HEALTH CARE

The Belgian health care system covers a very substantial share of the population. Public and semipublic hospitals possess up-to-date equipment, and university hospitals provide quite advanced treatments thanks to their own participation in research activities. Most hospitals operate in networks, which improves overall management as well as the spread of technical innovations.
Access to these services is relatively inexpensive, and most of the population is covered by the public health insurance program. Extensions to this insurance program, either through private insurance companies or through the “mutualités” or “mutualiteiten,” are quite affordable. The problem is that costs have been contained by cutting the wages of health personnel (nurses, paramedics, physical therapists) to such an extent that Belgium now faces difficulties in filling these vital positions. There is also increasing pressure from physicians, who threaten to leave the public system in order to increase their earnings. Thus, while total health care costs have been relatively well contained to date, it is likely that past policies cannot be pursued substantially farther if quality is to be maintained and costs contained as the population ages.

The main principles of health care in Denmark are: universal health care for all citizens, regardless of economic circumstances; services are offered “free of charge”; and sector governance, that is hospitals are governed by elected regional bodies, now governed by councils of the newly formed regions. But financing through taxes depends on the state budget, so regional authorities depend on annual budget negotiations with the Ministry of Finance.
While health expenditures for a number of years did not grow more than GDP, there has been an upward trend in recent years, implying that the expenditure share has increased one percentage point of GDP, to close to 10%. The expenditure share has thus moved from close to the OECD average to the top. This increase is mainly driven by a change in policy from a top-down system to a more demand-driven system. The latter has been motivated by a concern about long waiting lists and the move to offer a “time guarantee” where patients under the public system can turn to a private provider if the public health care system can‘t meet the time limit for treatment in a public hospital. In addition, the government has aimed to bring more private providers into the sector. This is also reflected in the tax deductibility of employer-provided, private health insurance.
A 2007 structural reform has shifted the responsibility for hospitals and health care from the old counties to the new regions. Health care is financed by a specific tax, however, which is part of the overall tax rate and over which regions have no control.
Basic principles underlying the health care sector have thus been changed in recent years. This reflects both ideological views but also the increasing demand for health care. A particular challenge for the future is how to manage and finance the need and demand directed toward health care.

The health care sector in Sweden has been subject to more or less continuous reform – as is the case in most other OECD countries. In the latest wave of reform, greater emphasis was put on primary care units as the first point of entry for people in need of health care.
Traditionally, health care in Sweden is public and organized by the counties (“landsting”). In recent years, health care has been gradually privatized. The center-right government further strengthened this policy. Today health care providers are allowed to make indefinite profits, a reform that the opposition social-democratic party after some hesitation backed.
In the past, the efficiency of health care was highly contested. Long waiting periods and restrictions on free choice of care have been criticized the most. The center-right government improved the options of the patients. During the economic crisis, the counties were confronted with fiscal problems that eroded their capacity to provide qualitatively satisfying health care. The government subsidized the counties in order to restore the quality of health care and to avoid dismissals in the health care sector. In total, privatization reduced the number of beds in hospitals as private providers were forced to contain costs.
A specific reform project in the period under review targeted dental care. Due to deregulation, private costs of dental care increased. The center-right government introduced a voucher system that subsidizes private costs to a certain extent. Furthermore, the government tried to install market transparency for the patients.
Health care in Sweden suffers – as in most other OECD countries – from governance problems. Currently, the health care sector is in a state of flux. It remains to be seen if continuing privatization increases the efficiency of the system (or undermines it). Today, the Swedish health care system provides high-quality care for the majority of the population. The cost efficiency is challenged by demographic changes, like in most OECD countries.

Health policy in Switzerland is said to be qualitatively excellent, to include the total population due to mandatory health insurance policy, and to be expensive. There are serious doubts about cost efficiency, in particular with regard to the organization of hospitals. Life expectancy is very high, with male life expectancy at birth 79.4 years and female life expectancy at birth 84.2 years (2008, Bundesamt für Statistik). This is about two years more than in Germany or Austria. Obviously, the health care system is important in this respect but is not the only explanatory variable; differences may also be due to the socioeconomic resources of the country, the quality of its natural environment, or other variables.
Health insurance is managed according to a very liberal formula: Premiums for health insurance do not depend on income, and premiums do not take into account the number of family members. Hence, insurance must be bought for each member of the family, but there are reduced levels of premiums for children. In the past years, however, this liberal model has been modified by subsidies for low-wage earners and their families. Therefore, there is now some limited progressivity and family-friendliness at the lower end of the income distribution. Nonetheless, health care reforms have not been particularly successful in terms of improving efficiency and controlling the structural rise in health expenditures.

Australia’s health care system, compared to other OECD countries, has a respectable record of providing high-quality health care to much of the population at a relatively low cost. However, the system comprises a complex mixture of public and private funding and provision that is rife with inefficiency, perverse incentives and significant inequality in access to some medical services, such as non-emergency surgery and dental care. Indigenous health outcomes are particularly poor. The most recent attempt by policymakers to address this issue was the establishment, following a summit between the federal and state governments in March 2008, of the National Indigenous Health Equality Council, which is tasked with overseeing the operation of various initiatives.

