snapshots of health systems

8/14/2019 Snapshots of Health Systems

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The state of affairs in 16

countries in summer 2004edited by

Susanne Grosse-Tebbe and Josep Figueras

European

Observatoryon Health Systems and Policies

Snapshots ofHealth Systems


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World Health Organization 2004,on behalf of the European Observatory on Health Systems and Policies

All rights reserved. The European Observatory on Health Systems and Policies welcomes requestsfor permission to reproduce or translate its publications, in part or in full.

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The views expressed by authors or editors do not necessarily represent the decisions or the statedpolicies of the European Observatory on Health Systems and Policies or any of its partners.

The designations employed and the presentation of the material in this publication do not implythe expression of any opinion whatsoever on the part of the European Observatory on Health Sys-tems and Policies or any of its partners concerning the legal status of any country, territory, city orarea or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where thedesignation country or area appears in the headings of tables, it covers countries, territories, cit-ies, or areas. Dotted lines on maps represent approximate border lines for which there may not yetbe full agreement.

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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


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Acknowledgements

European


The Snapshots of health systems - the state of affairs in 16 countries in summer 2004 provide very brief overviewsof the organization and financing of the health systems, the provision of health care as well as de-velopments 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 HealthSystems 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 OShea (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 gnrale de la securit sociale, Luxembourg) and Jean-PaulJuchem (Union of Sickness Funds, Luxembourg);

Netherlands:Jonas Schreyoegg with contributions of Peter Achterberg (RIVM, Centre for PublicHealth 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);


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Acknowledgements

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United Kingdom: Nadia Jemiai with contributions of David McDaid (European Observatoryon Health Systems and Policies and the departments responsible for health of England, Walesand Scotland.

The reports were edited by Susanne Grosse-Tebbe and Josep Figueras.The summaries presented also form part of WHO Regional Office for Europes Highlights

series 2004. The European Observatory on Health Systems and Policies is very grateful to theHighlights team of the Division of Evidence and Communication, WHO Regional Office forEurope, especially Anca Dumitrescu and Barbara Legowski for the opportunity to contribute tothe project.

The snapshots of health systems draw on the Observatorys Health Care Systems in Transi-tion (HiT) series of published profiles and summaries as well as drafts underway. The HiTs arecountry based reports providing a comprehensive analytical description of a countrys healthsystem 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-fice 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-makingthrough 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 Woodheadand Mary Stewart Burgher (copy editing) and Jesper Rossings (lay out). The reports reflect theinformation available in summer 2004.


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Snapshots of health systems

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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

Luxembourg

Ireland

Finland

Spain

United KingdomAustria

Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private

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

Organizational structureof the health systemThe Austrian health system isshaped by statutory health in-surance that covers about 95%of the population on a manda-tory and 2% on a voluntary ba-sis. Of the 3.1% of the popula-tion not covered in 2003, 0.7%had taken out voluntary substi-tutive insurance, while 2.4% hadno cover at all (for example some

Austria

groups of unemployed as well asasylum seekers). The 26 statuto-ry health insurance funds are or-ganized in the Federation of Aus-

trian Social Security Institutionsand do not compete with eachother since membership is main-ly mandatory and based on occu-pation or domicile. Since 2001family coinsurance has requireda (reduced) contribution butmany household members re-main exempt for example chil-dren, child-raising spouses or in-dividuals in need of substantialnursing care.

The Federal Ministry of Healthand Women is the main policy-maker in health care, responsi-ble for supervising the statuto-ry health insurance actors and is-suing nationwide regulations forexample on drug licensing andpricing. The nine Lnder govern-

ments deliver public health serv-ices and have strong competenc-es to finance and regulate inpa-tient care. Capacity planning in-creasingly has been undertak-en by a structural commission atfederal level and nine commis-sions at Lnderlevel and is gradu-ally being extended to all sectorsand types of care.


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Table 1. Total expenditure on health per capita US$

PPP (Public and Private)

2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166

Luxembourg 2 900 3 065

Netherlands 2 455 2 643

Portugal 1 662 1 702

Spain 1 567 1 646

Sweden 2 370 2 517

United Kingdom 2 012 2 160

US $ PPP: purchasing power parity in US dollarsSource:OECD Health Data 2004, 1st edition; Israel 2001 data from the WHO Regional

Office for Europe HFA database 2004; Israel 2002 data from the Central Bureau of

Statistics, Israel (2002).

Health care financingand expenditureIn 2002 Austria spent 7.7% of itsgross domestic product (GDP)on health and ranked below theprior to May 2004 15 Europe-

an Union Member States aver-age (figure 1).Total health ex-penditure remained stable be-tween 1997 and 2002; theshare of public expenditures de-creased from 5.8% in 1995 to5.4 % of GDP in 2002, account-ing for 67% of the total expend-iture in that year. The rise in pri-vate expenditures was attributa-ble mainly to an increase in di-

rect payments and co-payments.Calculated in US$ PPP (pur-chasing power parity in US dol-lars) expenditure per capita wasUS$ 2220 (table 1).

In 2000, 43% of total expend-iture was financed from socialsecurity schemes, 27% fromgovernment, 19% were paid viauser charges or direct payments,4% from other private funds and

7% from voluntary health in-surance. Financing of statutoryhealth insurance differs amongsickness funds but is alwaysbased on contributions repre-senting equal shares from em-ployers and employees, account-ing for 7.4% of salary in 2004.Ceilings for maximum incomeand contributions apply. Blue-collar workers paid higher con-

tribution rates than white-col-lar workers until 2003. Rates forcivil servants, the self-employedand farmers still differ from themain contribution rate.

