COMMISSION OF THE EUROPEAN COMMUNITIES studies The organization, financing and cost of health care in the European Community SOCIAL POLICY SERIES --- 1979 36 COMMISSION OF THE EUROPEAN COMMUNITIES The organization, financing and cost of health care in the European Community by Brian Abel-Smith Professor of Social Administration London School of Economics and Political Science Alan Maynard Senior Lecturer in Health Economics University of York COLLECTION STUDIES Social Policy Series No 36 Brussels, September 1978 This publication is also available in DA ISBN 92-825-0837-4 DE ISBN 92-825-0838-2 FR ISBN 92-825-0840-4 IT ISBN 92-825-0841-2 Nl ISBN 92-825-0842-0 Cataloguing data can be found at the end of this volume ©Copyright ECSC- EEC- EAEC, Brussels-luxembourg, 1979 Printed in Luxembourg Reproduction authorized, in whole or in part, provided the source is acknowledged. ISBN 92-825-Q839-0 Catalogue number: CB-NN-78-036-EN-C C o n t e n t s Part I - The organization and financing of health care A. Introduction . 7 B. Health care in Belgium 9 c. Health care in Denmark 23 D. Health care in RF of Germany 33 E. Health care in France. 43 F. Health care in Ireland 57 G. Health care in Italy 67 H. Health care in Luxembourg 77 J. Health care in the Netherlands 83 K. Health care in the United Kingdom 95 Part II - The cost of health care A. Introduction . 105 B. Trends in expenditure on health services (1966-1975/6) 107 C. Reasons for the increasing cost 115 D. Action to control expenditure on health services in each country: 125 Belgium . 125 Denmark . 128 RF of Germany 131 France. 135 Ireland . 138 Italy . 140 Luxembourg 142 Netherlands . 144 United Kingdom 147 E. Summary of measures taken to control expenditure . 151 Part I THE ORGANIZATION AND FINANCING OF HEALTH CARE - 7 - A. INTRODUCTION The objective of this section of the report is to analyse the health care systems of each of the nine Member States of the European Community. Each of the country chapters which follow are divided up in five sections: - a general description of the evolution of each health care system and an outline of its present administrative structure; - an analysis of the extent and type of health insurance coverage in each country; - the financial characteristics of each system; a brief summary of the range of benefits which is available and this. is presented in the form of a network analysis and a 'typical' patient progressing through the health care system: - an analysis of the main input series (numbers of hospital bedst numbers of doctors and their remuneration) and an attempt is made to emphasize the difference between stocks and flows and 'equity' of national geographical distributions. Throughout the analysis great effort has been made to make the coverage of each country chapter uniform. However in some cases unusual features in particular countries have necessitated a departure from this objective. - 9 - B. HEALTH CARE IN BELGIUM B.l. EVOLUTION AND ADMINISTRATIVE STRUCTURE B.1.1. Evolution The first national law to affect the finance and provision of health care in Belgium was enacted in 1894. Compulsory social insurance for health care was introduced in 1945 (degree of 28 December, 1944) but was not comprehensive. Legislation in 1963 extended the coverage of the compulsory social insurance programme. B.1.2. Administrative Structure The administrative structure of the Belgian health care system is very complex. B.1.2.1. Government At the national level there are seven ministries involved in national policy making, guidance and control in the care field - Labour, Public Work, Defence, Agriculture, Education, Public Health and the Family, and Social Welfare. Of these seven ministries, the Ministry of Social Welfare is of primary impor­ tance with regard to the general social insurance scheme and scheme for the self employed. The Ministry is concerned with the whole range of social security benefits. Social security contri­ butions to finance these ben~fits, which includes health care, is paid to an autonomous organ of the ministry (ONSS - the National Social Security Organization) which divides the monies amongst the various benefit programmes. The health care revenues are given to INAMI (the National Sickness Insurance Institution) which divides it amongst the six groupings of sickness funds. There are 600 local government areas (the smallest unit has 5 000 inhabitants) and these bodies have an important role in the provision of health care (e.g. public hospitals). - 10 - B.1.2.2. Sickness funds There are six groupings of sickness funds. There are five confe­ derations of sickness funds: the National Alliance of Christian Mutual Societies (ANC, 35 federations grouping 752 funds) which covers about 45% of the insured population; the