Total health care expenditure is relatively low, but as is the case in most developed countries, rising costs to government resulting from an aging population and the development of new diagnostic tools and treatments pose significant challenges. The government has sought to anticipate these additional costs in several ways. First, in the 2008 – 2009 budget, the federal government established the Health and Hospital Fund to fund capital investment in infrastructure. Second, the federal government’s 2007 election commitment was to provide more funding to the public hospital system, which is currently administered by the states and territories. There have been extensive negotiations concerning the control of hospitals, which in April 2010 resulted in a tentative agreement that the states would transfer control of public hospitals to the Commonwealth, in return for a higher level of funding.

A further initiative in health policy in the review period was an agreement reached by the Council of Australian Governments (COAG, the forum for cooperative action by the Commonwealth, state and territory governments) for a Preventative Health National Partnership to support a range of nutrition, physical activity, obesity and smoking initiatives. The federal government has agreed to contribute funding of AUD 872 million to the initiative over six years.

The Austrian health system is very good, but it is rather expensive. The system’s quality is manifest in the country’s consistent increase in life expectancy figures. However, cost efficiency is a problem, as there are several dual structures and the remuneration system for health services lacks the proper incentives for greater efficiency. Conflicts between local and state-level administration over the distribution of a very expensive medical infrastructure stand in the way of improving cost efficiency.
The system’s inclusiveness is generally guaranteed. Social security covers about 98.7% (2007) of all persons – citizens and non-citizens – residing legally in Austria.

Canada ranks high in terms of the effectiveness and efficiency of health care policies, as high-quality health care is freely provided for virtually the entire population. But Canada’s health spending as a share of GDP, while well below that of the United States, is above that of many European countries, suggesting that health services may be inefficiently oriented. The rationalization of health care costs is a major goal of government policy at this time, as illustrated by provincial governments’ moves to reduce payments to pharmacies for drugs.

Health policies in Finland have certainly promoted some aspects of public health, the very low level of infant mortality being one example and an efficient health insurance system being another. Other aspects, however, remain neglected. In particular, the ageing of the population and non-sufficient local government resources for health care have led to problems. The system of a low-cost, basic health care plan covering all medical needs and provided by communal health care agencies is challenged by a shortage of physicians willing to work for public health care centers. Many formerly municipal clinics are now run by private companies, which also provide physicians with more attractive employment conditions. The government is therefore challenged to maintain basic health care as well in rural regions. Shortcomings in municipal basic health care especially affect persons who are not covered by occupational health care (such as the chronically ill, the unemployed, the elderly and the poor).
These problems are clear and preventive measures have been scheduled in planning documents, as is evident from the high spending input in Finland during recent years on preventive and health programs. A central document is the 2015 public health program, which outlines targets for Finland’s national health policy. The main focus of the strategy is health promotion and prevention strategies, rather than developing the health service system. The program is a cooperation venture which provides a broad framework for health promotion across different sectors of administration and acknowledges that public health is largely determined by factors outside health care, such factors being, for instance, lifestyle, the environment and product quality. Concerning future measures for promoting health care information, Finland’s national objective is to secure the access of information for those involved in care, and the means used to achieve this objective have included a comprehensive digitalization of patient data as well as the development of the national health care infrastructure and information network solutions.

Health care policies have in recent times provided high-quality health care to all Icelandic citizens, in an increasingly efficient manner. However, this has varied to some extent, as the capital area and Akureyri in the north have experienced significant advantages compared with other, more peripheral parts of the country. This has meant that patients in more remote regions have had to travel to get more specialized medical help. The University Hospital in Reykjavik (LSH), the largest hospital in Iceland, has for some years been in difficult financial straits, as the government has been unwilling to provide additional public funds or to permit the hospital to raise revenue on its own through means such as levying patient service fees. The resulting shortage of staff, especially nurses, can be a threat to patient safety due to work pressures and long hours. After the economic collapse in 2008, the situation deteriorated due to heavy cutbacks in the health sector across the country. Some departments within hospitals have been closed, and services have been cut back in others. Due to a massive reduction in the purchasing power of salaries, the threat of a mass exodus of medical doctors, an especially footloose profession, looms over the health care system.

