to purchase over-the- providers. Since 1996 almost eve- isation for Economic Co-opera- counter drugs and to cover co- ry insured person has had the tion and Development (OECD). payments for prescribed drugs. right to choose a sickness fund In the same year, German to- On 1 January 2004, co-payments freely, while funds are obliged tal per capita expenditure, when were introduced for outpatient to accept any applicant. Since calculated in US $ PPP (purchas- visits and raised for virtually all 2004, decision-making in statu- ing power parity in Us dollars), other benefi ts. tory health insurance has been in- amounted to US $ 2817 (ta- The risk-compensation scheme tegrated into a trans-sectoral joint ble 1) and public per capita ex- among sickness funds aims to federal committee that is support- penditure ranked fi fth among the level out differences in the age, ed by an independent institute for OECD countries. sex and health-status structure quality and effi ciency. Of total expenditure, 57% of of those insured through the dif- the funds came from statutory ferent schemes. This system has Health care fi nancing health insurance, 7% from stat- been complemented by a high- and expenditure utory long-term care insurance, risk pool since 2001 and by in- In 2002, health expenditure in 4% from other statutory insur- centives for disease-management Germany comprised 10.9% of its ance schemes and 8% from gov- programmes for the chronically ill since 2003. Table 1. Total expenditure on health per capita US$ In ambulatory physician care, PPP (Public and Private) a regional physicians’ association negotiates a collective contract 2001 2002 with a single sickness fund in the Austria 2 174 2 220 form of a quasi-budget for physi- Belgium 2 441 2 515 cian services. The physicians’ association distributes the funds Denmark 2 523 2 580 among the general practicioners Finland 1 841 1 943 (GPs) and specialists who claim reimbursement mainly on a fee- France 2 588 2 736 for-service basis; limitations of Germany 2 735 2 817 service volumes apply. Greece 1 670 1 814 Hospitals are fi nanced on a dual basis: investments are planned by 2 059 2 367 Ireland the governments of the 16 Länder, Israel 1 623 1 531 and subsequently co-fi nanced Italy 2 107 2 166 by the Länder as well as the federal government, while sickness Luxembourg 2 900 3 065 funds fi nance recurrent expendi- Netherlands 2 455 2 643 tures and maintenance costs. Since Portugal 1 662 1 702 January 2004, the German adap- tation of the Australian diagno- Spain 1 567 1 646 sis-related group (DRG)-system is Sweden 2 370 2 517 the sole system of paying for recurrent hospital expenditures, ex- United Kingdom 2 012 2 160 cept for psychiatric care where US $ PPP: purchasing power parity in US dollars per diem charges still apply. Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

26 Snapshots of health systems Germany 2004

Health care provision and the private sector for 8% of In 2001, salaried employees in in- Ambulatory health care is mainly acute hospital beds in 2001. Al- patient care comprised about half delivered by sickness fund-con- though the number of beds and of the health care workforce. tracted GPs and specialists in pri- average length of stay in acute vate practice. Patients have free hospitals have been reduced sub- Developments and is- choice of physicians, psycho- stantially – to 6.3 beds per 1000 sues therapists, dentists, pharmacists population and 9.3 days in 2001 Since 1990, the health care sys- and emergency care. There is no – Germany still ranks high on tem in the eastern part of Germa- formal gate-keeping system for these indicators among the pri- ny has quickly been transformed GPs (about half of ambulatory or to May 2004 15 European Un- to a Bismarck model of care. By physicians), although their coor- ion Member States (table 2). The 2001, the gap in life expectan- dinating competencies have been traditionally strict separation be- cy between eastern and western strengthened in recent years, and tween ambulatory and hospi- Germany had narrowed to 1.5 sickness funds have been obliged tal care has been eased in recent years for men and 0.5 years for to offer gate-keeping models years by encouraging outpatient women. to their members since January clinics at hospitals, trans-sec- In international comparison, 2004. toral disease-management pro- the German health care system Acute inpatient care is delivered grammes and delivery networks. has a high level of ﬁ nancial re- by a mix of public and private From 1990 to 2002, the sources and physical facilities. providers, with the public sector number of physicians increased The population enjoys equal and accounting for 53%, non-proﬁ t- by 20%. The number of nurses in- easy access to a health care sys- making organizations for 39% creased by 8% in 2001 (table 2). tem offering a very comprehen-

27 Snapshots of health systems Germany 2004 sive benefi ts package at all levels of care; waiting lists and explicit rationing decisions are virtually unknown. There is doubt, however, whether the high spending on health translates into a suffi - ciently cost-effi cient use of resources. Various cost-containment measures – including sectoral budgets, reference prices, rational prescribing and user charges – have kept statutory health expenditure at the level of GDP growth. Yet, since fund revenues grew less than expenditure, sickness funds ran into defi cit in most years, and had to raise their contribution rates in the following year: from a mean of 12.4% of gross salaries in 1991 to 14.3% in 2003. Current discussions focus on two alternative concepts of reforms on the revenue side: either to introduce a fl at-rate health premium for people currently covered by statutory health insurance, with tax support for the poor, or to extend contribution- based insurance to the entire population, including, for example, civil servants and the self- employed.

The German summary was written by Annette Riesberg (European Observa- tory on Health Systems and Policies) with contributions of Reinhard Busse (European Observatory on Health Systems and Policies). The text draws on the HiT for Ger- many and its summary of 2004.

28 European Observatory on Health Systems and Policies Snapshots of health systems Greece cates resources. Seventeen Re- gional Health Authorities (PeS- YPs) are given extensive respon- social cohesion. In addition, 97% sibilities for the implementation of the population is covered by of national priorities at region- approximately 35 different so- al level, coordination of region- cial insurance funds (compulso- al activities and organization and Organizational structure ry SI) and 8% of the population management of health care and of the health care system maintains complementary vol- welfare services’ delivery with- The Greek health care system untary health insurance cover- in their catchment areas. Decen- is characterized by the coexist- age, bought on the private insur- tralization efforts devolved polit- ence of the National Health Serv- ance market. ical and operational authority to ice (NHS), a compulsory social The Ministry of Health and So- Regional Health Authorities but insurance and a voluntary pri- cial Solidarity decides on overall stopped short of granting full fi - vate health insurance system. The health policy issues and the na- nancial responsibility. The PeSYPs NHS provides universal coverage tional strategy for health. It sets were not given individual budg- to the population operating on priorities at the national lev- ets and all fi nancial transactions the principles of equity, equal ac- el, defi nes the extent of funding still have to be validated by the cess to health services for all and for proposed activities and allo- Ministry itself.

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

29 Snapshots of health systems Greece 2004

per capita expenditure in US$ (by fi xed per-diem or per-case Health care fi nancing PPP (purchasing power parity in fees) and the actual cost of the and expenditure US dollars) accounting for 1814 provided services. Health services in Greece are USD (fi gure 1; table 1). 4.5%, i.e. Despite the latest law on prima- funded almost equally by pub- 47,4% of total expenditure ac- ry care (February 2004) that con- lic and private sources. Public counted for private health ex- tains provisions for the gradual expenditure is fi nanced by tax- penditure, the highest percent- establishment of fi nancial and ades (direct and indirect) and com- age in absolute terms in all 15 ministrative autonomy for prima- pulsory health insurance contri- countries and Israel (fi gure 1). ry care centres the latter are cur- butions (by employers and in- The NHS budget is set annu- rently still fi nanced through the sured persons). Voluntary pay- ally by the Ministry of Economy budget of the respective hospital ments by individuals or employ- and Finance based on historical covering their administration. ers represent a very high percent- data. Taxes provide approximate- All NHS staff (doctors, nurses, age of total health expenditure ly 70% of all hospital funding, dentists, pharmacists and tech- (more than 42% in 2002), mak- the remaining 30% are derived nical and administrative support ing the Greek health care system from a mixture of social securi- staff) are salaried government one of the most “privatized” of ty and out-of-pocket payments. It employees. NHS doctors are for- the EU countries. should be noted that tax revenue bidden to practice privately (ex- In 2002, Greece’s expenditure is used often to fi ll the gap be- cept within the hospital premis- on health was 9.5% of gross do- tween the offi cially determined es during out of offi ce (after- mestic product (GDP), with a level of social security funding noon) hours, for which they are compensated on a per-case/ Table 1. Total expenditure on health per capita US$ appointment-basis). Following PPP (Public and Private) the new government’s pre-elec- tion commitment to remove it, 2001 2002 this restriction is currently un- Austria 2 174 2 220 der review. IKA, the largest social Belgium 2 441 2 515 security fund, is mainly responsible for primary health care de- Denmark 2 523 2 580 livery to 5.5 million benefi ciaries Finland 1 841 1 943 through its 350 units. It is currently implementing a pilot pro- France 2 588 2 736 gramme to introduce GPs into Germany 2 735 2 817 the health care delivery structure Greece 1 670 1 814 and is in the process of review- ing a comprehensive GP contract, 2 059 2 367 Ireland based on a mixed capitation- and Israel 1 623 1 531 performance- related remunera- Italy 2 107 2 166 tion system. Luxembourg 2 900 3 065 Health Care Provision Netherlands 2 455 2 643 Primary health care in the pub- Portugal 1 662 1 702 lic sector is delivered through a dual system of primary health Spain 1 567 1 646 care centres and hospital am- Sweden 2 370 2 517 bulatory (outpatient) services that belong to the NHS and United Kingdom 2 012 2 160 IKA primary care units that be- US $ PPP: purchasing power parity in US dollars long to the largest social insur- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional ance fund. Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

