Week 10 - Healthcare

Question 1

When did modern system of hospitals appear?

Answer 1

Professionalized medical service;
Systematic training; Secular approach; Social security/insurance;
Late 19th century

Question 2

Name 4 basic healthcare policy models

Answer 2

Bismarck
Beveridge
National Health Insurance Model (combination of Bismarck and Beveridge)
Private Healthcare Insurance Model

Question 3

Describe Bismarck model

Answer 3

National solidarity idea: everybody contributes - Insurance system with insurers called “sickness funds” (about 300 funds)

• Financed jointly by employers and employees through payroll deductions;
• Tight government cost control regulation
• Examples: Germany, France, Netherlands, Japan, Switzerland

Question 4

Describe Bismarck model Germany:

Answer 4

• About 90% covered by national insurance, 10% in private insurance
• No gate-keeping – choice of doctors
• System is decentralized

Question 5

Describe Bismarck model France:

Answer 5

• Tax-based system of universal coverage
• Voluntary insurance (complementary)
• Patients pay then get reimbursed
• No gate-keeping – choice of doctors
• System is mostly decentralized
• Financial sustainability is an issue

Question 6

Describe Beveridge model

Answer 6

• Healthcare is financed by government through tax payments (progressive)
• Government acts as sole payer, controls what doctors can do and what is charged
• Examples: Britain, Spain, New Zealand, Nordic countries

Question 7

Describe Beveridge model United Kingdom:

Answer 7

• National Health Service (NHS) paid by taxes
• Primary care done by GPs
• GPs act as gate-keepers (give referrals to doctors)

Question 8

National Health Insurance Model (NHI) (combination of Bismarck and Beveridge models)

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Answer 8

• Care is offered primarily through private sector
• Government pays through single-payer system
• People pay through personal/corporate taxes
• Examples: Canada, Taiwan and South Korea

Question 9

Describe Private Health Insurance Model

Answer 9

Paid via employer/employee contributions

• Private insurers determine payments
• Less regulations overall, lack of “system-wide” planning and coordination
• Emergency situations: non-insured patients will be admitted to hospitals, but costs will be divided across insured people
• Example: United States

Question 10

Name Soviet legacy features in Healthcare policies

Answer 10

Healthcare primarily administered by Ministries of Health Yet many parallel systems (Military, MIA, large factories had their own systems)
Extensive network of hospitals; republic/oblast/district levels
Care was free; but informal payments, use of blat and connections was common
Private vs State Systems guarantee universal coverage, but face limited resources;
Defined benefit package (state-covered) and official patient co-payments;
Limited private sector across CA, mostly pharmacies, dental care and diagnostic facilities

Question 11

What does Private vs State Benefit package (state-covered) include?

Answer 11

Ambulance and medical evacuation
Primary care Consultations with specialists (upon primary care specialist’s recommendation)
Basic standard care
Nursing care

Question 12

Kazakhstani Healthcare system after 1991

Answer 12

Insurance systems: KZ: introduced nationwide system in 1996, but abandoned in 1998, reintroduced in 2018 2018: in KZ employer pays 5%, employee 2% of salary Voluntary (private) health insurance remains small, despite being encouraged

Question 13

Why Kazakhstani national averages are misleading?

Answer 13

Rural vs Urban differences:
Physicians mostly in urban areas KZ: 588 physicians per 100,000 in urban areas; only 130 in rural areas KZ: ‘mandatory’ posting of physicians to rural areas Soviet system – no emphasis on family doctors, focus on the policlinics

Question 14

How do choices of hospitals or family doctors differ in urban and rural areas of Kazakhstan and Central Asian countries?

Answer 14

Urban areas: primary & secondary care in polyclinics/family doctors
Rural areas: basic care in local facilities, secondary care in oblast hospitals and more complex care in national hospitals
TJ: Health Houses as gatekeepers to hospitals
KG: Traditional local points retained
Overall: reliance on hospitals rather than primary care

Question 15

How do healthcare infrastructure and training differ during Soviet Union and after 1991?