Sickness funds contract withindividual physicians on the ba-sis of negotiations between thefunds and medical associationsat Lnder level. Contracted phy-sicians in private practice are re-

imbursed by per capita flat ratesfor basic services and fee-for-service remuneration for servicesbeyond these. The split betweenthese components and possi-ble volume restrictions may varyby speciality and Land and part-ly by the type of health insurancefund. For visits to non-contractedphysicians the health insurancefunds reimburse their SHI-in-

sured at 80% of the regular con-tracted rate per billed service.

Since 1978, hospital care hasbeen financed from funds atLnder level with separate divi-sions for recurrent and invest-ment expenditures. Since 1997hospital care has been financedfrom funds at Lnder level withseparate divisions for recurringand investment expenditures.The funds are financed by fed-eral, Lnder and district govern-ments and, most importantly, bylump sums from health insur-ance funds.

Public and not-for-profit hospi-tals that are accredited in hospitalplans for acute care at Lnderlev-el (fund hospitals) are eligiblefor investments and reimburse-

ment of services for individu-als covered by SHI. Introduced in1997, the performance-orient-ed payment scheme consists of acore component of national uni-form diagnosis-related groups(DRG) and a steering system toaccount for hospital characteris-tics. The latter may vary consid-erably between Lnder. Fund hos-pitals derive additional income

from co-payments, supplementa-ry insurance or their owners. Pri-

Austria 2004


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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

(year)

Physicians

(year)

Acute hospital

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 Office for Europe, health for all database, 2004

vate for-profit hospitals may con-tract selectively with health in-surance funds and then be reim-bursed according to DRGs.

Long-term nursing care ben-efits are financed mainly fromfederal taxes. They are granted toabout 4% of the population, re-gardless of income, on the basis

of seven categories of need thatdepend on the hours of nursingcare required per month. Poolingand allocation of benefits is car-ried out by the statutory pensionfunds.

Health care provisionSelf-employed providers in sin-gle practice deliver most pri-mary and secondary outpatient

care. Outpatient clinics ownedby hospital providers or statu-

tory health insurance funds de-liver secondary outpatient anddental care. General practition-ers coordinate care and referralsand serve as formal gatekeepersto inpatient care, except in emer-gency cases. In practice, howev-er, patients often access outpa-tient clinics directly. A co-pay-

ment for this type of service didnot impact substantially on fundrevenues and care-seeking behav-iour and was abolished in 2003.The number of outpatient con-tacts was 6.8 per person in 2002.Public health authorities deliverantenatal care, child health careand screening services, many ofwhich are financed by statutoryhealth insurance.

Acute secondary and terti-ary inpatient care is provided

by fund hospitals accredited inhospital plans or by private for-profit hospitals. In 2001, 28%of beds were provided by pri-vate hospitals and 73% by fundhospitals owned by municipali-ties, the Lnder and religious orother not-for profit organiza-tions. While the numbers of hos-

pital beds have been reduced to6.1 beds per 1000 population in2002, the density of beds in Aus-tria remains high compared withthe EU 15 average (table 2). Ad-mission rates have increased fur-ther and reached the highestshare in Europe at 29 cases per100 population in 2002. Thismay be attributable in part tothe introduction of the new DRG

system that attracted surgery cas-es, which previously had been

Austria 2004


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dealt with in ambulatory care, toinpatient care. At the same time,average length of stay was re-duced from 13 days in 1990 to 6days in 2002 when the occupan-

cy rate was 76%.The number of physicians in-creased continuously to 3.3 per1000 population in 2002, similarto Germany but below the EU-15average. The ratio of nurses to in-habitants also increased to 5.9 per1000 but ranks substantially be-low neighbouring countries orthe EU-15 average (table 2).

Developments & issuesThe vast majority of the Austrianpopulation has access to a com-prehensive set of statutory ben-efits in preventive, curative, pal-liative and long-term care, basedon the principles of solidari-ty and risk pooling. The Minis-try of Health and Women aimsto expand the HI coverage of asy-lum-seeking immigrants. Qual-ity management initiatives havebeen intensified and patient om-budsmen have been introducedin all nine Lnder to handle andreport complaints in all sectorsof care in order to increase theresponsiveness of services.

Recently cost-containment hastargeted rising pharmaceutical ex-penditures by introducing price

cuts, new price categorizationschemes, margins for wholesal-ers and pharmacists and measuresto increase the low rate of genericprescribing.

Despite substantial achieve-ments in downsizing hospitalbeds and shifting acute capacitiesto nursing, geriatric and pallia-tive care, acute bed capacities andutilization remain high by Eu-

ropean comparisons, particular-

Austria 2004

ly in urban areas. Major politicaldebates also are concerned withstrategies to curb the (growing)deficits of health insurance fundsand to secure the revenue basis

of the statutory health insurancesystem.

The Austrian summary was written

by Annette Riesberg (European Ob-

servatory on Health Systems and Pol-

icies) with contributions of Rein-

hard Busse (European Observatory on

Health Systems and Policies), Maria

Hofmarcher (Institute for Advanced

Studies, Vienna) and the Austrian Fed-

eral Institute for Health Care. The text draws on the HiT for Austria

of 2001 and work in progress.


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European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemBelgium has a health care systembased on a compulsory socialhealth insurance model. Healthcare is publicly funded and main-ly privately provided. The Nation-al Institute for Sickness and Disa-bility Insurance oversees the gen-eral organization of the healthcare system, transferring fundsto the not-for-profit and privately

managed sickness funds. Patientshave free choice of provider, hos-pital and sickness fund.