30 Snapshots of health systems Greece 2004

Most secondary and tertiary there are still signifi cant patient centres, public hospitals and re- care is provided in 123 gener- fl ows to hospitals in the capital. gional teaching hospitals result- al and specialized hospitals to- In 2001 there were 4.5 prac- ed in a number of signifi cant ad- talling 36 621 beds, and 9 psy- tising physicians per 1000 in- vances in the population’s access chiatric hospitals totalling 3500 habitants, one of the highest ra- to effective health care servic- beds. Public hospitals outside the tios in the EU 15. Meanwhile, de- es and an improvement in vital NHS include 13 military hospi- spite concerted efforts to increase health status indicators. Despite tals fi nanced by the Ministry of the number of nurses at 3.9 per these achievements a number of Defence, 5 IKA hospitals and 2 1000 inhabitants in 1999, this challenges remain, for example: university teaching hospitals. In remains one of the lowest in Eu- drafting a National Action Plan Greece there were 3.9 acute beds rope (table 2) . for Public Health, integrating per 1000 inhabitants in 2000 primary care services, establish- (table 2). Approximately 75% of Developments and issues ing a clear distinction between beds are provided by the pub- In the early 1980s the incep- the purchaser and provider sides lic sector; 243 private hospitals, tion of the NHS coincided with of the health care market, reduc- mainly general hospitals and ma- the introduction of the social- ing the high level of pharmaceu- ternity clinics, account for 25% ist principles of equity, solidarity tical expenditure and the need of all hospital beds. The establish- and equal access to services that to modernize NHS management ment of new regional universi- the newly-elected government by introducing market mech- ty hospitals has counteracted the was trying to infuse in public ad- anisms. The latest NHS reform inequalities in the distribution of ministration. The development of (Law 2889/2001) underpins the hospital beds to some extent, but rural surgeries, primary health effort to introduce private sector

31 Snapshots of health systems efﬁ ciency tools into the NHS, but has remained largely inspiration- al and is currently under review.

The Greek summary was written by Christina Golna (European Observa- tory on Health Systems and Policies) with contributions of the Ministry of Health and Social Solidarity, Athens. The text draws on work in progress on the HiT for Greece to be published in 2005.

32 European Observatory on Health Systems and Policies Snapshots of health systems Ireland contribution towards the cost of most other services. Voluntary health insurance cial services remains with seven (VHI) has played an important regional health boards and the role in the Irish health system for Eastern Regional Health Author- almost 50 years. In 2002 com- ity (ERHA) that serves the Dub- munity rated voluntary health Organizational structure lin area. insurance covered almost 50% of the health system All residents are eligible for all of the population. The Voluntary Ireland’s health care system is services. Category I patients, 29% Health Insurance (VHI) Board, characterized by a mix of public of the population, hold medi- set up in 1957, operates as a not- and private health service fund- cal cards that entitle them to free for-proﬁ t, semi-state private in- ing and provision. The govern- services, particularly in prima- surance body with board mem- ment holds overall responsibili- ry care. The qualiﬁ cation crite- bers appointed by the Minister of ty for the health care system, ex- ria for these cards are largely in- Health and Children. The Board ercised through the Department come- and age-related. Category holds 80 % of the market share. of Health and Children (DOHC). II patients have cover for public Approximately one quarter of the Until January 2005 the provision hospital services, subject to some population have neither a medi- of health care and personal so- capped charges, but must make a cal card nor health insurance. In-

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

33 Snapshots of health systems Ireland 2004 dividuals join VHI because this cording to the Irish Central Sta- ic factors, commitments to service guarantees more immediate ac- tistical Offi ce, in 2002 total ex- provision and national pay poli- cess to some hospital interven- penditure on health amounted cies. The Department also provides tions. Care funded through VHI to 8.2% of gross domestic prod- some direct funding to voluntary may be provided within state, uct (GDP), with 6.6% on pub- hospitals and other service deliv- voluntary sector and private hos- lic expenditure. OECD estimates ery agencies in the voluntary sec- pitals. were 5.5% for public and 1.8% tor. The ERHA enters directly into for private expenditure (fi gure agreements with these agencies. Health care fi nancing 1). This seems low as expendi- and expenditure ture has increased substantially Health care provision The health service remains pre- but is masked by strong econom- General practitioners (GPs) are dominantly tax-funded: approxi- ic growth. US$ PPP (purchas- self-employed, 50% are in sin- mately 75.2% of health expendi- ing power parity in US dollars) gle-handed practices, others in ture came from public sources in per capita expenditure on health partnerships of (typically) two 2002 (fi gure 1). Other expend- care in 2002 was US$ 2367 (ta- or three. The majority treat both iture can be attributed to out- ble 1). private and public patients, and of-pocket payments for prima- Health service funding is deter- enter into contract agreements ry care services, pharmaceuticals mined annually in negotiations to provide services for Category and private hospital treatment as between the Department of Fi- I individuals in return for capi- well as payments to voluntary nance and the DOHC. These budg- tation-based payments for treat- health insurance providers. Ac- ets are infl uenced by demograph- ment. The GPs have a complex gatekeeping role: individuals Table 1. Total expenditure on health per capita US$ who are not entitled to free pri- PPP (Public and Private) mary health care may go to secondary care facilities. There is a 2001 2002 small charge for consultations of Austria 2 174 2 220 non-emergency cases that have Belgium 2 441 2 515 not been referred by a GP. Multi-disciplinary primary care Denmark 2 523 2 580 teams are being developed and Finland 1 841 1 943 are intended to serve a population of between 3000 and 7000 France 2 588 2 736 people depending on wheth- Germany 2 735 2 817 er the location is urban or rural. Greece 1 670 1 814 Between 600 and 1000 primary care teams will be phased in over 2 059 2 367 Ireland 10 years, the fi rst 40 to 60 by the Israel 1 623 1 531 end of 2005. The health boards Italy 2 107 2 166 also are responsible for delivering a range of health promotion Luxembourg 2 900 3 065 and public health services across Netherlands 2 455 2 643 the country, taking account of Portugal 1 662 1 702 both local needs and national strategies for the general popu- Spain 1 567 1 646 lation as well as specifi c groups Sweden 2 370 2 517 such as Travellers. The public hospital sector in- United Kingdom 2 012 2 160 corporates voluntary and health US $ PPP: purchasing power parity in US dollars board hospitals. Health board Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional hospitals are funded directly by Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

34 Snapshots of health systems Ireland 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 the state and administered by the 2000 indicate that private use of Health is a signifi cant sociopo- boards. Public voluntary hospi- beds is higher for elective proce- litical issue that features consist- tals are fi nanced primarily by the dures, at around 30%. In 2002 ently as a source of dissatisfac- state but may be owned and op- there were 3.0 acute care beds tion, particularly among poor- erated by religious or lay boards and 2.4 physicians per 1000 er non-VHI members. Signifi - of governors. In 2000 there population, both below the EU- cant additional resources have were 60 acute hospitals in Ire- 15 average (table 2). With 15.3 been invested, with concerted at- land, 23 of which were located nurses per 1000 population in tempts to reduce the inequalities in the ERHA. In addition there is 2002 the number of nurses is in health outcomes between so- a small number of purely private among the highest in the EU- cioeconomic groups and to im- sector hospitals. Hospital con- 15 (table 2). There is an identi- prove access to and availability sultants are paid on a salaried ba- fi ed need for signifi cantly higher of public health and social care sis for the treatment of public pa- numbers of general practitioners, services. However, the propor- tients. Furthermore, the contracts other primary care workers and tion of the population fully en- permit extensive private practice hospital consultants to imple- titled to free services has been reimbursed on a fee-for-service ment planned reforms and com- decreasing because of econom- basis. ply with the requirements of the ic growth. Private patients are Public/voluntary hospital beds European Working Time Direc- treated more rapidly within pub- are designated for either pub- tive. lic hospitals, especially day cases. lic or private use (80:20 recom- The National Treatment Purchase mended ratio) in order to protect Developments and is- Fund, a major initiative intended access to hospital care. Data from sues to reduce public waiting lists, has