Answer 15

Infrastructure Soviet system: extensive network of hospitals (questions of efficiency) Hospitals also played an important social care role
After 1991: former USSR countries sought to reduce hospital capacity and networks, many facilities closed or reduced
Healthcare: Training Soviet model Specialization at undergraduate level, tend to prioritize specialists
Post-1991: Family medicine, upgrade of nursing programs, many doctors retrained in family medicine Specialists still get prioritized

Question 16

What are the implications of relying more on hospitals than family doctors?

Answer 16

Reliance on inpatient (in-hospital) care leads to inefficiency: gaps, duplications, fragmented nature of services
Integrated primary care, based on family medicine, acting as a gatekeeper, remains limited
Over-diagnosis, inadequate keeping up with international practices
KZ: more sporadic approach to health reforms
KG: most comprehensive

Question 17

What is the main critique of Alma-Ata declaration of 1978?

Answer 17

Alma Ata declaration of 1978 – too generic, not specific enough

Question 18

How does US Healthcare system in one of the most complex in the world, according to the article of Frogner et al?

Answer 18

Article demonstrates that the U.S. system shares attributes with systems of many other countries.
The existence of multiple payment systems makes the U.S. approach both unique and complex.
Health insurance is administered by private insurance companies for U.S. employees, as is the case in the Netherlands or Switzerland.
Although U.S. employees generally contribute to the cost of their health premiums, their employers also may contribute, which is the practice in France and Germany. Medicare beneficiaries experience a health system similar to that of Australia or Canada.
U.S. military veterans who use the VHA system may feel camaraderie with UK citizens regarding their similar health care experiences.

Question 19

What trends does the article find connected to centralized and decentralized systems?

Answer 19

Lower costs tend to be associated with more centrally administered health systems, due to lower overhead and stronger cost-control measures. The tradeoff is that more decentralized health systems may offer more consumer choice, by relying more heavily on private health insurance options to supplement or cover gaps in benefits.

Question 20

Name 7 major drivers of China’s success to provide universal healthcare system, according to article of Hao Yu?

Answer 20

(1) the SARS outbreak as a wake-up call,
(2) strong public support for government intervention in health care,
(3) renewed political commitment from top leaders,
(4) heavy government subsidies,
(5) fiscal capacity backed by China’s economic power,
(6) financial and political responsibilities delegated to local governments
(7) programmatic implementation strategy. Three of the factors seem to be unique to China (i.e., the SARS outbreak, the delegation, and the programmatic strategy.) while the other factors are commonly found in other countries’

Question 21

Name Lessons from two decades of health reform in Central Asia according to article of Rechel et al?

Answer 21

1) Importance of political leadership, governance and continuity. Countries that demonstrated a consistent commitment to comprehensive reforms (such as Kyrgyzstan) fared better than those that followed a more erratic approach (such as Kazakhstan).
2) a lack of local capacity-building (Tajikistan)
3) he co-ordination of donor activities as a challenge
4) the pooling of health funds and the use of single payer mechanisms have been necessary to address regional and sectoral inequalities. The countries inherited a fragmented budgetary system from the Soviet period that was divided into three administrative tiers (republican, oblast and rayon or city), and the pooling of health funds at the national level allowed them to overcome this fragmentation and use resources more efficiently and equitably.
While in Kyrgyzstan the introduction of a state-guaranteed benefit package and patient co-payments was embedded in a wider reform of health care financing and delivery , in Tajikistan the new scheme was not accompanied by new mechanisms of health financing or an emphasis on primary health care. This meant that although most services under the basic benefit package were to be delivered at primary care level, the budget was still directed at the operating costs of hospitals

5) experience in Central Asia highlights the importance of piloting reform elements before rolling them out nationwide, example is the failed introduction of the benefit package in Tajikistan, versus the more step-wise introduction elsewhere, such as in Kyrgyzstan, which allowed consensus to be built on reforms and for their refinement where necessary.
6) the involvement of the general population and of health workers has been an element of successful reforms in some countries of Central Asia and was missing in reform attempts that failed. This might not be surprising in many countries, but is so in the political context of Central Asia, which is generally characterized by the strong role of the executive and the powers vested in the presidency. It seems that even in less permissive political environments, health reforms depend on the buy-in of health workers and the general population.