The public health system in Luxembourg is very efficient, as confirmed by the Euro Health Consumer Index (EHCI). In 2009 Luxembourg fell four places in this index because of failures in the field of e-health, namely e-transfer of medical data between professionals. The country still remains eighth in the classification of 33 states. Luxembourg also ranks first in the new European ranking of conditions for people living with HIV (Euro HIV Index).
There recently has been a major reform of public health insurance funds. The funds organized by professional bodies for historical reasons have been brought together to form one single administration.
Because of the permanent growth of the workforce, the age distribution of the insured is very favorable in Luxembourg and, in recent years the health insurance fund has not encountered the same funding problems as experienced in other countries. Only in 2009 did a small deficit appear. This deficit is expected to grow rapidly in 2010, and for this reason a recovery plan is under discussion, with the presentation of a bill expected on April 23, 2010. Two of the key measures of this bill should be a better balancing of the infrastructure between hospitals to avoid doubling-up, especially for expensive equipment, and the introduction of the so-called primary care physician model (Hausarztmodell), with a family doctor as gatekeeper to coordinate medical services and avoid duplication of treatment.

Health care in New Zealand is generally of a high quality, cost-effective and relatively efficiently managed. At the same time, it faces growing expectations and rising cost pressures. Gains have been made in terms of reducing the health status between Maori and non-Maori. The establishment of district health boards has not achieved devolution and limited the potential for economies of scale, in both service operation and governance. Gaps in life expectancy have been reduced but more remains to be done, including changes in behavior and lifestyle. Concerns about health disparities have been an ongoing concern, as noted by OECD reports. Concerns about rising costs and the lack of productivity gains in the sector led to the establishment of a ministerial review group and a national health board in 2009 with the task of improving coordination between the ministry and district health boards and to advise on the allocation of budgets. Various efforts at restructuring over the last decade have taken their toll on the workforce and despite a relatively high level of support among the population for the public health system concerns about rising costs and productivity remain.

There were no major changes in the health care system during the period under review. Korea has a high-quality and inclusive medical system, and has experienced the OECD’s highest increase in life expectancy (a rise of 27 years) as compared to 1960. This success was achieved despite the second-lowest ratio of doctors per capita ratio, and a nurse per capita ratio far below the OECD average, although this situation has improved in recent years. Health spending per person has grown significantly over the past decade, but remains lower than OECD average. The public sector provides slightly more than half of all health care funding.
The universal health insurance system has relatively low premiums but high copayments. Koreans can freely choose doctors, including service at most privately owned clinics, but the scope of coverage of medical procedures is narrower than in most European countries. High copayments have the problematic effect that access to medical services depends on personal wealth.

For three decades, Chile has maintained a dual health system, with one pillar represented by private insurance and private health-care services chosen by self-financing participants (typically upper-middle-income and high-income groups), and another pillar of public, highly subsidized insurance and public health-care services for participants who pay only a part of their health costs. This system provides broad coverage to most of the population, but with large differences in the quality of health-care provision (including waiting times for non-emergency services). A significant reform has been implemented gradually since 2003, expanding the range of guaranteed coverage and entailing a corresponding extension of government subsidies to low and middle-income population groups. The quality and efficiency of public health-care provision (government clinics and hospitals) varies widely.

The Czech health care system was developed in the early 1990s following the example of neighboring West European countries. All citizens are entitled to equal and free medical treatment paid for by the state and private insurance schemes. Increased life expectancy and very low infant mortality demonstrate the quality of health care in the Czech Republic. The most visible problem is a periodic failure of the insurance system to cover rising costs. In early 2008, the Topolánek government initiated the first stage in its conception of health care system reform, introducing fees for pharmacy prescriptions, visiting a doctor and receiving overnight treatment in a hospital. These were set at a very low level, but caused controversy both by breaking the constitutional commitment to free health care (the Constitutional Court found this acceptable by one vote) and by imposing the charge on everyone, irrespective of age or means. In January 2009, the dissatisfaction with health care reform, even within the governing coalition, led to the dismissal of Minister of Health Tomáš Julínek. The Fischer government failed to agree on health care reform and did not adopt any measures.

France has a high-quality health system, which is also largely inclusive. Since its establishment, it has remained a public system based on a compulsory, uniform insurance for all French citizens, with employers’ and employees’ contributions calculated according to wage levels. Together with widespread complementary insurances, they cover most individual costs. About 10% of GDP is spent on health, one of the highest ratios in Europe. The problem is cost efficiency and containment of deficits (in 2009: €12 billion).
To face rising problems, the choice has been to keep the public system and not to privatize, even in part. Measures of modernization, rationalization and better efficiency of the system and the treatments on offer (e.g., hospitals) have been undertaken, as well as measures of limited cost sharing by individuals. Since 1996, the parliament has voted on an annual expenditure target for the whole system but, in practice, this target has been exceeded regularly. The government has found it difficult to impose its targets for the evolution of expenditures, pharmaceutical prices, medical treatment and remuneration.
The current government has not put forward dynamic measures to contain the financial evolution of the health system. A measure of cost sharing for medical treatment has been announced; the idea of transferring part of the financing from social contributions (which should be cut for reasons of competitiveness) to an increased VAT has been discussed but finally was abandoned.