35 Snapshots of health systems Ireland 2004 made some progress by paying private hospitals to treat public patients at high expense but private patients continue to be treated in public hospitals at less than the market rate. Another weak- ness has been the lack of evaluation or an evidence-based approach to resource allocation. The system is now undergoing the most extensive reforms since 1970. The DOHC, all the health boards and ERHA will be abolished. From January 2005 the Health Service Executive (HSE) will manage services as a single national entity, accountable directly to the Minister for Health. It will have three divisions: a Na- tional Hospitals’ Ofﬁ ce (NHO); a Primary, Community and Con- tinuing Care Directorate; and a National Shared Services Centre to promote wider economies of scale. The ongoing Primary Health Care Strategy is delivering multi- sector primary care teams. Signif- icant modernization and reform of mental health care is now under way. Cross border cooperation with Northern Ireland on common health objectives is increasing. Following the 1998 British- Irish (also known as Good Fri- day or Belfast) Agreement, an all Ireland Institute of Public Health has been established and the pos- sibility of a joint air ambulance service examined.

The Irish summary was written by David McDaid (European Observato- ry on Health Systems and Policies) with contributions of Eamon O’Shea (National University of Ireland). The text draws on work in progress on the HiT for Ireland to be published in 2005.

36 European Observatory on Health Systems and Policies Snapshots of health systems Israel Although the Ministry of Health has devolved some central government authori- functioning of the health system. ty to lower administrative lev- Four competing health plans, els through its regional offi c- voluntary not-for-profi t organ- es, it retains substantial author- izations, cover the entire popu- ity at national level. Similarly, al- Organizational structure lation and offer their members a though the health plans have re- of the health system benefi ts package defi ned by leg- gional offi ces, authority remains The Israeli health system is fi - islation. Enrolment is mandatory with the national headquarters. nanced through social insur- but there is free choice of plan. The NHI law has increased gov- ance and taxation and based on About 65% of Israelis have sup- ernment control of the health regulated competition between plementary voluntary health in- system, particularly for the reg- health plans. The introduction of surance (VHI) offered by the ulation of benefi ts and health national health insurance (NHI) health plans, 26% are covered by plan fi nancing. Efforts to transfer in 1995 achieved universal cov- commercial supplementary VHI responsibility for service provi- erage. The Ministry of Health and 20% are covered by both sion from the government to the has overall responsibility for the health plan and commercial sup- voluntary sector have been un- health of the population and the plementary VHI. successful to date.

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

37 Snapshots of health systems Israel 2004

Health care fi nancing an earmarked payroll tax collect- and the age mix. The remaining and expenditure ed by the NHI Institute with ex- 5% is allocated on the basis of the Total expenditure on health care emptions for several groups (for number of health plan members in Israel was estimated to be example pensioners and recipi- with certain diseases (AIDS, end- 8.8% of gross domestic prod- ents of income maintenance al- stage renal disease etc). uct (GDP) in 2002, similar to lowances). Private funding con- Currently, public hospitals (both the average of the prior to May sists of out-of-pocket payments government-owned and not-for- 2004 15 European Union Mem- and VHI. The latter accounts for profi t privately-owned hospitals ber States. Public expenditure ac- about 16% of private spending that together constitute 96% of counted for 68% of total expend- on health care. acute beds) are reimbursed ac- iture on health (fi gure 1). Cal- Each year the government sets cording to fee-for-service charge culated in US $ PPP (purchas- the NHI budget based on the pre- lists for hospital outpatient care in ing power parity in US dollars) vious year adjusted automatical- ambulatory clinics and emergen- the per capita expenditure of US ly for infl ation. It may also be ad- cy departments and by per diem $ 1531 was below the EU 15 av- justed to take account of demo- fees for inpatient admissions and erage (table 1). graphic and technological chang- case payments (diagnostic-relat- In 2000 total health expend- es. The four health plans are allo- ed groups) for about 30 types iture consisted of general tax- cated 95% of public NHI fi nanc- of admission. A hospital revenue ation (46%), the health tax ing on the basis of a capitation cap was established in 1995 to re- (25%) and private sources of fi - formula that takes account of two duce the growth in hospital utili- nance (29%). The health tax is factors: the number of members zation and lower the health plans’ expenditure for services above the Table 1. Total expenditure on health per capita US$ cap. PPP (Public and Private) The largest health plan, Clalit, covers 60% of the population. 2001 2002 Clalit offers primary care from Austria 2 174 2 220 its own clinics with free choice Belgium 2 441 2 515 of physicians. These are paid by salary and monthly capitation Denmark 2 523 2 580 payment based on enrolment. In Finland 1 841 1 943 the other health plans, most primary care physicians work inde- France 2 588 2 736 pendently and are paid on a capi- Germany 2 735 2 817 tation basis based on either actu- Greece 1 670 1 814 al patient visits or enrolment lists (as in Clalit). Community-based 2 059 2 367 Ireland specialists may be salaried or in- Israel 1 623 1 531 dependent (paid on an ‘active’ Italy 2 107 2 166 capitation basis in addition to fee-for-service payments). Hos- Luxembourg 2 900 3 065 pital-based physicians generally Netherlands 2 455 2 643 are paid salaries based on their Portugal 1 662 1 702 clinical/administrative responsibility and years of experience. Spain 1 567 1 646 Sweden 2 370 2 517 Health care provision Access to primary health care United Kingdom 2 012 2 160 has improved substantially in the US $ PPP: purchasing power parity in US dollars past decades. In three out of four Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional health plans, the cost of primary Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

38 Snapshots of health systems Israel 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 care visits to health plan physi- erage length of stay and high ad- and urban-rural discrepancies in cians is covered fully by NHI and mission and occupancy rates. physician density. The number of waiting times are minimal. For all The Ministry of Health oper- nurses (6 per 1000 inhabitants) health plans, primary care physi- ates a Public Health Service that also is close to the EU-15 average cians act as gatekeepers to hos- coordinates regional and district (table 2). pital-based specialists. However, offi ces. Vaccination coverage in members of the small health plans Israel is high. Key issues in public Developments and is- have access to plan-affi liated com- health centre around the low lev- sues munity-based specialists without els of spending (0.8% of nation- Israel’s health system represents prior authorization. The number al health expenditure); devel- a synthesis of government and of outpatient contacts in Israel oping methods for prioritizing market forces; consists of organ- was 7.1 per person in 2000. and funding public health inter- izations that combine funding Approximately 50% of all ventions; and changing owner- and delivery functions; employs acute hospital beds are in gov- ship and modernization of fam- risk-adjusted capitation fi nancing ernment-owned hospitals. Clalit ily health centres (the primary to limit creaming-off by insurers; (33%), private for-profi t hospi- source for screening). has an explicit method of setting tals (5%) and voluntary not-for- Israel has a high physician-pop- priorities and defi ning the ben- profi t hospitals own the remain- ulation ratio (3.7 physicians per efi ts package; and maintains a der. Israeli health care is charac- 1000 population in 2002) that strong focus on equity. terized by a low overall general approximates the EU-15 average The health system is predom- care bed-population ratio of 2.2 of 3.5. However, there are short- inantly publicly funded through (2002) (table 2), a very low av- ages in some medical specialities progressive taxation, provides

39 Snapshots of health systems Israel 2004 broad population coverage and The Israel summary was written by Sara good geographical access to pri- Allin (European Observatory on Health mary health care. However, eq- Systems and Policies) and Sarah Thom- uity remains an issue due to the son with contributions of Bruce Rosen relatively high proportion of pri- (Brookdale Institute, Jerusalem). vate fi nance. While health care is The text draws on the HiT for Israel highly equitable within the pub- 2003 and its summary of 2004. lic system, private health services have expanded in recent years and several important components of health care remain outside the public system – for example, dental care and institutional long-term nursing care. The 1988 Netanyahu Commis- sion critique of the health system stimulated recent reforms that sought to improve effi ciency. Some of these efforts were implemented quite effectively for example introducing NHI and improving patients’ rights, but so far there have been no efforts to reduce government responsibility for health service delivery. Efforts to reform mental health care are underway and it is likely that the foundation has been laid for future improvements in this area. Current issues on the policy agenda include continued fi nancial strain and the need to improve methods of measuring and rewarding quality of care. The challenges facing Israel’s health system include adapting to the special health needs of a large number of immigrants, making effective use of the large number of physicians, ensuring adequate and responsive care to the Arab population and managing the strain on emergency and reha- bilitative services due to a high number of casualties from ter- rorism and confl ict.