A comprehensive benefit pack-

age is available to 99% of thepopulation through compulsoryhealth insurance. Reimbursementby individual sickness funds de-pends on the nature of the serv-ice, the legal status of the provid-er and the status of the insured.There is a distinction betweenthose who receive standard reim-bursements and those who ben-efit from higher reimbursements(vulnerable social groups).

Substitutive health insurancecovers 80.2% of the self-em-ployed for minor risks. Sick-ness funds offer complementa-ry health insurance to their in-sured. Private for-profit insur-ance remains very small in terms

of market volume but has risensteadily as compulsory insurancecoverage has decreased.

The federal government reg-ulates and supervises all sec-tors of the social security sys-tem, including health insur-ance. However, responsibilityfor almost all preventive careand health promotion has beentransferred to the communitiesand regions.

Belgium


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2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





Health care financingand expenditureStatutory health insurance is fi-nanced mainly through incomecontributions from employersand employees. There are differ-

ent schemes for salaried workersand the self-employed althoughthese will merge by July 2006.Currently, these two schemesreceive extra funding in partsof the value added tax revenue.Sickness funds are funded partlythrough a risk adjusted prospec-tive budget, partly retrospective-ly on the basis of their individu-al share of total expenditure. Fur-

ther state subsidies are allocat-ed for administrative costs. Pa-tients finance 19.1% of healthexpenditure mostly throughout-of-pocket payments but also

through voluntary health insur-ance premiums.

In 2002, total health expendi-ture was above the prior to May2004 EU 15 average and account-ed for 9.1% of its gross domes-

tic product (GDP), 71,4% camefrom public sources (figure 1).Calculated in US$ PPP (purchas-ing power parity in US $), healthcare expenditure amounted toUS$ 2515 per capita (table 1). A fixed annual budget for com-pulsory health insurance and sec-toral target budgets are set at fed-eral and community level. Healthcare delivery in Belgium is main-

ly private: most doctors, dentists,pharmacists and physiotherapistsare self-employed and paid on afee-for-service basis. The fees arenegotiated at national level be-

tween the National Committeeof Sickness Funds and providersrepresentatives. Other health careprofessionals are mainly salaried.Hospitals obtain most of their fi-nance through a dual structure: a

fixed prospective lump sum foraccommodation services and afee-for-service payment for med-ical and technical services.Health care provisionPrivate sole general practitionersand specialists deliver most pri-mary care. There is no referral sys-tem. In 2002 the average numberof physician contacts per person

was relatively high at 7.3, com-pared to an EU 15 average of 6.2.

In 2002 Belgium had 4.6 acutehospital beds per 1000 popula-tion, above the EU 15 average of3.8 (table 2). In 2003 there were218 not-for-profit hospitals, 149general and 69 psychiatric. Themajority of hospitals (147) areprivate. The hospital legislationand the financing mechanism arethe same in both the public andprivate sector. Between 1980 and2003 the number of hospitalsdropped from 521 to 218 andthe average capacity of a hospi-tal rose from 177 to 325 beds. Ofthe 218 hospitals, 55% were lo-cated in the Flemish region, 30%in the Walloon region and 15%in the Brussels region.

The communities are respon-sible for health promotion andpreventive services, except fornational preventive measures. Forthis reason public health policiesand services differ between theFrench and Flemish Community.

In 2002 there were 4.5 physi-cians per 1000 population (table2). In the last 30 years staff num-bers in most health care profes-

sions have doubled (or even tre-bled) mainly due to a lack of sup-

Belgium 2004


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Nurses

(year)

Physicians

(year)

Acute hospital

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)


ply-side control. Until recentlythere was no limit on the numberof trainees entering these pro-fessions, resulting in very highdoctor/population and nurse/population ratios compared withthe rest of western Europe.

Developments and is-

suesThe Belgian health system pro-vides comprehensive health carecoverage to almost all the popula-tion while maintaining a wide de-gree of choice for the insured andthe providers. Since the 1980s theBelgium Governments two mainobjectives have been cost con-tainment and improving access tohealth care services.

In the hospital sector financ-ing system, the change from per

diem rates to a prospective diag-nosis-related groups (DRG) pay-ment scheme has been quite suc-cessful in controlling costs. Previ-ously based on structural featuressuch as the number of accreditedbeds, financing now takes accountof the justified activity of thehospital. This justified activity is

based upon the hospitals case-mixand the average national length ofstay per DRG. To stimulate day care,one-day hospitalization is integrat-ed into this calculation.

In the field of pharmaceuticalpolicy the reimbursement pro-cedures were simplified, the revi-sion process for new and existingmedicines was improved and areference reimbursement system

introduced to promote the use ofgenerics.

The efficiency gains from giv-ing greater financial responsibil-ity to sickness funds have beenconstrained: since the latter arenot allowed to selectively con-tract with providers they onlyhave limited influence over pro-viders behaviour.

Other measures introduced

have aimed at tariff cuts, supplyrestrictions and increases in co-payments but these have not yetsucceeded in curbing public ex-penditures. In this context the di-vision of power between the fed-eral and regional government isregarded as an additional chal-lenge.

A system of preferential reim-bursement and social and fis-

cal exemptions was introducedto improve access to health care.

Belgium 2004


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14

As the social exemption appliesto only certain social categories,and the fiscal exemption pro-vides only for a reimbursementafter an average of two years, the

system of a maximum invoicewas introduced. This aims to im-prove access by limiting pay-ments for health care to a maxi-mum amount for example a fam-ilys out-of pocket expenses. Theamount varies according to fam-ily income and other socioeco-nomic factors.

The Belgium summary was writtenby 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.

Belgium 2004


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European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemDenmark has a tax-based, decen-tralized health system that pro-vides universal coverage for allDanish residents. Hospital care,general practicioners (GP) andpublic health services are free atthe point of use.