Health policy is still an evolving issue in German social policy. Due to a decision by the former grand coalition, the so-called health fund became effective in January 2009, fundamentally changing the funding of German health care. It is a centralized institution responsible for collecting income-based contributions and allocating the money to the various health insurance plans. The latter activity is done with reference to a highly complicated morbidity-oriented risk structure compensation scheme, which compensates for variations among the insured within the various insurance plans, and fosters fair competition between plans as they seek to attract new members and reduce costs. In addition, the health care system is increasingly subsidized by government monies, thus breaking with the hitherto basic principle of a solely contribution-financed system. The grand coalition also introduced a uniform contribution rate, which for the first time is set by the government and not by the individual insurance plans.
After the general elections, the coalition agreement between the CDU/CSU and FDP announced additional far-reaching reforms focusing mainly on financial matters. First, the parties agreed to freeze the contribution rate for employers at the level of 7%, thus breaking with the principle of parity-financing the health care system. Expected future increases in the contribution rate will thus be borne only by employees. Second, high-income earners are allowed to opt out of the compulsory health care insurance program after one year of exceeding the income threshold of the state system (instead of three years), and to change instead to private insurance companies.
Because of some ambiguous passages in the coalition agreement and subsequently intense conflict between the coalition partners, a heated debate arose over how to reform health care more broadly. Due to the fiscal crisis, it seemed impossible to shift financing to a lump-sum payment model as favored by the FDP and elements within the CDU. Introducing this new mode of funding the system would drastically increase the government funds provided to the health care system. Low-income earners would have to be subsidized by the state to be able to finance their lump sum payments, whereas high-income earners would be better off compared to the contribution-financed system. At the time of writing, it remained unclear whether the government would stick to its coalition agreement or redefine its policies and retain the existing contribution-based system.
In the meantime, the new government has sought to contain pharmaceutical costs. The Federal Ministry of Health has proposed key points aimed at reducing drug costs. Pharmaceutical companies have to provide a dossier on the expected benefits of new drugs. In addition, the trade association for health insurance plans is allowed to bargain with pharmaceutical companies over price reductions of up to 16% of the market price.
In addition, a committee was established to debate future health care reforms to be introduced in 2011. However, the committee consists exclusively of members of the government, and includes not a single nonpolitical expert. As of the time of writing, it appeared that the proposed reforms would focus on financial issues, and would not be likely to increase health care system efficiency, which is low compared to that of other European countries. From January 1, 2009, due to reforms implemented by the grand coalition, all citizens in Germany will have health insurance coverage, whether in the private or state sector. However, the rationing of medical services could increasingly become an issue. Already today, some types of rationing exist: While patients with insurance coverage from a private health insurance company get fast access to all kinds of diagnostic tests and specialized doctors, patients with coverage from the statutory health insurance plans face significantly longer waiting times and increasing copayments. This de facto rationing of diagnoses and treatment must be expected to spread further if no major efficiency improvements are realized.

Italy’s national health system provides universal comprehensive coverage for the entire population. It is funded predominantly by the national budget, but is administered by regional authorities. Overall, it provides almost completely free, medium- to high-quality health care for the whole population. However, due to significant differences in local infrastructures, cultural factors, and the political and managerial proficiency of local administrations, the quality of public health care is not nationally uniform. In spite of similar levels of per capita expenditure, services are generally better in northern and central Italy as compared to those of southern Italy. In these latter regions, due to lower quality levels and typically longer waiting lists, wealthier individuals will often turn to private sector medical care. Regional disparities also lead to a significant amount of “health tourism” heading north. Early moves in the direction of fiscal federalism are now stimulating efforts to change this situation through the introduction of a system of national quality standards (correlated with resources), which should be implemented across regions.
Especially in the south, health care is affected by corruption, inefficiency and high prices. For example, in the autonomous region of Sicily it is reported that mafia activity has entered the public health care system. All across Italy (but again, more often in southern Italy) authorities often shut down hospitals or wards in hospitals because of sanitary deficiencies. Costs for health care in some regions are definitely out of control.
Preventive health programs are virtually nonexistent or are not well publicized, at least for the average health care user.

Japan has had a universal health-care system since 1961. The overall accomplishment of the country’s medical system is evident in the fact that Japan has one of the world’s highest life expectancies, and that infant mortality rates are among the world’s lowest. Despite these achievements, the health care system faces a number of challenges due to remaining weaknesses and newly emerging trends. One issue is quality. Several problems persist in various fields, including, for instance, an extremely long waiting period before globally top-selling drugs and medical devices are introduced in Japan, the professional standards of physicians, and rather high delinquency rates in paying dues to the National Health Insurance system. Another problem concerns coverage: Non-regular workers in particular sometimes lack coverage under the extant payment mechanisms. A serious structural issue is the aging of the population, which is leading to ever-rising cost pressure.
The DPJ, the senior governing party since September 2009, concentrated particularly on one aspect of the issue in its election manifesto: the perceived shortage of doctors. The number of doctors per head is some 40% lower than in Germany or France. The DPJ is considering measures such as an increase in medical services fees. Funding is to some extent earmarked as coming from regulated drug price revisions. Yet even if these measures are both appropriately executed and successful, other challenges associated with calibrating higher costs and acceptable quality in a rapidly aging population still linger.