National Union of Belgian Non-Denominational Mutual Societies (UNN, 31 fede­ rations grouping 454 funds) which covers about 10% of the insur­ ed population; the National Union of Socialist Mutual Societies (UNS, 28 federations grouping 108 funds) which covers 29% of the insured population; the National Union of Belgian Liberal Mutual Societies (UNL, 17 federations grouping 236 funds) which covers about 5% of the insured population; the National Union of Belgian Occupational Mutual Societies (UNP, 13 federations grouping 175 funds) which covers 10% of the insured population; and the Auxiliary Fund (CAAMI) which covers the rest of the compulsorily insured population. The 1 745 sickness funds are the administra­ tive units which reimburse the insured and the institutions which provide care. The employees of the Belgian railway and their dependents and seamen and their dependents have separate insur­ ance arrangements. Two types of additional insurances are offered by the sickness funds, 'compulsory-voluntary' insurance and voluntary insurance. Compulsory-voluntary insurance is not laid down in statute law but membership of a particular sickness fund obliges the insured person to contribute towards the cost of provision. Voluntary insurance is provided by the funds to 'top up' statutory benefits. B.1.2.3. Other The activities of the private insurance market are small. B.2. COVERAGE Like France, Belgium does not have one system of social insur­ ance for health care. However the effect of the various statu­ tory schemes is that over 99% of the population have social insurance cover. (In 1960 the extent of coverage was only 73%. However the extent of coverage varies between the various groups. In particular the self employed and their dependents (some 1.5 million) are covered for heavy risks only (hospital care, the social diseases (TB, cancer etc.), etc). Those not covered, in part or in whole, by the social insurance schemes have access to the social aid programme (means' tested benefits provided by local government). - 11 - B.3. FINANCE The sickness funds have to balance income and expenditure by estimating their future costs and negotiations with INAMI (see section B.1.2.1. above) to acquire an income sufficient to meet its obligations. The funds finance the payment of hospitals and doctors. B.3.1. Income The contribution rates for health care social insurance are of two types: one for general scheme beneficiaries (who have full cover) and one for heavy risk beneficiaries (i.e. the self­ employed who only have partial cover). At 1 June 1978, the con­ tribution rate for general benefits in kind for those in the general scheme, levied on wages, without any ceiling, was 3.75% for employers and 1.80% for employees, a total of 5.55%. The programme for the self-employed is financed by a contribution related to their income. Railway workers and seamen pay different levels of contribution. The contribution rates finance medical care only. B.3.1.2. Government contributions The State meets 95% of the cost of treating the social diseases ·(cancer, TB, poliomyelitis, mental illness and handicap). For ordinary medical care a State subsidy of 27% of the budget of the insurance institutions is paid to INAMI. The State pays contributions to sickness funds on behalf of the unemployed (at a rate equal to the average daily value of all contributions for all insurance organizations for each day of unemployment). Also the Government at the local level finances social aid health care benefits. It is important to note that despite this substantial involvement in the financing of care, the State exercises little control over expenditure. The sickness funds are autonomous and decentralized to a considerable degree. - 12 - B.3.1.3. Private finance B.3.1.3.1. Prtvate insurance The premium income of private insurance institutions is small. The income of the social insurance schemes which provide voluntary and 'voluntary-compulsory' (see section B.1.2.2. above) is considerable (see Table 1). Table 1 (Mio BFR) Operating Investments Total costs State expenditure 17 832.8 6 854.7 24 687.5 Social Security 89 008.0 89 008.0 Provinces 2 209.0 369.1 2 578.1 Municipalities 391.0 4 593.7 4 984.7 Semi-Public and private 68 848.6 68 848.6 illOTAL 178 289.4 11 817.5 190 106.9 As 2ercentages State expenditure 10.0 58.0 13.0 Social security 49.9 46.8 Provinces 1.2 3.1 1.4 Municipalities 0.2 38.9 2.6 Semi-Public and private 38.7 36.2 TOTAL 100.0 100.0 100.0 B.3.1.3.2. Pricing The private insurance and the additional insurance provided by the sickness funds and firms enables the insured to meet the costs of care which are not covered by social insurance. The - 13 - extent of social insurance reimbursement is determined by the ticket moderateur.