Pendanaan pelayanan kesehatan: Sebuah perspektif internasional Who Pays? Who Benefits? What values are reflected?

Umum pengalaman negara-negara industri untuk lebih dari satu abad laluBiaya penyakit adalah hasil dari gaji yang hilang dari pekerjaan, bukan biaya perawatan medis Peningkatan kompetensi medis Semakin tingginya ekspektasi konsumen Peningkatan pemanfaatan pelayanan medis meningkatnya biaya

Common developmentsa. Hampir semua negara-negara industri menjamin sebagian besar biaya rawat inap untuk sebagian besar warganya b. Universalisme berkurang saat Anda bergerak menjauh dari rumah sakit untuk perawatan rawat jalan, barang medis, dll c. Belanja publik mendominasi strategi pendanaan Sumber daya terkonsentrasi pada rumah saki

Health systems main source of financing

TaxesSocial insurance contributionsPrivate insurancepremiumsAustraliaFranceGermanyJapanU.K.U.S.

Very different proposals for government actionFor example:Bismarcks Germany: started with health insurance for industrial workers (1880s)England: started with health insurance for low income workersIn most cases, broader expansion part of government action

More on government actionBy 1940, no Western European country was without a compulsory government health insurance programU.S. was late in the game (1965) with MedicareAustralia was even later (1972) with Medibank Medicare

National Health ServicesAccess to health care is a right of citizenship or residenceGenerally, characterized by/associated with:General taxation fundingUniversal coveragePublic ownership of health care facilitiesSalaried medical professionalsWaiting listsSome NHS include U.K., Australia, Denmark, Sweden, Italy, Greece, Spain, PortugalSmall role for private health insurance cover uncovered services, elective surgery, cost sharing

Nationalization always remains incomplete!Outside public hospitals, physicians in NHS still mostly private contractors Private hospital beds supplement publicAustralia 25% private; U.K. 5% privateSome services not covered--prescriptions drugs, dental, eyeglasses

Social insurance schemes

Social reflects public, collective, compulsory aspectsInsurance reflects private, individualistic and voluntary Together, Social insurance means publicly-mandated, though paid for and provided by independent institutions

Social insurance schemes are characterized byFunding through payroll contributions (mandated insurance premiums), usually split between employer and employeeEntitlement language, direct linkage between contributions and benefitsLimits to state intervention, preserves a private sectorSome social insurance examples are Germany, France, Japan, the Netherlands

Example: GermanyArchetypal social insurance system1st in the world (Bismarck 1880s)Compulsory health insurance--paid 1/2 employer, 1/2 employee750 sickness fundseach is independent, self-governing unit Sponsorship range from: local, company, occupation

More on GermanyBenefits include income maintenanceSickness funds contract directly with providersHospital capital investment regionally planned

AustraliaUniversal entitlement based on citizenship/residencyGeneral tax fundingDelivery system is public/private hybridPrivate insurance encouraged

U.S. hybrid systemHow insurance schemes (private, Medicare, Medicaid) pay providers is beyond scope of talk, but it varies significantlyOn delivery side,About of hospital beds are publicly owned

What social values are reflected through funding?AccessEquityCost control (global)Income protection (individual)Efficiency (at macro and micro levels)Including target efficiency (benefits flow to the most financially or medically needy)Freedom of choice Innovation

Adequacy of access: the right to health careAccess to health care as necessary to general welfare of country Along with education, police/fire protectionGeneral welfare as necessary to individual freedom and self sufficiencyGeneral welfare as supporting economic growthAs health spending makes up greater % of GDP, this notion is less strong

SolidarityIn contrast to the individualistic (market) notions of a right to health care and individual freedoms and self-sufficientSolidarityvery important notion in European health care schemesThe mutual responsibility of citizens for the health care of each other

Income protectionWithout universal coverage, some must bear the cost of care entirely out of pocketRemember: average per capita spending ranges from $2249 - 6102, the range is greatThis is devastating to all but the highest income and impacts the unhealthy disproportionately

EquityThe ways in which health care is paid for have a significant bearing on questions of equity or fairness

Equity issues reflected in whether payment is progressive, regressive, proportional

Cost control2 ideas here:First, controlling total HC spendingpublic funding = public controlSecond, controlling HC spending relative to other national spending priorities (education, safety)General tax funding makes this explicit

ChoiceThe essence of economic and social freedom!Made up of all of the followingThe choice of doctorThe choice by a doctor about how she wants to practice medicineThe choice of a health care systemThe personal choice of how much to pay for health care

More about choiceCompetition is supposed to lead to more satisfaction because there is more choiceConsumers role in choosing between providers is questionable in many areas of the health systemInformation on which to compare

InnovationThe market has been potent force behind innovation and medical progressCommercial creation of medical goods of all kinds---drugs and devices(medical progress has increased peoples expectations and costs)

ResourcesMedicine and the Market: Equity v. Choice by Daniel Callahan and Angela Wasunna (2006)The Politics of Health in Europe by Richard Freedman (2000)www.oecd.org

*Australia has been put in both NHS and Soci ins. Categories in different readings*Diferent ways of financing provider greater or lesser opportunities to control spendingPublic funding = public control*