40 European Observatory on Health Systems and Policies Snapshots of health systems Italy of health care services at the local level and serve geographical areas with average populations of regions, with a clear cut north- about 300 000. south divide. Under the 2001 reform of the Health care fi nancing Italian constitution, the central and expenditure Organizational structure state and the regions share re- Although one of the principal of the health system sponsibility for health care. The tenets of the 1978 reform was a In 1978 the National Health state has exclusive power to de- quick move toward progressive Service (NHS) was established. fi ne the basic benefi t package fi nancing of the NHS, through- The system aimed to grant uni- (Livelli Essenziali di Assistenza – out the 1990s social health insur- versal access to a uniform lev- LEA) that must be provided uni- ance contributions still made up el of care throughout the coun- formly throughout the country. more than 50% of total public fi - try, fi nanced by general taxa- The 20 regions have responsibil- nancing. In 1998 a regional busi- tion. Universal coverage has been ity for the organization and ad- ness tax replaced social contribu- achieved although there are wide ministration of the health care tions. This tax is supplemented differences in health care and system. Local health authorities by a central grant fi nanced from health expenditure between the are responsible for the delivery value added tax revenues, in or-

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

41 Snapshots of health systems Italy 2004 der to ensure adequate resources counter drugs. Approximately took account of the age structure for each region. 15% of the population has com- and health status of the popula- Out-of-pocket payments cover plementary private health insur- tion. Based on capitation formu- cost-sharing for public services ance that is either individual- la, regions also transfer funds to for example co-payments for di- ly subscribed or offered by em- the local health units (LHUs). agnostic procedures, pharmaceu- ployers. Tertiary hospitals have trust sta- ticals and specialist consultations. In 2002, Italy’s total expend- tus and enjoy expanded fi nancial Since 1993, patients have had iture on health amounted to freedoms. Public secondary hos- to pay for the cost of outpatient 8.5% of gross domestic product pitals are granted some fi nancial care up to a maximum amount (GDP) (fi gure 1); per capita ex- autonomy but remain under the (€36 since 2000). Co-payments penditure in US $ PPP (purchas- control of LHUs. A (diagnosis-re- for drugs and ambulatory spe- ing power parity in US dollars) lated group) DRG-based prospec- cialist services have had a limited was US $ 2166 (table 1). Public tive payment system for inpatients impact, however. In 1996 these sources covered 75% of the costs. is in place, excluding rehabilita- peaked at 4.8% of total NHS rev- Since the introduction of co-pay- tion and long-term care, with the enues but fell to 2.9% in 2002 af- ment schemes private expendi- tariffs defi ned by the regions. ter drug co-payments were abol- ture has increased, reaching 25% Hospital physicians are salaried ished at the national level. in 2002. employees. General practitioners Furthermore, patients need to In 1997 a weighted capitation and paediatricians are independ- pay out-of-pocket for private rate for the regional resource al- ent contractors of the NHS paid health care services and over-the- location was introduced. This mainly on a capitation basis. Re- forms have aimed to provide ad- Table 1. Total expenditure on health per capita US$ ditional incentives for effi ciency: PPP (Public and Private) additional income from fees for specifi c treatments and fi nancial 2001 2002 rewards for effective cost con- Austria 2 174 2 220 tainment. 2 441 2 515 Belgium Health care provision Denmark 2 523 2 580 GPs and paediatricians working Finland 1 841 1 943 as independent contractors to the NHS provide primary health France 2 588 2 736 care. They act as gatekeepers to Germany 2 735 2 817 secondary care. Greece 1 670 1 814 LHUs are responsible for pro- tecting and promoting public 2 059 2 367 Ireland health mainly through disease Israel 1 623 1 531 prevention (especially immuni- Italy 2 107 2 166 zation), health promotion and food control. Specialized serv- Luxembourg 2 900 3 065 ices are provided either direct- Netherlands 2 455 2 643 ly by LHUs, or through contract- Portugal 1 662 1 702 ed out public (61%) and private (mainly not-for-profi t) facilities Spain 1 567 1 646 accredited by LHUs. The number Sweden 2 370 2 517 of beds per 1000 population decreased from 7.2 in 1990 to 4 in United Kingdom 2 012 2 160 2001 (table 2). US $ PPP: purchasing power parity in US dollars There were 6.1 physicians per Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional 1000 population in 2001, among Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

42 Snapshots of health systems Italy 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 the highest ratios in western Eu- tive changes, including the dev- rope. The number of nurses was olution of administrative and fi s- among the lowest in the EU15 at cal responsibilities to the regions. 3.0 per 1000 population in 1989 Remaining challenges concern (table 2). the guarantee of free provision of a basic benefi t package as well Developments and is- as ensuring uniform levels and sues quality of health care across the The inception of the Italian NHS regions. in 1978 represented an ambi- tious, laudable effort to rational- ize and expand public health care The Italian summary was written by services. The initial reform aims Susanne Grosse-Tebbe (European Ob- have been achieved only partially servatory on Health Systems and Poli- due to mounting fi nancial pres- cies) with contributions of Francesco sures and incomplete implemen- Taroni (Agenzia Sanitaria Regionale, tation. The market-oriented re- Bologna) and the Ministry of Health, forms in 1992 and 1993 aimed Rome. to address some of the most The text draws on the HiT for Italy pressing issues. The period be- and its summary of 2001. tween 1997 and 2000 witnessed a series of radical and innova-

43 European Observatory on Health Systems and Policies Snapshots of health systems Luxembourg health insurance coverage, mostly to pay for services that are cat- egorized as non-essential under profession-based funds, manag- the compulsory schemes. es and provides statutory health insurance for 99% of the pop- Health care fi nancing ulation. Civil servants and em- and expenditure Organizational structure ployees of European and inter- Similar to its neighbouring coun- of the health system national institutions have their tries of Belgium, France and Ger- Luxembourg’s health care sys- own health insurance funds; fur- many, Luxembourg’s health care tem is based on three fundamen- thermore, any unemployed per- system is mainly publicly fi nanced tal principles: compulsory health son who is receiving neither un- through social health insurance. insurance, patients’ free choice employment benefi t nor a public In 2000 total health expendi- of provider and compulsory pro- pension is excluded. ture (THE) was funded by stat- vider compliance with the fi xed Voluntary health insurance has utory insurance (72.7%), taxes set of fees for services. always played a limited role in (15.1%), out-of-pocket payments The standard contribution lev- Luxembourg. Nevertheless, ap- (7.7%) and voluntary health in- el is set by the Union of Sickness proximately 75% of the popula- surance (1.6%). THE was estimat- Funds that, together with nine tion purchases complementary ed to be 6.2% of gross domestic

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

44 Snapshots of health systems Luxembourg 2004 product (GDP) in 2002, the low- Luxembourg is very small so Health Care Provision est share among the prior to May few resource allocation decisions Usually providers are contracted- 2004 15 European Union Mem- are delegated to local authori- out. The insured can choose their ber States. Public sources were es- ties. The exceptions are hospital providers freely and any level of timated to account for 86% (fi gure budgets that are negotiated be- care provision that they choose 1). In the same year, health care tween individual hospital admin- (hospital, clinic, etc) is eligible expenditure per capita calculat- istrative boards and the Union of for reimbursement. ed in US $ PPP (purchasing pow- Sickness Funds. On 1 January 2004 there were 14 er parity in US dollars) was US $ Health professionals’ pay- acute care hospitals. One of these, 3065, the highest fi gure among ments are based on a fi xed stat- specialized in maternity services, the EU 15 (table 1). This apparent utory fee level. Individual hospi- is run for profi t. The remaining 13 contradiction can be explained by tals negotiate global prospective are run by local authorities as well two factors: (i) per capita expend- budgets with the Union of Sick- as not-for-profi t and mainly reli- iture calculations are based on the ness Funds. For pharmaceuticals, gious organizations. The number resident population which can be a comprehensive list of drugs of acute care beds decreased from misleading since 25% of Luxem- is approved for use as a nation- 7.4 in 1980 to 5.7 per 1000 popu- bourg’s insured workers are com- al formulary and guide for reim- lation in 2003. muters from neighbouring coun- bursement. It is maintained by Preventive services are the re- tries; and (ii) Luxembourg’s per the Directorate of Health’s Divi- sponsibility of the Ministry of capita GDP is the highest in the sion of Pharmacy. Health. Interventions are pro- EU. vided by public services, private practitioners and not-for-profi t Table 1. Total expenditure on health per capita US$ associations paid from the Min- PPP (Public and Private) istry’s budget. The number of physicians, spe- 2001 2002 cialists and dentists per 1000 Austria 2 174 2 220 population increased during the Belgium 2 441 2 515 1980s and 1990s but remained below the numbers in other Denmark 2 523 2 580 EU15 countries. In 2002 there Finland 1 841 1 943 were 2.6 physicians and 7.8 nurses per 1000 population (ta- France 2 588 2 736 ble 2). The Directorate of Health’s Germany 2 735 2 817 Division of Pharmacy maintained Greece 1 670 1 814 relatively constant pharmacist numbers over this period. Lux- 2 059 2 367 Ireland embourg imports all pharmaceu- Israel 1 623 1 531 tical products and bases most re- Italy 2 107 2 166 tail prices on those determined in the country of origin. Luxembourg 2 900 3 065 Netherlands 2 455 2 643 Developments and is- Portugal 1 662 1 702 sues Luxembourg provides a compul- Spain 1 567 1 646 sory social health insurance sys- Sweden 2 370 2 517 tem under which the insured enjoy access to a comprehensive United Kingdom 2 012 2 160 benefi t package and free choice US $ PPP: purchasing power parity in US dollars of providers. Health care expend- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional iture as a percentage of GDP has Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