Central government, in theform of the Ministry of the Inte-rior and Health, plays a relative-

Denmark

ly limited role in health care. Itsmain responsibilities include es-tablishing the goals for nationalhealth policy; preparing health

legislation and regulation in-cluding the supervision of healthpersonnel; promoting coopera-tion between the different healthcare actors; and providing healthinformation. The Ministry of Fi-nance plays a key role in settingthe overall economic frameworkfor the health sector.

Most health care is funded andprovided by the counties. Theseown and run most hospitals as

well as control the number andlocation of the privately prac-tising general practitioners. Themunicipalities are responsible forproviding services such as nurs-ing homes, health visitors, homenurses and school health servic-

es.

Health care financingand expenditureIn 2002 Denmark spent 8.8% ofits gross domestic product (GDP)on health (figure 1), calculated inUS $ PPP (purchasing power par-ity in US dollars) this amountedto US$ 2580 per capita (table 1).A combination of state, coun-ty and municipal taxes financed


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2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





83% of the total expenditure onhealth care. Central governmentholds overall financial responsi-bility for the health service: localtaxes are supplemented by annu-

al state subsidies calculated ac-cording to the size of these localrevenues. In addition, resourc-es are transferred between coun-ties and municipalities accordingto a formula that takes account ofage structures and socioeconom-ic indicators.

Private payments accountedfor 17% of total expenditure onhealth and can be attributed to

out-of-pocket expenses such asco-payments for physiotherapy,dental care, spectacles and phar-maceuticals as well as contribu-tions to voluntary health insur-

ance schemes. About 30% of thepopulation purchases VHI in or-der to cover the costs of the stat-utory co-payments.

The most significant resourceallocation mechanism in Den-

mark is the annual national budg-et negotiation between the Min-istry of the Interior and Health,the Ministry of Finance, the As-sociation of County Councils andthe National Association of Lo-cal Authorities. This sets overalllimits for the average growth ofcounty and municipal budgetsand the levels of funding.

Public hospital resources are

allocated mainly through pro-spective global budgets set bythe counties in negotiation withhospital administrators. In addi-tion, since 2000 diagnosis-relat-

ed group (DRG) payments forpatients treated in hospitals out-side their own counties havebeen introduced. DRG paymentsare being introduced gradually inall county hospitals and now ac-

count for 20% of expenses.General practitioners remu-neration is a mixture of quarterlycapitation payments (30% of re-muneration) and fees for service.County-licensed specialists arepaid on a fee-for-service basis.Public hospital staff receive sala-ries.

Health care provision

Self-employed health care pro-fessionals and municipal healthservices provide primary healthcare. Privately practising gener-al practitioners play a key role inthe Danish health care system: asthe patients first point of con-tact and as gatekeepers to spe-cialists, physiotherapists and hos-pitals. Danish residents over 16have been able to choose fromtwo general options: Group 1patients may access a GP free ofcharge at the point of use if theyaccept that this GP acts as a gate-keeper; Group 2 patients mayvisit any GP or specialist with-out referral but must pay part ofthe treatment/ consultation coststhen. In 2002 only 1.7% of thepopulation opted for Group 2,

partly due to the extra costs in-volved and partly due to gener-al satisfaction with the GP refer-ral system.

The counties own and financethe majority of hospitals. Excep-tions include hospitals in the Co-penhagen area and private for-profit hospitals, the latter ac-counted for less than 1% of thetotal number of hospital beds in

2002. The number of beds per1000 population fell from 7.6 in1980 to 3.4 in 2001. The general

Denmark 2004


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17



Nurses

(year)

Physicians

(year)

Acute hospital

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)


decline in the number of beds inboth general and psychiatric hos-pitals has been associated with alarge increase in the number ofoutpatient visits.

In 2002 there were 3.7 phy-sicians and 9.7 nurses per 1000population (table 2). It is felt thatthe recruitment of nurses may

become increasingly problemat-ic as the profession is associat-ed with low salary levels, a heavyworkload and poor working con-ditions.

Developments & issuesNational and local reforms initi-ated during the last decade havefocused on increasing produc-tivity and quality and reducing

waiting lists for non-acute care.These include the introductionof a free choice for hospital treat-

ment in 1993, contracts and tar-get-based management in hos-pitals, restructuring delivery onthe basis of functional units,DRG classification, in parts ac-tivity-based hospital financing,the development of quality indi-cators and waiting-time guaran-tees. Most current reform initia-

tives focus on hospitals and inpa-tient care.

Primary care continues to be akey strength of the Danish healthcare system and a source of high-level satisfaction for the popula-tion. Further structural changes,possibly associated with a great-er role for the private sector, arebeing considered but the Danishsystem will remain committed to

the welfare ideals of tax financ-ing and universal access to highquality health care, in accord

with general political consensus.The Government has proposed

a radical change to the regionaladministrative structure of Den-mark to reduce the numbers ofmunicipalities and counties/regions. The reform is being ne-gotiated with the political partiesin parliament (June 2004).

The Danish summary was written

by Susanne Grosse-Tebbe (European

Observatory on Health Systems and

Policies) with contributions of Sig-

nild Vallgarda (University of Copen-

hagen).

The text draws on the HiT for Den-mark of 2001, the HiT summary 2002

and work in progress.

Denmark 2004


18/6218


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Finland

Organizational structureof the health systemFinland has a compulsory tax-based health care system thatprovides comprehensive cov-er for the entire resident popu-lation.