The system of financing health care underwent a complete transformation in 2006. This more market-oriented system includes price competition for a standardized basic benefits package, community rating, sliding-scale income-based subsidies for patients and risk equalization for insurers. However, the Dutch health insurance model does not control costs or increases in consumer premiums, and insurance companies report large losses on the basic policies. Public satisfaction is not high and perceived quality is down. Consumers may not behave as economic models predict, as they may remain unresponsive to price incentives. Health insurers announced mergers that have been approved by the Dutch competition authority. After these mergers, about 90% of the population will be insured by six large insurance groups, while the other 10% will be insured by seven small regionally oriented health insurers.

In 2008, the electronic patient dossier (Elektronisch Patiënten Dossier, EPD) was introduced as a pilot project in order to facilitate the exchange of patient medical information between nursing staff, general practitioner and pharmacists. Participation is now on a volunteer basis but will be made mandatory in the future. The system saves time and money but is also highly debated because it touches upon privacy issues.

An international study on infant mortality showed that within a group of 25 European countries (plus Norway), the Netherlands has a higher infant mortality rate than France and Latvia. The numbers of mortality are especially high during the pregnancy period and in the first week after birth. Women in the Netherlands are on average older at childbirth and more twins are born in the Netherlands, two factors which are associated with more complications during birth. The infant mortality rate is particularly high in the group of women with foreign background.

Norway has an extensive health system, providing good services to its resident community. Anyone who is resident in Norway has a right to publicly provided economic assistance and other forms of community support during illness. Health care for mothers and children is especially good, as in other Scandinavian countries. Infant mortality is the sixth lowest in the world. Per capita health expenditures in Norway are more than 50% higher than the OECD average. The country’s total health expenditures total about 12% of GDP, a third more than the OECD average. The public share of this expenditure in Norway is also high, with 84% of health spending financed by the government.
Yet although Norway offers high-quality health care services to the entire population, its efficiency is questionable. In a major structural health care reform in 2002, ownership of all public hospitals was transferred from the regions to the central state. Subsequently, new “health care regions” were established, which were larger than the previous ones. These were given management responsibility, without ownership. The intention was for these regions to streamline and coordinate health care services, and impose a stricter regime of budget discipline. However, reorganization has been slow, and remains ongoing and seemingly unending. Vast amounts of resources are being consumed by procedural work and pervasive conflict, and the efficiency gains, if any, have yet to be identified. This reform has been uniquely unsuccessful by Norwegian standards. A previous reform, which came into effect in 2001, established a general-practice system for the first time, so that all persons and households would have a designated primary care doctor or practice. This was implemented with relative ease, and contributed to a notable improvement in access to quality primary health care.

Portugal’s population shows comparatively good levels of overall health. Life expectancy has grown consistently in the last decade, reaching 76.24 years for men and 82.41 years for women in 2008. Infant mortality was 3.3 per 1,000 live births in 2008, a rate lower than that of United Kingdom, Austria, Netherlands, Italy, Denmark, Germany or Spain. Portugal has a universal and general National Health Service (NHS), accessible to all residents. According to the constitution (Article 64) this service, “with particular regard to the economic and social conditions of the citizens who use it, shall tend to be free of charge,” and is financed predominantly through taxation. While this system faces challenges, as do virtually all systems if this kind in Europe, it is a relative success story in Portugal. Indeed, the relative effectiveness of the health service is reflected in the comparatively high score achieved by Portugal when considering the life expectancy-to-spending ratio: Portugal’s life expectancy is close to the OECD average, with a significantly lower than average health care expenditure per person.
Health policy in the 2008 – 2010 period continued the reform highlighted in the SGI 2009 report, seeking to rationalize health provision structures. Some emergency health services were closed in areas of low population density, generating as a result substantial protests in Valença in March 2010. The government also introduced health center clusters (approved in 2008 with Decree-Law No. 28/2008, and further specified in the form of Decree-Law 82/2009) and implemented public health services in these clusters (Decree-Law 82/2009). One emerging problem in this period is that of a lack of doctors in the NHS.
There is in addition a private health care system that provides high-quality care, but this is expensive, and can be afforded by only a small minority of perhaps 5% of the population.