45 Snapshots of health systems Luxembourg 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Ofﬁ ce for Europe, health for all database, 2004 remained low over the past dec- While Luxembourg is small in ades compared to other EU15 area and population size it has members. a very high GDP. Therefore, al- The reforms of the 1980s and though cost-containment has 1990s mostly focused on attain- been a priority area on the polit- ing ﬁ nancial stability for the sick- ical agenda it has not been pur- ness funds. The main measures in- sued as urgently as in other Euro- troduced during this period were pean countries. an increase in co-payments, the establishment of the Union of Sickness Funds’ reserve for deal- The Luxembourg summary was writ- ing with any budget imbalance ten by Nadia Jemiai (European Ob- and the transfer of responsibilities servatory on Health Systems and Pol- from individual sickness funds to icies) with contributions of Michele the Union of Sickness Funds. Wolter (Ministry of Health, Luxem- In 1995 a change in the payment bourg), Marianne Scholl (Inspection system was introduced in response générale de la securité sociale) and to spiralling hospital costs: a tariff Jean-Paul Juchem (Union of Sickness scheme with annually negotiat- Funds, Luxembourg). ed global prospective budgets be- The text draws on the HiT for Lux- tween the individual hospitals and embourg of 1999 as well as work in the Union of Sickness Funds. progress on its update to be published in 2005.

46 European Observatory on Health Systems and Policies Snapshots of health systems The Netherlands

65 % of the population, i.e. anyone whose annual salary is below a ceiling (currently 30 700) on one side and private, most- as well as all social security re- ly voluntary health insurance on cipients are insured by sick- the other. The third compartment ness funds (ZFW). Anyone with includes voluntary supplementa- earnings above this ceiling is in- Organizational structure ry health insurance. sured by private health insurance of the health care system The ﬁ rst compartment: under the (WTZ) that covers 28% of the The Netherlands has a health in- Exceptional Medical Expenses Act population. The health insurance surance based system. Three par- (AWBZ) the insurance for excep- schemes for public servants cov- allel compartments of insurance tional medical expenses associat- er another 5% of the total popu- coexist: the ﬁ rst includes a na- ed with either long-term care or lation. tional health insurance for ex- high-cost treatment was set up. The third compartment includes ceptional medical expenses. The Almost everyone living in the forms of care that are considered second compartment compris- Netherlands is covered by this less vital, such as dental care, es different regulatory regimes insurance. prostheses, hearing aids, etc., - compulsory sickness funds for The second compartment is intended and therefore not covered by the persons under a certain income to cover standard medical care. other compartments. The costs in

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

47 Snapshots of health systems The Netherlands 2004 this sector are covered largely by amounted to an expenditure of supplementary private medical Health care fi nancing US$ 2643 per capita (table 1). insurance. and expenditure Sickness funds have a budg- These different compartments Long-term care (AWBZ) is fi - eting system in which they ne- and the systems that constitute nanced by payroll deductions gotiate with providers about the them are steered and supervised and government funds and rep- quality, quantity and (to some by different ministries and have resents 41% of health expendi- extent) price of services. This of- (at least) partly different relation- ture. The ZFW funds for normal fers the funds some fl exibility ships with the insured on one and medical care make up 38% of and provides incentives to pur- the providers on the other side. health expenditure. Aside from chase care as effectively as possi- Over recent years responsibil- these major sources of funding, ble, as well as encouraging mar- ities have shifted from govern- the main complementary sourc- ket competition. Since 2000 hos- ment to the private sector (del- es are private health insurance pital payment has been perform- egation or functional decentralization) (15%) and out-of-pocket pay- ance-related, the fi rst step to- and there has been a transfer of ments (6%). wards changing the hospital pay- competencies from central to Total health care expenditure ment system to a (diagnosis-re- provincial/local governments was estimated to account for lated group) DRG-type treatment (devolution or territorial decentraliza- 9.1% of gross domestic product system. Furthermore, hospitals tion). This is illustrated by the lo- (GDP) in 2002 (fi gure 1). Cal- receive additional budgets for cal and provincial governments’ culated in US $ PPP (purchasing major capital expenditures. Phy- increased infl uence on planning. power parity in US dollars) this sicians in specialist training are salaried employees of the hospi- Table 1. Total expenditure on health per capita US$ tals. GPs are paid on a per capita PPP (Public and Private) basis for patients insured under the ZFW and on a fee-for-service 2001 2002 basis for the privately insured. Austria 2 174 2 220 Belgium 2 441 2 515 Health care provision Primary health care is well-de- Denmark 2 523 2 580 veloped and provided mainly by Finland 1 841 1 943 general practicioners (GPs). Each patient is supposed to enrol with France 2 588 2 736 one GP who acts as a gatekeeper Germany 2 735 2 817 for specialist and inpatient care. Greece 1 670 1 814 The majority of medical problems (2/ of all ambula tory care con- 2 059 2 367 3 Ireland tacts) are treated by family physi- Israel 1 623 1 531 cians so the referral rate is low. Italy 2 107 2 166 Most secondary and tertiary care is provided by medical specialists Luxembourg 2 900 3 065 in hospitals with both outpatient Netherlands 2 455 2 643 and inpatient facilities. More than Portugal 1 662 1 702 90% of the hospitals are private, not-for-profi t facilities, the rest are Spain 1 567 1 646 mainly public university hospitals. Sweden 2 370 2 517 Hospitals are classifi ed as general (100), teaching (8) and special- United Kingdom 2 012 2 160 ist hospitals (28). Hospitals have US $ PPP: purchasing power parity in US dollars increased their capacity through Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional mergers or expansion despite the Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

48 Snapshots of health systems The Netherlands 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Ofﬁ ce for Europe, health for all database, 2004 required decrease in beds in each nurses (2001) per 1000 popula- cussed. The new health insurance region. In 2001 3.1 acute beds per tion worked in the Dutch health scheme to be set up would 1000 population were available system (table 2). combine statutory and private (table 2). The so-called “transmu- (voluntary) health insurance in ral care” sector, introduced in the Development and issues one single mandatory scheme. early 1990s to bridge the organi- A prominent trend over the last Parliament, including the biggest zational and ﬁ nancial gap between decade has been the shift of re- opposition party, supports the ambulatory and institutional care, sponsibility for purchasing care health insurance reforms and continues to grow. from government to insurers. these are scheduled to come into Public health is organized at There has also been a trend to- effect on 1 January 2006. municipal or district level and wards more competition between supervised and monitored at re- providers of care. Efforts are made gional and national level by the to combine market and non-mar- The Netherlands summary was writ- Health Care Inspectorate. The ket elements in health care. ten by Jonas Schreyoegg (European leading theme of public health There are ongoing discus- Observatory on Health Systems and services has been strengthe ning sions about whether health in- Policies) with contributions of Peter preventive policies. Emphasis is surance should be merged into Achterberg (RIVM, Centre for Public placed on longer and healthy one system. Furthermore, re- Health Forecasting, Bilthoven) and Lejo lives/lifestyles as well as reduc- form of the health insurance sys- van der Heiden (Ministry of Health, ing health inequalities. tem with a per capita, risk-inde- Welfare and Sport, The Hague). According to WHO estimates pendent premium instead of a The text draws on the HiT for the in 2002 3.2 physicians and 13.3 percen tage contribution are dis- Netherlands and its summary of 2004.