Central government and the mu-nicipalities are the main players inthe organization of health care inFinland. At national level the Min-istry of Social Affairs and Health

issues framework legislation onhealth and social care policy andmonitors its implementation. Mu-nicipal health committees, coun-

cils and executive boards plan andorganize health care at local level.Municipalities (444 in 2004) alsohave responsibility for health pro-motion and prevention, prima-ry medical care, medical rehabil-itation and dental care. The coun-try is divided into 20 hospital dis-tricts, federations of municipali-ties are responsible for arrangingand coordinating specialized carewithin their area.

Health care financingand expenditureThe Finnish health care systemis mainly tax financed. Both thestate and municipalities have theright to levy taxes. In 2002 about

43% of total health care costswere financed by the municipal-ities, 17% by the state (mainlythrough state subsidies), 16% byNational Health Insurance (NHI)and about 24% by private sourc-es.

In both absolute and relativeterms there has been an over-all increase in private financing,from 20.4% of total health ex-penditure in 1980 to 24.3% in


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19



2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





2002. This is accounted for by in-creased user charges for munici-pal services, the abolition of taxdeductions for drugs and othermedical treatment costs and re-

ductions in the NHI reimburse-ments for pharmaceuticals.Total health expenditure (THE)accounted for 7.3% of Finlandsgross domestic product (GDP)in 2002 for that year the low-est among the Nordic countriesand lower than the average of theprior to May 2004 15 Europe-an Union Member States. In thesame year health expenditure in

US $ PPP (purchasing power par-ity in US dollars) was US$ 1943per capita (table 1). Public ex-penditure on health was 75.3%of THE.

Municipalities pay hospitals forthe services used by their inhab-itants. Hospital physicians andmost doctors in municipal healthcentres are salaried employees.Under the personal doctor sys-

tem, physicians are paid a com-bination of basic salary (approxi-mately 60%), capitation payment(20%), fee for service (15%) andlocal allowances (5%).

Health care provisionPrimary curative care, preven-tive care and public health serv-ices are provided by multidisci-plinary teams working in pri-

mary health care (PHC) centres.These publicly owned centres arethe responsibility of municipali-ties and play an important role inguiding patients through the dif-

ferent levels of care. The personaldoctor system introduced in the1980s includes the requirementthat doctors see their patientswithin three days and made sala-ries more workload-related. This

has improved access to GPs andreduced waiting times. Publichealth policy has been particular-ly successful in reducing mortal-ity and risk factors related to car-diovascular diseases.

Outpatient and inpatient depart-ments provide secondary and ter-tiary care in public hospitals. Acutehospitals had 2.3 beds per 1000population in 2002 (table 2).

In 2002 there were 3.2 phy-sicians per 1000 population,matching the EU 15 average. At21.7 per 1000 population the ra-tio of nurses was the highest inwestern Europe (table 2). Theageing population is expectedto increase demand on the exist-ing shortage of doctors and otherhealth personnel.

Developments & issuesDuring the last decades Finlandshealth care system has been verysuccessful in many ways: it pro-vides generally good qualitycare, is fairly efficient comparedto other countries and, in overallterms, the Finns are satisfied withtheir system. Reforms are intend-ed to solve specific problems

rather than promote major struc-tural changes. The introductionof the personal doctor system inthe 1980s was an attempt to ad-dress increasing waiting timesfor health centre doctors.

Since 1997 cost-containmentmeasures have been implement-ed in response to rising phar-maceutical costs. In 2001 qual-ity guidelines for mental health

care services were negotiated andapproved in order to facilitate the

Finland 2004


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20



Nurses

(year)

Physicians

(year)

Acute hospital

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)


development of community carein parallel with rapid reductionsof capacity in the hospital sector.In the same year a national pro-gramme of health promotionwas approved, setting guidelinesfor the next 15 years based onWHOs health for all policy. Alsoa number of local projects and

pilots have been developed re-cently for example experiment-ing with the integration of pri-mary and secondary providers.

Some challenges that remaininclude enhancing access to care,increasing the systems respon-siveness to patients preferenc-es, addressing the limited free-dom to choose GPs and hospi-tal, improving coordination be-

tween primary and secondaryhealth care, addressing the short-

age of personnel and increases inout-of-pocket payments.

The Finnish summary was written by

Vaida Bankauskaite (European Ob-

servatory on Health Systems and Poli-

cies) with contributions of Jutta Jaer-

velin (STAKES, Helsinki).

The text draws on the HiT for Fin-land and its summary of 2002.

Finland 2004


21/6221


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemThe French health system isbased on a national social insur-ance system complemented byelements of tax-based financing(especially the General Social Tax- CSG) and complementary vol-untary health insurance (VHI).The health system is regulatedby the state (parliament, the gov-ernment and ministries) and the

statutory health insurance funds.The state sets the ceiling forhealth insurance spending, ap-proves a report on health and so-

cial security trends and amendsbenefits and regulation.

There are three main schemeswithin the statutory health insur-ance system. The general schemecovers about 84% of the popu-lation (employees in commerceand industry and their families).The agricultural scheme coversfarmers and their families (7.2%of the population). The schemefor self-employed people covers

5% of the population. In 2004 aninsurance fund was establishedspecifically for dependent elderlypeople. In 1999 universal healthinsurance coverage (CMU) wasestablished on the basis of res-idence in France (99.9% cover-

age).Complementary VHI has ex-

panded significantly over recentdecades and since the introduc-tion of CMU in 2000 has beenavailable free to those on low in-comes. VHI covered about 85%of the population in 2000 andnow covers over 95%.

The French health system isgradually decentralizing fromnational to regional level. At the

France


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22



2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





same time, power has shiftedfrom the health insurance fundsto the state.