Spain’s public health care system is faced with two pressing problems: restraining spending and improving quality. Health-care spending absorbed a third of state revenues in 2009, representing approximately 6% of GDP. Moreover, 32% of these expenses were associated with pharmaceuticals (compared to an EU average of 25%). Whereas the current economic crisis makes the situation difficult in the short run, population aging trends (in 10 years time, one out of five Spaniards will be over 65 years old), chronic disease proliferation, new and highly expensive treatments, and a general abuse of free medical appointments puts the sustainability of the system at high risk in the medium and long term.
This critical situation led to an unprecedented agreement between the central government and the autonomous regions in March 2010, aimed at saving an estimated €1.5 billion per year. Among other provisions, this plan will implement the so-called bill-in-the-shade system (that is, informing citizens about the costs of the assistance they receive, so to encourage reasonable use). A head purchasing office will be created, which regions will be able to join voluntarily in hopes of getting better prices from suppliers. Reference pricing for drugs will be recalculated downwards, and the use of generic drugs will be encouraged.
Beyond these issues, the quality of health care in Spain has deteriorated somewhat in recent years. According to the Euro Health Consumer Index, which compares health care systems in Europe, Spain has fallen from the 14th position to the 21st since 2005. The most recent report emphasizes deficiencies in patient rights and prevention. There is also significant interregional inequality. Waiting lists continue to grow, and the use of alternative private services has increased accordingly. In 2006, a Quality Plan for the National Health System was adopted. After three years, a report on this plan was issued for the period 2009 – 2010. It included additional measures, but no detailed analysis of the results achieved during the previous phase was provided.

The National Health Service (NHS), the cornerstone of the United Kingdom’s welfare state, has survived a number of privatization attempts in the past. It remains very popular in the country in spite of many criticisms raised in detail about its performance. It is of totemic importance in the national psyche and often appears to be untouchable as a political priority, with every government over the 60 years since the program’s introduction having substantially increased real spending. Combining universal coverage with central management and control, it has in the past enabled the United Kingdom to achieve a good performance (as measured by several health indicators) at a cost considerably below that of the EU average. In 2000, when Tony Blair announced the ambition to increase health spending so as to converge rapidly on the EU-14 (i.e., excluding the UK) average of about 9% of GDP, UK health care spending accounted for 6.6% of GDP, of which 5.4% was publicly funded. Policy under the Labour government focused on increasing spending levels in order to improve service quality, while shortening or eliminating waiting lists that in the past had existed even for essential operations. In real terms, public spending on health continued to rise over the period 2008 – 2010, with an annual average real increase for the decade as a whole of 6.56% (Appleby, Crawford and Emmerson, 2009). Aggregate spending reached 8.2% of GDP in 2009 – 2010, on track to meet the government’s commitment. In their 2010 election manifestos, all the main parties committed themselves to exempting health spending from the public expenditure cuts that would have to begin in 2010.

Massive increases in spending have improved performance, although debates persist as to what proportion has gone into cost inflation in the face of labor market constraints for health professionals, especially doctors. Although the NHS’s 1.3 million staff members make it the world’s third-largest employer, problems remain in the staffing and delivery of front-line welfare services. Efficiency and responsiveness reforms focused on improving patient outcomes have proven difficult to evaluate because of the complex environment and the multiple incentives actors face in this area. Some critics argue that an excessive reliance on targets has distorted resource allocation, and has unnecessarily resulted in managers more concerned with monitoring and massaging targets than with delivering patient care. One consequence is that the effects of the reforms remain a matter of debate between government and opposition parties. It has also become clear that patients’ expectations have risen in line with improvements in the system, and bearing in mind the rising real cost of health provision brought about by technological advances, patient satisfaction has not increased in line with spending.

The creation of a health database covering all citizens has also been a subject of political dispute, because of cost overruns (typical of many large information technology projects in the UK) and growing concerns about the security of information.

In March 2010, Congress enacted a major plank of the Obama administration’s reform program when it passed a historic health care reform package, the Patient Protection and Affordable Care Act, which was the result of a protracted and complicated legislative struggle lacking broad consensus. It was enacted over the concerted opposition of Republicans in Congress, thus laying out in the open a deep societal discord over the direction that health care policy should take. Public opinion is divided, and it remains to be seen whether long-term majority support or a sustainable consensus for the reform can be achieved. Many provisions of the bill are not well defined and will only become clear in the process of implementation. The most important provisions will not take effect until 2014, others not until 2019. This leaves time to water down the reform or even reverse the major provisions, although Democrats will be able to defend their handiwork while in control of the White House and potentially longer through the Senate filibuster. The bill’s effect consists basically of filling the many gaps of coverage in the existing system, although it does not eliminate all the gaps. Outside the health care system for the elderly (i.e., Medicare) the bill succeeds in expanding coverage to 94% of legal residents (up from 83%), adding about 34 million people.
Because of its magnitude and complexity and the uncertainty of its effects, the new law can be expected to create winners and losers, and it will surely have unintended consequences. This explains the polarized discussion about the reform that is not settled with its passage. Public opinion has been sharply divided, with a modest majority disapproving it. A good deal of opposition centers on the requirement for individuals who are otherwise not covered to purchase health insurance under threat of penalty. The big-ticket items of the reform such as employer mandate or insurance market reform will not start until 2014, giving opponents an incentive to reverse the reforms. Because of the Republicans’ united opposition and their anger about the legislative process, it can be expected that the reform will remain on the agenda beyond the 2010 congressional election and in the 2012 presidential contest. Constitutional challenges against important provisions of the reform package will ultimately be resolved by the Supreme Court.