49 European Observatory on Health Systems and Policies Snapshots of health systems Portugal gional level. In practice, however, RHA autonomy over budget setting and spending has been tion is covered by the health sub- limited to primary care. systems, 10% by private insurance schemes and another 7% by Health care ﬁ nancing mutual funds. and expenditure Organizational structure The Ministry of Health is re- The NHS is funded predomi- of the health system sponsible for developing health nantly through general taxation. The Portuguese health system policy as well as managing the Employer (including the state) is characterized by three co-ex- NHS. Five regional health ad- and employee contributions are isting systems: the National ministrations (RHAs) imple- the main funding sources of the Health Service (NHS), special so- ment the national health pol- health subsystems. In addition, cial health insurance schemes for icy objectives, develop guide- direct payments from patients certain professions (health sub- lines and protocols and super- and voluntary health insurance systems) and voluntary private vise health care delivery. Decen- premiums account for a large health insurance. The NHS pro- tralization efforts have aimed at proportion of funding. vides universal coverage. In ad- shifting ﬁ nancial and manage- In 2002 Portugal’s expenditure dition, about 25% of the popula- ment responsibility to the re- on health amounted to 9.3% of

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

50 Snapshots of health systems Portugal 2004 its gross domestic product (GDP) plans put forward by the Min- such as overtime constitute sig- (fi gure 1). Calculated in US $ istry of Health. The Ministry of nifi cant additional sources of in- PPP (purchasing power pari- Health allocates a budget to each come. An experimental payment ty in US dollars) this accounted RHA for the provision of prima- system for groups of GPs/family for US$ 1702 per capita (table ry health care to a geographi- doctors based on capitation and 1). As a percentage of GDP (1.4% cally defi ned population. Public professional performance was in 2001) Portugal has the high- hospitals are fi nanced through introduced in 1999 and is under est level of public expenditure on case-mix adjusted global budg- revision. pharmaceuticals in the prior to ets drawn up by the Ministry May 2004 EU-15. In 2002 pri- of Health. Since 1997 a grow- Health care provision vate health expenditure accounting proportion of the budget has GPs/ family doctors working in ed for 29% of total expenditure, been based on diagnosis-related the HCs deliver most primary refl ecting a large share of out-of– groups (DRG) and on non-ad- health care in the public sector. pocket payments (including co- justed outpatient activity. Prima- GPs act as gatekeepers so there payments). These co-payments ry health care centres (HCs) are is no direct access to second- and the heavy reliance on indi- fi nanced by the RHAs and have ary care. The number of outpa- rect taxes make the funding sys- neither fi nancial nor administra- tient contacts per person (3.4 in tem slightly regressive. tive autonomy. 1998) is among the lowest in the The NHS budget is set annu- All NHS doctors are salaried European Region. ally by the Ministry of Finance government employees. Private Secondary and tertiary care is based on historical spending and practice and additional payments provided mainly in hospitals, although some health centres still Table 1. Total expenditure on health per capita US$ provide specialist ambulatory PPP (Public and Private) services. There is an uneven distribution of health resources be- 2001 2002 tween the regions, however, hos- Austria 2 174 2 220 pitals in rural/inland areas have Belgium 2 441 2 515 benefi ted from a programme of additional investments in recent Denmark 2 523 2 580 years. Finland 1 841 1 943 In 1998 Portugal had 3.3 acute hospital beds per 1000 popu- France 2 588 2 736 lation, approximately 75% of Germany 2 735 2 817 which were provided in the Greece 1 670 1 814 public sector. Of the 205 hospitals, 84 were private and half of 2 059 2 367 Ireland them were for-profi t. Non-clini- Israel 1 623 1 531 cal services often are outsourced Italy 2 107 2 166 to the private sector. Private providers also deliver most diagnos- Luxembourg 2 900 3 065 tic and therapeutic services in the Netherlands 2 455 2 643 ambulatory sector. Portugal 1 662 1 702 In 2001 there were 3.3 physicians per 1000 population. The Spain 1 567 1 646 Portuguese ratio of nurses to in- Sweden 2 370 2 517 habitants has increased steadily but remains one of the lowest in United Kingdom 2 012 2 160 Europe (3.9 in 2001) (table 2). US $ PPP: purchasing power parity in US dollars Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

51 Snapshots of health systems Portugal 2004

Developments and is- of challenges remain for the Por- The Portugal summary was written sues tuguese health care system. These by Susanne Grosse-Tebbe and Josep In the early 1970s Portugal was include low effi ciency and ac- Figueras with contributions of Vaida one of the fi rst European coun- countability in comparison with Bankauskaite (all European Observa- tries to adopt an integrated ap- other NHS-based systems; high tory on Health Systems and Policies). proach to primary health care levels of private expenditure; high The text draws on the HiT for Por- through the development of levels of pharmaceutical expendi- tugal and its summary of 2004. a comprehensive network of ture; inequities in the health sec- health centres. This resulted in tor; and the need to modernize signifi cant advances in the pop- the organizational structure and ulation’s health status such as the management of the NHS. After dramatic decline in infant mor- a fi rst attempt in the recent past, tality since the 1960s. The reform there appear to be good prospects agenda since 2002 has included for developing a comprehensive measures to reduce surgical wait- health strategy for Portugal. ing lists; innovations in the management of hospitals and primary HCs; positive changes in drug policy and a stronger role for the private sector. Despite the remarkable achievements in health policy, a number

52 European Observatory on Health Systems and Policies Snapshots of health systems Spain health care provision. It has legislative power, sets up information systems and assures cooperation Civil servants are free to opt for between national health author- coverage under one of the three ities and the autonomous com- publicly funded mutual funds. munities. The Ministry also is re- Private insurance companies pro- sponsible for inter-territorial and Organizational structure vide complementary health care international health issues and of the health care system coverage and increasingly cover publishes comparative reports The Spanish health care system services outside the basic pack- (benchmarking and highlighting is tax-based. During the last two age. Often they are bought also ‘best practice’). decades responsibility for health to avoid waiting lists. In 2003, The autonomous communities care largely has been devolved 18.7% of the population pur- decide how to organize or pro- to Spain’s 17 regions - the au- chased private insurance poli- vide health services and imple- tonomous communities. The Na- cies. ment the national legislation. The tional Health Survey of 1997 The Spanish Ministry of Health inter-territorial council (Conse- showed population coverage to and Consumer Affairs establishes jo Interterritorial del Sistema Nacion- be 99.8%, including the low-in- norms that deﬁ ne the minimum al de Salud - CISNS) is composed come and immigrant population. standards and requirements for of representatives of the autono-

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

53 Snapshots of health systems Spain 2004 mous communities and the state relatively large fi scal autonomy. was relatively low at 71.4% of administration and promotes the Public fi nancing is complement- total health expenditure (fi gure cohesion of the Spanish health ed by out-of-pocket payments to 1). system. The municipalities’ role the public system (for example The autonomous communi- is limited to complementary co-payments for pharmaceuti- ties have varying hospital pay- public health functions linked to cals), as well as to the private sec- ment mechanisms. Traditionally hygiene and the environment. tor (for example private outpa- hospital expenditures have been tient care) and contributions to retrospectively reimbursed, with Health care fi nancing voluntary insurance. no prior negotiation and no for- and expenditure Spain has one of the lowest lev- mal evaluation. During the last The health care system is fi - els of health expenditure in the two decades the use of contract- nanced out of general taxation prior to May 2004 15 European programmes with prospective fi - (for example VAT and income Union Member States. In 2002, nancing of target activities has tax) and regional taxes. The rate expenditure in US $ PPP (pur- increased, this is especially the of taxation at the regional level chasing power parity in US dol- case in the private hospital sec- may be modifi ed up to a thresh- lars) was estimated to amount to tor. old fi xed by the national govern- US $ 1646 per capita (table 1), Most physicians are employed ment. Some autonomous com- total health care expenditure ac- by the public sector and receive munities also receive grants from counted for 7.6% of gross do- fi xed salaries. the central state; País Vasco and mestic product (GDP). In the Navarra, for example have gained same year public expenditure Health care provision Following the General Health Table 1. Total expenditure on health per capita US$ Act of 1986, primary health care PPP (Public and Private) (PHC) was given an independent, reinforced status. The law 2001 2002 strengthened the role of the gen- Austria 2 174 2 220 eral practitioner as the fi rst point Belgium 2 441 2 515 of contact in the health system acting as a gatekeeper. By 2001, Denmark 2 523 2 580 most autonomous communities Finland 1 841 1 943 had moved away from the tradi- tional model of a sole practition- France 2 588 2 736 er working part-time to the re- Germany 2 735 2 817 formed model based on a PHC Greece 1 670 1 814 team working full-time on a salaried basis. 2 059 2 367 Ireland Despite the political focus on Israel 1 623 1 531 PHC the health system still cen- Italy 2 107 2 166 tres around hospitals. In 2001, Spain had 4.0 hospital beds per Luxembourg 2 900 3 065 1000 population; in 2002, an es- Netherlands 2 455 2 643 timated 39% of the hospitals was Portugal 1 662 1 702 publicly owned. An extensive network of outpatient ambula- Spain 1 567 1 646 tory centres works alongside the Sweden 2 370 2 517 hospital system. In the reformed model, members of the special- United Kingdom 2 012 2 160 ist teams in clinical departments US $ PPP: purchasing power parity in US dollars cover outpatient care in ambula- Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional tory centres on rotation. While Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