Health care financing

and expenditureIn 2002, total expenditure onhealth care in France was esti-mated at 9.7% of gross domes-tic product (GDP) and amount-ed to US $ 2736 per capita whencalculated in US $ PPP (pur-chasing power parity in US dol-lars) (figure 1; table 1). Pub-lic expenditure constituted 76%of total health expenditure in

the same year. As shown in fig-ure 1, as a proportion of GDPFrance spends the second high-est amount on health in the pri-or to May 2004 15 European Un-

ion Member States. In 2002 so-cial health insurance constitut-ed 73.3% of total health expend-iture, the remainder consisted ofVHI (13.2%), out-of-pocket pay-

ments (9.8%) and national taxes(3.7%).Since 1996 parliament has ap-

proved a national ceiling forhealth insurance expenditure(ONDAM) annually. Once theoverall ceiling is set, the budg-et is divided between four sub-groups: private practice, pub-lic hospitals, the regions, pri-vate for-profit hospitals and so-

cial care.The main health insurance

scheme pays public hospitalsthrough prospective global budg-ets. For-profit hospitals are paid a

fixed rate covering all costs ex-cept doctors, these are paid on afee-for-service basis. Private not-for-profit hospitals can choosebetween the two systems of pay-ment (public or for-profit). A re-

form currently underway aims tointroduce an activity-linked re-imbursement system and to har-monize the financing of the pub-lic and private sectors. Self-employed physicians pro-vide the majority of outpatientand private hospital services. Pa-tients pay direct fees for serviceand are then partially reimbursedby the statutory health insurance

system. The national agreementbetween doctors and the fundsspecifies a negotiated tariff. Alter-natively, from 1980 all doctors,but since 1990 only those withspecific qualifications, have beenable to join Sector 2 (currentlyabout 24% of doctors) which al-lows them to charge higher tar-iffs. Doctors in public hospitalsare paid on a salary basis, since1986 they have been permit-ted to engage in part-time pri-vate practice within their hospi-tals as an incentive to remain inthe public hospitals.

Health care provisionSelf-employed doctors, dentists,medical auxiliaries, around 1000health centres managed by local

authorities and, to a lesser extent,salaried staff in hospitals deliv-er primary and secondary healthcare. There is no gatekeeping andpatients have free choice of doc-tor. Recent attempts to introducea gatekeeping system have notbeen particularly successful, de-spite financial incentives for bothdoctors and patients.

Hospitals in France are ei-

ther public (65% of all inpa-tient beds), private not-for-prof-

France 2004


23/62


23



Nurses

(year)

Physicians

(year)

Acute hospital

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)


it (15%) or private for-profit(20%). Private for-profit hospi-tals deal mainly with minor sur-gical procedures; public and pri-vate not-for-profit hospitals fo-cus more on emergency admis-sions, rehabilitation, long-termcare and psychiatric treatment.With 8.4 beds per 1000 inhab-

itants, half of which are acutebeds, France is close to the EU15average.

The many actors and sources offinance involved in public healthpolicy and practice in France leadto a lack of cohesion among theactors and diluted responsibili-ties. In March 2003 a new billwas proposed to tackle this prob-lem. It set out a comprehensive

legislative framework for a publichealth policy that developed stra-

tegic plans in designated priori-ty areas and established a frame-work of objectives and targets.

There are approximately 1.6million health care professionalsin France, accounting for 6.2% ofthe working population. In 2002there were 3.3 physicians and6.9 nurses per 1000 population,

both figures below the EU 15 av-erage (table 2). The distributionof doctors shows geographicaldisparities favouring Paris andthe south of France and urbanrather than rural areas.

Developments and is-suesThe French health system is not-ed for its high level of freedom

for physicians and choice forpatients, plurality in the provi-

sion of health services, easy ac-cess to health care for most peo-ple and, except for some special-ties in certain parts of the coun-try, the absence of waiting listsfor treatment. In recent years anumber of reforms have trans-formed its original characteris-tics by increasing parliaments

role, replacing employees wage-based contributions with a con-tribution (tax) based on total in-come and basing universal cover-age on residence rather than em-ployment. Financial sustainability has beena key issue for the French healthsystem since the 1970s. The sys-tems organizational structuremakes it difficult to control ex-

penditure and, although relative-ly high levels of expenditure on

France 2004


24/62


24

health have resulted in patientsatisfaction and good health out-comes, cost containment remainsa permanent policy goal. Howev-er, during the late 1990s con-

cerns for equity led to a majorreform (CMU) aimed at remov-ing financial barriers to accessbut which went against the gen-eral trend of cost containment.

In May 2004 the conservativegovernment proposed a seriesof reforms to raise revenue andreduce expenditure, purported-ly to save 15 billion by 2007.The government proposes the

introduction of several changes:charge all patients 1 per visit toa doctor; oblige pensioners whocan afford it to pay substantial-ly more; raise health care levieson firms; reduce waste and over-consumption (particularly ofpharmaceuticals); reduce reim-bursement of expensive pharma-ceuticals; prevent national healthinsurance card fraud; establish acomputerized, personal medicalrecord accessible by any Frenchhealth care professional to pre-vent patients from shoppingaround; and continue to movetowards gatekeeping.

The French health system is in-stitutionally complex leading totensions between the state, thehealth insurance funds and pro-

viders. In future it will be impor-tant to improve relations by clari-fying the responsibilities of thesekey 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.

France 2004


25/6225


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemThe roots of the German healthsystem date back to 1883, whennationwide health insurance be-came compulsory. Todays systemis based on social health insuranceand characterized by three co-ex-isting schemes. In 2003, about87% of the population were cov-ered by statutory health insurance;based on income, membership

was mandatory for about 77% andvoluntary for 10%. An addition-al 10% of the population took outprivate health insurance; 2% were

covered by governmental schemesand 0.2% were not covered by anythird-party-payer scheme.