No other area of public service provision arouses as much controversy in Ireland as health care. The media is filled with complaints about waste, inefficiency and poor service in public hospitals. On the other hand, policymakers and politicians with responsibility in this area point to progress being made, as evidenced by rationalization of care delivery, improved services and better outcomes.
The body responsible for the delivery of public health services in Ireland is the Health Services Executive (HSE), created in 2005 through the amalgamation of regional health boards that had previously run the system in a fragmented way. The HSE now has a budget of €17 billion, equal to 10% of GDP. During the period under review, it continued the task of rationalizing and streamlining the delivery of public health services, and has claimed significant success in many areas, notably cancer and primary health care. The rationalization of the health services sector has inevitably involved centralization of specialized facilities in a smaller number of “centers of excellence” as compared to the historical network of small-scale units dispersed in a large number of places throughout the country. Given the country’s low population density, it is inevitable that specialization along these lines entails longer travel times for some patients. This reorganization has provoked widespread protests and demonstrations in favor of maintaining a full range of services in small local hospitals.
Any evaluation of the Irish public health services today should bear in mind both the low starting point in the 1990s, and the exceptional growth in the population since that time, in particular the recent baby boom which has placed substantial pressure on maternity and pediatric services. Revelations of overcrowding, inefficiencies, waste, poor services, and extremely long waiting lists for access to specialized services continued unabated over the reference period and receive prominent press coverage. The gradual improvements in the overall delivery of health care and outcomes have received less publicity.
The Irish health care system is a two-tier system, with about half the population relying exclusively on the public health system and the other half enjoying additional services mainly paid for through private insurance policies. Thus, the system cannot be scored highly on the inclusiveness of public health care provision. Private health insurance is a way of avoiding the waiting lists typical of public hospitals. This generates inequalities in access to health care. But an increasing proportion of the population has found private health insurance too expensive, and has switched to exclusive reliance on the public health system. This has increased the strain on the system.
During the reference period, several problems received widespread publicity, notably in regard to the failure to diagnose cancers in public care patients and the recent revelation that an extraordinary number of X-rays were not properly dealt with in one of the largest hospitals in the country. In March 2010, the Health Information and Quality Authority (HIQA), the national body responsible for standards and safety in the health services, issued a statement saying that it believed as many as 57,000 backlogged X-rays remained unread. This is only one, albeit one of the worst, example of the grounds for concern regarding absolute standards as well as value for money in the Irish public health services.
On the other hand, the substantial increase in resources devoted to cancer screening under the National Cancer Control Program was judged to have resulted in significant progress in this area, according to a review published by HIQA in February 2010.
Undoubtedly severe problems of overcrowding persist in many public hospitals, despite the increase in resources made available. An unexpected source of this pressure has been the steady increase in population and the number of births, despite a resumption of emigration. The number of births registered in Ireland rose from 61,000 in 2005 to 75,000 in 2008, an increase of 28% for which no additional budgetary provision was made, as the birth rate was expected to fall. Despite these problems, the infant and maternal mortality rates have continued to decline and are today among the lowest in the world.

Health care in Greece is organized through a British-style national health system (NHS), covering the population as a whole and funded on the basis of general taxation. However, health care is also organized along occupational lines: certain professions, such as liberal professionals and bank employees, have their own health care programs that mirror their occupation-based pension plans. At the same time, owing to fiscal constraints, inefficiency and the unpredictable quality of service offered by the Greek NHS, there has been a shift over time toward private health care by those who can afford it. This trend was evident in the increase of the ratio of private to public health spending in 2003 – 2007, as OECD data shows.
This situation is reflected in basic statistics. In 2006, Greek public expenditure on health care amounted to 11.5% of total public spending, the lowest such level among southern European countries (Greece, Italy, Portugal and Spain). The same low ranking held true for Greece’s per capita public expenditure on health. However, compared to the rest of southern Europe, Greece has the highest number of hospital beds and the highest number of physicians (50 physicians per 1,000 residents in 2005). The country’s rate of infant mortality at birth is as low, and its life expectancy is as high as the rest of its southern European peers (respectively 4.0 deaths per 1,000 live births, and 80.0 years). Still, the NHS is in disarray, as the very large debts incurred by public hospitals testify. These debts are the result of mismanagement and comparatively large expenditures on pharmaceuticals, as OECD data show.
As a result, while health care policies do not generally provide poor health care to the population, inclusiveness is doubtful and cost efficiency leaves much be desired. Problems with poor budget management in the health system are profound and endemic; they also provide ample scope for corruption.