54 Snapshots of health systems Spain 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 waiting times have been reduced, a social security system to a tax- The Spanish summary was written they still remain considerable. funded system has reaped par- by Susanne Grosse-Tebbe and Hans Most medical staff have a status ticularly favourable results. Fur- Dubois (both European Observatory similar to that of civil servants. In thermore, the system has largely on Health Systems and Policies) with 2000 the total number of doctors been decentralized to the auton- contributions of Rosa Urbanos (Span- approached the EU-15 average omous communities. ish Observatory). with 3.2 per 1000 population, The formal goal of shifting the The text draws on the HiT for Spain increasing from 2.3 in 1990. The health care system’s focus to- of 2000, its summary of 2002 as well total number of nurses remained wards PHC has not been accom- as work in progress on its update. relatively low at 3.7 per 1000 plished yet. Citizens’ satisfaction population in 2000 (table 2). regarding topics such as waiting times and administrative proce- Health care reforms dures for accessing hospital care During the 1980s and 1990s the remains low. Outstanding chal- Spanish health system under- lenges include information de- went major change that achieved velopment, managerial autono- a signifi cant extension of cover- my and the expansion of social age, developed a new reformed and community care. PHC network and rationalized fi - nancing and management structures. The extension of the public network and the transition from

55 European Observatory on Health Systems and Policies Snapshots of health systems Sweden quality in the processing of insurance and benefi ts. At regional level the coun- publicly operated. It is organized ty councils provide and fi nance on three levels: national, region- health care services. Usually these al (21 counties) and local (290 are divided into health care dis- municipalities). At national lev- tricts consisting of one hospi- Organizational structure el the Ministry of Health and So- tal and several primary health of the health system cial Affairs is responsible for en- care (PHC) units that are separat- Sweden has a compulsory, pre- suring that the system runs ef- ed further into PHC districts. The dominantly tax-based health care fi ciently. The National Board of 21 counties are grouped into 6 system providing coverage for Health and Welfare (NBW) is medical care regions to facilitate the entire resident population. the government’s central advi- cooperation in tertiary care. Voluntary insurance is very lim- sory and supervisory agency for At local level the municipalities ited and typically provides only health and social services. There deliver and fi nance social wel- supplementary coverage to the are several associated national fare services including childcare, public health system. institutions such as the Nation- school health services and care The Swedish health care system al Social Insurance Board (NSIB) for the elderly, people with disa- is mainly regionally-based and that guarantees uniformity and bilities and long-term psychiatric

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

56 Snapshots of health systems Sweden 2004 patients. They also operate public counted for 85.9% of total Swed- agnostic-related groups (DRG)- nursing homes and home care ish health expenditure. based payment systems are most services. Regional taxes fi nance the ma- widely used. Most health care jor part of health expenditure. personnel are publicly employed. Health care fi nancing Private expenditure (14.1% in Physicians at public facilities are and expenditure 2002) consisted mainly of out- paid a monthly salary from the During the 1990s a combina- of-pocket payments and volun- counties and also have received tion of recession and cost-con- tary insurance. In about 90% of a capitation fee since the mid tainment led to relatively slow cases employers pay for volun- 1990s. The NSIB reimburses pri- growth in health expenditure. tary insurance to avoid payments vate dentists through a fee-for- In 1990 health care expenditure for employees’ long-term sick service system. amounted to 8.2% of gross do- leave. mestic product (GDP) with a rel- Resource allocation varies Health care provision atively small increase to 8.7% among counties. Using global The PHC services deliver both in 2001. In 2002, it was calcu- budgets most counties have de- basic curative care and preven- lated to be 9.2% of GDP (fi gure centralized fi nancial responsibil- tive services through local health 1), representing a US $ PPP (pur- ity to health districts. Moreover, centres and hospital outpatient chasing power parity in US dol- about half of the county councils departments and private clinics. lars) expenditure of US $ 2517 have introduced some form of Compared to other EU 15 coun- per capita (table 1). In the same purchaser-provider organization. tries outpatient visits to hospitals year total public expenditure ac- For short-term somatic care di- are relatively higher than those to health centres. Health centre phy- Table 1. Total expenditure on health per capita US$ sicians must be trained in gener- PPP (Public and Private) al practice. They act as gatekeepers, guiding the patients to the 2001 2002 right level of care within the sys- Austria 2 174 2 220 tem. Public funding for private Belgium 2 441 2 515 health care providers is dependent on an agreement of coopera- Denmark 2 523 2 580 tion with the country. Finland 1 841 1 943 Secondary and tertiary care is provided through regional France 2 588 2 736 (mainly for highly specialized Germany 2 735 2 817 care), central county and district Greece 1 670 1 814 county hospitals. In 2002 there were 2.3 beds per 1000 popu- 2 059 2 367 Ireland lation (table 2). Municipalities Israel 1 623 1 531 play a central role regarding pre- Italy 2 107 2 166 ventive measures and the Nation- al Institute of Public Health is re- Luxembourg 2 900 3 065 sponsible for managing public Netherlands 2 455 2 643 health at national level. Portugal 1 662 1 702 The number of people employed in the health care sector Spain 1 567 1 646 increased substantially during Sweden 2 370 2 517 the 1970s and the early 1980s. However, the number of physi- United Kingdom 2 012 2 160 cians (3.0 per 1000 population US $ PPP: purchasing power parity in US dollars in 2000) remains below the EU Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional 15 average and there is a short- Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

57 Snapshots of health systems Sweden 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Ofﬁ ce for Europe, health for all database, 2004 age of physicians in isolated rural were launched against a back- The Swedish summary was written by areas. As in other Nordic coun- ground of tightened cost-con- Hans Dubois (European Observatory tries, Sweden has a relatively high tainment policies. As a result, on Health Systems and Policies) with number of nurses (9.8 per 1000 there is evidence of productiv- contributions of Catharina Hjortsberg inhabitants in 2000) but there is ity gains in regional and coun- (Swedish Institute for Health Eco- a countrywide shortage of nurses ty health services and successful nomics, Lund). with specialist skills. containment of health care ex- The text draws on the HiT for Swe- penditure. den of 2001 and its summary of Developments and is- While the Swedish health care 2002. sues system is among the best per- The Swedish health care sys- forming in the world, some rel- tem has undergone several ma- atively minor challenges remain. jor structural changes, particu- Changes in government, increas- larly during the 1990s. Responsi- ing fragmentation of governance bilities were transferred gradual- and provision, problems of coor- ly to local governments and pro- dination among different admin- viders and new management and istrative levels and lack of a glo- organizational schemes were in- bal perspective have impeded a troduced. This was the continua- coordinated reform strategy. tion of the devolution process in- itiated in the 1970s . In the late 1980s internal market reforms

58 European Observatory on Health Systems and Policies Snapshots of health systems The United Kingdom of Great Britain and Northern had supplementary private med- Ireland ical insurance. Although NHS beneﬁ ts are com- sponsibilities to local bodies prehensive, they are not explic- (Primary care trusts in England, itly deﬁ ned. Since 1999 in Eng- Health Boards in Scotland, Lo- land and Wales, the Secretary of cal Health Boards in Wales and State for Health and the Welsh As- Organizational structure Primary care partnerships in sembly Government have received of the health system Northern Ireland). recommendations from the Na- The United Kingdom has de- Coverage is available to all le- tional Institute for Clinical Excel- volved health care responsibil- gal residents of the United lence (NICE). These state whether ities to its constituent coun- Kingdom, residents of the Eu- a particular service is both effec- tries: England, Northern Ire- ropean Economic Communi- tive and cost-effective and should land, Scotland and Wales. All ty and citizen of other coun- be made available to all or part of these countries fund health tries with which the UK has re- the population. Although the im- care mainly through nation- ciprocal agreements. For this rea- plementation of approved NICE al taxation, deliver services son, there is a quite low uptake guidance is mandatory, early indi- through public providers and of private medical insurance. In cations suggest that implementa- have devolved purchasing re- 2001, 11.5% of the population tion has been variable.