The health care system has adecentralized organization, char-acterized by federalism and dele-gation to nongovernmental cor-poratist bodies as the main actorsin the social health insurance sys-tem: the physicians and dentistsassociations on the providersside and the sickness funds and

their associations on the purchas-ers side. Hospitals are not repre-sented by any legal corporatistinstitution, but by organizationsbased on private law. The actorsare organized on the federal aswell as the state (Land) level.

The Ministry of Health and So-cial Security proposes the healthacts that when passed by par-liament define the legislativeframework of the social healthinsurance system. It also super-vises the corporatist bodies and with the assistance of a numberof subordinate authorities ful-fils various licensing and super-visory functions, performs scien-tific consultancy work and pro-

Germany


26/62


26



2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





vides information services.The 292 sickness funds col-

lect the contributions of the stat-utory insurance for health andlong-term care. They also negoti-ate contracts with the health care

providers. Since 1996 almost eve-ry insured person has had theright to choose a sickness fundfreely, while funds are obligedto accept any applicant. Since2004, decision-making in statu-tory health insurance has been in-tegrated into a trans-sectoral jointfederal committee that is support-ed by an independent institute forquality and efficiency.

Health care financingand expenditureIn 2002, health expenditure inGermany comprised 10.9% of its

gross domestic product (GDP),and 79% was covered by pub-lic funds, giving the country thehighest rank among those shownin Fig. 1 and ranking it thirdamong countries in the Organ-

isation for Economic Co-opera-tion and Development (OECD).In the same year, German to-tal per capita expenditure, whencalculated in US $ PPP (purchas-ing power parity in Us dollars),amounted to US $ 2817 (ta-ble 1) and public per capita ex-penditure ranked fifth among theOECD countries.

Of total expenditure, 57% of

the funds came from statutoryhealth insurance, 7% from stat-utory long-term care insurance,4% from other statutory insur-ance schemes and 8% from gov-

ernment sources. Private healthinsurers financed 8%, employers4% and non-profit-making or-ganizations and households 12%.Most out-of-pocket paymentswere spent to purchase over-the-

counter drugs and to cover co-payments for prescribed drugs.On 1 January 2004, co-paymentswere introduced for outpatientvisits and raised for virtually allother benefits.

The risk-compensation schemeamong sickness funds aims tolevel out differences in the age,sex and health-status structureof those insured through the dif-

ferent schemes. This system hasbeen complemented by a high-risk pool since 2001 and by in-centives for disease-managementprogrammes for the chronicallyill since 2003.

In ambulatory physician care,a regional physicians associationnegotiates a collective contractwith a single sickness fund in theform of a quasi-budget for physi-cian services. The physicians as-sociation distributes the fundsamong the general practicioners(GPs) and specialists who claimreimbursement mainly on a fee-for-service basis; limitations ofservice volumes apply.

Hospitals are financed on a dualbasis: investments are planned bythe governments of the 16 Lnder,

and subsequently co-financedby the Lnder as well as the fed-eral government, while sicknessfunds finance recurrent expendi-tures and maintenance costs. Since

January 2004, the German adap-tation of the Australian diagno-sis-related group (DRG)-system isthe sole system of paying for re-current hospital expenditures, ex-cept for psychiatric care where

per diem charges still apply.

Germany 2004


27/62


27



Nurses

(year)

Physicians

(year)

Acute hospital

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)


Health care provisionAmbulatory health care is mainlydelivered by sickness fund-con-tracted GPs and specialists in pri-vate practice. Patients have freechoice of physicians, psycho-therapists, dentists, pharmacistsand emergency care. There is noformal gate-keeping system for

GPs (about half of ambulatoryphysicians), although their coor-dinating competencies have beenstrengthened in recent years, andsickness funds have been obligedto offer gate-keeping modelsto their members since January2004.

Acute inpatient care is deliveredby a mix of public and privateproviders, with the public sector

accounting for 53%, non-profit-making organizations for 39%

and the private sector for 8% ofacute hospital beds in 2001. Al-though the number of beds andaverage length of stay in acutehospitals have been reduced sub-stantially to 6.3 beds per 1000population and 9.3 days in 2001

Germany still ranks high onthese indicators among the pri-

or to May 2004 15 European Un-ion Member States (table 2). Thetraditionally strict separation be-tween ambulatory and hospi-tal care has been eased in recentyears by encouraging outpatientclinics at hospitals, trans-sec-toral disease-management pro-grammes and delivery networks.

From 1990 to 2002, thenumber of physicians increased

by 20%. The number of nurses in-creased by 8% in 2001 (table 2).

In 2001, salaried employees in in-patient care comprised about halfof the health care workforce.

Developments and is-suesSince 1990, the health care sys-tem in the eastern part of Germa-ny has quickly been transformed

to a Bismarck model of care. By2001, the gap in life expectan-cy between eastern and westernGermany had narrowed to 1.5years for men and 0.5 years forwomen.

In international comparison,the German health care systemhas a high level of financial re-sources and physical facilities.The population enjoys equal and

easy access to a health care sys-tem offering a very comprehen-

Germany 2004


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29/6229


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health care systemThe Greek health care systemis characterized by the coexist-ence of the National Health Serv-ice (NHS), a compulsory socialinsurance and a voluntary pri-vate health insurance system. TheNHS provides universal coverageto the population operating onthe principles of equity, equal ac-cess to health services for all and

social cohesion. In addition, 97%of the population is covered byapproximately 35 different so-cial insurance funds (compulso-

ry SI) and 8% of the populationmaintains complementary vol-untary health insurance cover-age, bought on the private insur-ance market.