The quality of health care varies widely in Mexico. Private, self-financed health care is limited for the most part to middle-class and upper-class Mexicans. This group encompasses about 13% of the total population, but receives about 33% of all hospital beds. A larger minority of around one-third of the population (most of whom work in the formal sector) can access health care through state-run occupational and contributory insurance schemes such as the Mexican Social Security Institute (Instituto Mexicano del Seguro Social, IMSS) and the State Employees’ Social Security and Social Services Institute (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE). These are based on automatic contributions for workers in the formal sector, and in practice work reasonably well, although with some variation across different parts of the country. The system has been decentralized to the state level. In order to extend the insurance principle, the government has set up the so-called Popular Insurance (Seguro Popular) program, which is open to contributors on a voluntary basis, with means-tested contributions from citizens supplemented by substantial government subsidies in order to encourage membership. The government is aiming at virtually full coverage by the end of 2010, but this is optimistic. It is doubtful that there would be enough capacity to provide the vast majority of Mexicans with health care even if financial problems did not limit access, which is the case. The law does entitle Mexicans who have not contributed to an insurance program to have access to such health care as is available. There are some health facilities available to the poor, though they are undercapitalized and often hard to reach for those Mexicans who live in rural areas. Overall, health care spending accounts for a relatively small proportion of GDP due in part to Mexico’s relatively young population. Pressures on health facilities are likely to increase over time as the average age of the population increases.

Since the Polish health care system has suffered from high deficits and a low level and quality of services, health care reform has been among the priorities of the Tusk government. The envisaged reforms consisted of three main elements: more precisely defined public benefits, the corporatization of hospitals, and opening the system to private health insurance companies. These plans faced strong resistance by the opposition and by President Kaczyński, who vetoed the bill at the end of 2008. Lacking the support by the leftist SLD, the parties of the governing coalition were not able to overcome this veto. Since the veto, the Tusk government has tried to transform the hospitals in cooperation with the bodies of regional self-government.

Slovakia has a mandatory social insurance system that provides all residents with primary, secondary and tertiary care, pharmaceuticals and medical devices. The state covers insurance for children, pensioners and women on maternity leave. Whereas the health care reforms of the previous government emphasized market principles and individual responsibility, the Fico government stressed equity issues. It cut VAT on medicine, abolished the (largely symbolic) extra fees introduced by its predecessor (€0.66 paid for each visit and each prescription) and increased access to health care at spas. The most important structural reform was the controversial move to interdict private health-insurance companies to make profits. Despite promises during the 2006 election campaign, the government did not increase the wages in the health care sector, thus keeping petty corruption alive. Nor did it undertake any significant attempts to increase the quality and efficiency of health care services.

According to Turkey’s State Planning Organization, the basic objectives of Turkey’s health policy, as implemented since 2004 through the Health Transformation Program, are to ensure that all citizens take part in economic and social life as healthy individuals and to assist them in raising their quality of life. In order to achieve this objective, Turkey aims to strengthen preventive health care services; make primary care services and the family medicine system more effective; meet demands for infrastructure and health personnel, while balancing their allocation to reduce disparities among regions and socioeconomic groups; and provide health care services on an egalitarian and just basis, in such a way as to be respectful of patient rights, accessible, high-quality and efficient.
In the context of the Health Transformation Program, the pilot implementation of the family medicine program initiated in 2005 had been extended to 40 provinces by October 2009. Turkey is aiming to disseminate the practice to the whole country by the end of the year 2010. Furthermore, in order to reduce consumption of tobacco products which are risk factors for chronic diseases, smoking has been forbidden in indoor areas since July 2009.
The country has a shortage of health personnel, with just 14.3 active physicians per 10,000 people, and 13 nurses per 10,000 people in 2008. In order to mitigate this shortage, the country increased the capacity of medical and nursing schools during the period 2007 – 2009. In addition, new faculties of medicine have been established. Furthermore, Turkey introduced a system of compulsory duty. As a result, the allocation of doctors and nurses between provinces has improved considerably. In addition, Turkey has started the Tele-Medicine Project, developed for the purpose of supporting hospitals with a lack of qualified health personnel. This has prevented unnecessary referrals and provided cost efficiency in health services.
Public hospitals still face a serious lack of both staff and equipment, however. Due to relatively low salaries, physicians and nurses tend to turn to private hospitals immediately after they have finished compulsory public service. To better the situation in public hospitals, the government passed a new law in January 2010 prohibiting hospital physicians from simultaneously running their own private practice.

The Hungarian health care system has suffered from inefficiencies, rising costs, low quality and an erosion of universal access through an increasing reliance on informal payments. The Gyurcsány government launched a far-reaching and highly controversial health care reform in December 2006. After a central element of reform – the introduction of fees for visits – was rejected by more than 80% of voters in a referendum in March 2008, the government retreated entirely from the health reform project. In May 2008, the MPs of the governing Hungarian Socialist Party (MSzP) joined the parliamentary opposition in cancelling the opening of the market for private health insurance funds adopted by parliament just six months earlier in December of 2007 . Since the health care reform had been drafted by a minister of the liberal Alliance of Free Democrats (SzDSz), this move led to the breakdown of the coalition.