Source: OECD Health Data 2004, 1st edition; Israel data from World Health Report, 2004 estimated for 2001

59 Snapshots of health systems The United Kingdom 2004

quite low relative to the prior Boards (LHBs) and Primary care Health care fi nancing to May 2004 EU 15 average. In trusts (PCTs), covering popu- and expenditure 2002, it accounted for 7.7% of lations of between 50 000 and The NHS is funded mainly gross domestic product (GDP), 250 000 people, are the main through general taxation: direct with public sources estimated to purchasers of health services. A taxes, value added tax and em- provide 83% of total expenditure weighted capitation formula is ployees’ income contributions. (fi gure 1). Public sources are es- used to allocate central govern- Further funding for social servic- timated to provide 83% of total ment funding to the PCTs and es is available is available via local expenditure (Fig. 1). In the same LHBs. taxation. Private funding can be year, health care expenditure cal- General practitioners (GPs) broken down into out-of-pocket culated in US $ PPP (purchasing are self-employed. On 1 April payments for prescription drugs, power parity in US dollars) was 2004 remuneration of their ophthalmic and dental services, US $ 2160 per capita (table 1). ser vices moved from a system and private medical insurance In England budgets for health based mainly on capitation and premiums. In 2003 the Govern- care are set every three years, fol- fi xed allowances to one which ment announced that an extra lowing negotiations between the combines capitation and quali- 1% of income was to be levied Chancellor of the Exchequer and ty points. Most of the population as an earmarked tax through na- Department of Health. Budgets is concentrated in urban areas so tional health insurance. are set separately by the devolved access to, and the sustainability Total health expenditure in the administrations in the rest of the of, quality services are reduced in United Kingdom has remained United Kingdom. Local Health remote and rural areas. Hospitals receive activity-based Table 1. Total expenditure on health per capita US$ and contract fi nancing. Most hos- PPP (Public and Private) pital staff are salaried, but hospital consultants are permitted to 2001 2002 earn money in the private sector Austria 2 174 2 220 too. 2 441 2 515 Belgium Health care provision Denmark 2 523 2 580 In the United Kingdom primary Finland 1 841 1 943 care is publicly provided by GPs in group practices (on average 3 France 2 588 2 736 GPs per practice). A patient must Germany 2 735 2 817 be a resident of the designated Greece 1 670 1 814 practice area in order to register with a GP. In England, in 2002, 2 059 2 367 Ireland each GP was responsible for an Israel 1 623 1 531 average of 1800 members of the Italy 2 107 2 166 local community. Although there is a small Luxembourg 2 900 3 065 number of NHS walk-in clinics, Netherlands 2 455 2 643 GPs act as gatekeepers in the sys- Portugal 1 662 1 702 tem and a referral is required in order to access specialist servic- Spain 1 567 1 646 es. In 2002 the United King- Sweden 2 370 2 517 dom had 3.9 acute hospital beds per 1000 population (table 2). In United Kingdom 2 012 2 160 2004 secondary care in the Eng- US $ PPP: purchasing power parity in US dollars lish NHS was provided by 209 Source: OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional NHS Trusts. In addition 23 Men- Offi ce for Europe HFA database 2004; Israel 2002 data from the Central Bureau of Statistics, Israel (2002).

60 Snapshots of health systems The United Kingdom 2004

Table 2. Selected health care resources per 100 000 population in the prior to May 2004 15 European Union Member States (EU-15) and Israel, latest available year Nurses Physicians Acute hospital (year) (year) beds (year) Austria 587.4 (2001) 332.8 (2002) 609.5 (2002) Belgium 1075.1 (1996) 447.9 (2002) 582.9 (2001) Denmark 967.1 (2002) 364.6 (2002) 340.2 (2001) EU-15 average 676.9 (2000) 353.1 (2001) 407.7 (2001) Finland 2166.3 (2002) 316.2 (2002) 229.9 (2002) France 688.6 (2002) 333.0 (2002) 396.7 (2001) Germany 973.1 (2001) 335.6 (2002) 627.0 (2001) Greece 256.5 (1992) 451.3 (2001) 393.8 (2000) Ireland 1676.2 (2000) 238.3 (2001) 299.5 (2002) Israel 598.4 (2002) 371.3 (2002) 218.0 (2002) Italy 296.2 (1989) 606.7 (2001) 394.4 (2001) Luxembourg 779.3 (2002) 259.3 (2002) 558.7 (2002) Netherlands 1328.2 (2001) 314.9 (2002) 307.4 (2001) Portugal 394.0 (2001) 331.2 (2001) 330.8 (1998) Spain 367.2 (2000) 324.3 (2000) 296.4 (1997) Sweden 975.1 (2000) 304.1 (2000) 228.3 (2002) United Kingdom 497.2 (1989) 163.9 (1993) 238.5 (1998) Source: WHO Regional Offi ce for Europe, health for all database, 2004 tal Health Trusts provided special- for health service administra- point of use. Although diffi cult ist mental health services in hos- tion and delivery differ between to measure, the funding system pitals and the community. There the United Kingdom’s countries. based on national taxation is in- are about 240 private acute hos- In England, for example, public dicated to be mildly progressive. pitals. Less than 5% of all beds are health personnel function with- Recent issues surrounding in private hospitals. Patients must in the Central and Regional De- health care in the United King- have a referral from their GP in partment of Health, the Strate- dom have focused on improving order to access secondary care. gic Health Authorities and the the effi ciency, responsiveness and In 2001, there were 0.6 GPs per PCTs. In Wales, a National Pub- equity of the system. The “Deliv- 1000 population. There is con- lic Health Service has been es- ering the NHS Plan” in England sidered to be an under-supply of tablished to provide services and is to give patients wider choice of skilled staff in the NHS. In view support to the LHBs, other or- hospitals although their choice of this, the government has com- ganizations in the NHS and local of treatment remains limited. In mitted to increase the NHS work- authorities. particular, from summer 2004 force by establishing staff growth all patients waiting six months targets to be met by 2004, for Developments and is- for surgery should be able to ob- example an additional 2000 GPs. sues tain treatment from another hos- The Welsh Assembly Government In the United Kingdom tax-based pital or provider. Concordats have also has set targets to increase the funding provides universal cov- been agreed with the private sec- numbers of doctors, nurses and erage. Out-of-pocket payments tor to deliver treatments where dentists in Wales. for patients are relatively low as necessary or even to send pa- The organizational structures the system is mostly free at the tients abroad. National Service

61 Snapshots of health systems The United Kingdom 2004

Frameworks have been devel- health and social care services. oped to ensure that a common In Wales, the Welsh Assembly approach to prevention, treat- Government has reformed the ment and rehabilitation is adopt- NHS by establishing LHBs to plan ed across the country. The inde- and commission services to meet pendent Healthcare Commission most health needs while an all- is responsible for monitoring the Wales body commissions special- clinical and fi nancial perform- ist hospital services. There is in- ance of NHS Trusts, and deter- creased emphasis on preventing mining whether NICE guidance ill health and reducing health in- is being implemented. equalities. Developments include Furthermore, initial legislation adjustments to the way that NHS has been passed to create NHS resources are allocated in order Foundation Trusts in England. Al- to take account of the needs of ready 20 have been granted foun- disadvantaged areas, and an Ine- dation status. Foundation Hospi- qualities in Health Fund to help tals remain within the NHS, but people to reduce their risk of have greater management and heart disease and to address in- fi nancial responsibilities and equities in access to health serv- freedoms. Such measures have ices. The Assembly Government been introduced to achieve par- also has announced the phased ticular aims including reduced abolition of co-payments for pre- waiting lists; improved quality of scriptions for all, regardless of provision, increased funding and income, over a fi ve-year period staff numbers; encouragement of beginning in 2004. innovation and extended patient choice. A recent review of public ex- The UK summary was written by Na- penditure on health recommend- dia Jemiai with contributions of Dav- ed greater investment in health id McDaid (both European Observa- promotion and public health tory on Health Systems and Policies interventions, with the subse- and the departments responsible for quent publication of a consulta- health of England, Wales and Scot- tion paper on the future of pub- land. lic health. The text draws on work in progress Devolution increasingly is on the update of the HiT for the leading to quite different direc- United Kingdom to be published in tions in reform across the Unit- 2005. ed Kingdom. In Scotland major differences include the funding of both personal and nursing care for people in long-term care; and the decision not only to reject Foundation Trusts but also to abolish hospital trusts and re- organize primary care and develop community health partnerships. In contrast to the rest of the United Kingdom, Northern Ireland has always had integrated