The Ministry of Health and So-cial Solidarity decides on overallhealth policy issues and the na-tional strategy for health. It setspriorities at the national lev-el, defines the extent of fundingfor proposed activities and allo-

cates resources. Seventeen Re-gional Health Authorities (PeS-YPs) are given extensive respon-sibilities for the implementationof national priorities at region-al level, coordination of region-al activities and organization and

management of health care andwelfare services delivery with-in their catchment areas. Decen-tralization efforts devolved polit-ical and operational authority toRegional Health Authorities butstopped short of granting full fi-nancial responsibility. The PeSYPswere not given individual budg-ets and all financial transactionsstill have to be validated by theMinistry itself.

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31



Nurses

(year)

Physicians

(year)

Acute hospital

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)


Most secondary and tertiarycare is provided in 123 gener-al and specialized hospitals to-talling 36 621 beds, and 9 psy-chiatric hospitals totalling 3500beds. Public hospitals outside theNHS include 13 military hospi-tals financed by the Ministry ofDefence, 5 IKA hospitals and 2

university teaching hospitals. InGreece there were 3.9 acute bedsper 1000 inhabitants in 2000(table 2). Approximately 75% ofbeds are provided by the pub-lic sector; 243 private hospitals,mainly general hospitals and ma-ternity clinics, account for 25%of all hospital beds. The establish-ment of new regional universi-ty hospitals has counteracted the

inequalities in the distribution ofhospital beds to some extent, but

there are still significant patientflows to hospitals in the capital.

In 2001 there were 4.5 prac-tising physicians per 1000 in-habitants, one of the highest ra-tios in the EU 15. Meanwhile, de-spite concerted efforts to increasethe number of nurses at 3.9 per1000 inhabitants in 1999, this

remains one of the lowest in Eu-rope (table 2) .

Developments and issuesIn the early 1980s the incep-tion of the NHS coincided withthe introduction of the social-ist principles of equity, solidarityand equal access to services thatthe newly-elected governmentwas trying to infuse in public ad-

ministration. The development ofrural surgeries, primary health

centres, public hospitals and re-gional teaching hospitals result-ed in a number of significant ad-vances in the populations accessto effective health care servic-es and an improvement in vitalhealth status indicators. Despitethese achievements a number ofchallenges remain, for example:

drafting a National Action Planfor Public Health, integratingprimary care services, establish-ing a clear distinction betweenthe purchaser and provider sidesof the health care market, reduc-ing the high level of pharmaceu-tical expenditure and the needto modernize NHS managementby introducing market mech-anisms. The latest NHS reform

(Law 2889/2001) underpins theeffort to introduce private sector

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32

efficiency tools into the NHS, buthas remained largely inspiration-al and is currently under review.

The Greek summary was written byChristina 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.


33/6233


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemIrelands health care system ischaracterized by a mix of publicand private health service fund-ing and provision. The govern-ment holds overall responsibili-ty for the health care system, ex-ercised through the Departmentof Health and Children (DOHC).Until January 2005 the provisionof health care and personal so-

cial services remains with sevenregional health boards and theEastern Regional Health Author-ity (ERHA) that serves the Dub-

lin area.All residents are eligible for all

services. Category I patients, 29%of the population, hold medi-cal cards that entitle them to freeservices, particularly in prima-ry care. The qualification crite-ria for these cards are largely in-come- and age-related. CategoryII patients have cover for publichospital services, subject to somecapped charges, but must make a

contribution towards the cost ofmost other services.

Voluntary health insurance(VHI) has played an importantrole in the Irish health system foralmost 50 years. In 2002 com-munity rated voluntary health

insurance covered almost 50%of the population. The VoluntaryHealth Insurance (VHI) Board,set up in 1957, operates as a not-for-profit, semi-state private in-surance body with board mem-bers appointed by the Minister ofHealth and Children. The Boardholds 80 % of the market share.Approximately one quarter of thepopulation have neither a medi-cal card nor health insurance. In-

Ireland


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2001 2002

Austria 2 174 2 220

Belgium 2 441 2 515

Denmark 2 523 2 580

Finland 1 841 1 943

France 2 588 2 736

Germany 2 735 2 817

Greece 1 670 1 814

Ireland 2 059 2 367

Israel 1 623 1 531Italy 2 107 2 166




Spain 1 567 1 646

Sweden 2 370 2 517





dividuals join VHI because thisguarantees more immediate ac-cess to some hospital interven-tions. Care funded through VHImay be provided within state,

voluntary sector and private hos-pitals.

Health care financingand expenditure

The health service remains pre-dominantly tax-funded: approxi-mately 75.2% of health expendi-ture came from public sources in2002 (figure 1). Other expend-iture can be attributed to out-

of-pocket payments for prima-ry care services, pharmaceuticalsand private hospital treatment aswell as payments to voluntaryhealth insurance providers. Ac-

cording to the Irish Central Sta-tistical Office, in 2002 total ex-penditure on health amountedto 8.2% of gross domestic prod-uct (GDP), with 6.6% on pub-

lic expenditure. OECD estimateswere 5.5% for public and 1.8%for private expenditure (figure1). This seems low as expendi-ture has increased substantiallybut is masked by strong econom-ic growth. US$ PPP (purchas-ing power parity in US dollars)per capita expenditure on healthcare in 2002 was US$ 2367 (ta-ble 1).

Health service funding is deter-mined annually in negotiationsbetween the Department of Fi-nance and the DOHC. These budg-ets are influenced by demograph-

ic factors, commitments to serviceprovision and national pay poli-cies. The Department also providessome direct funding to voluntaryhospitals and other service deliv-

ery agencies in the voluntary sec-tor. The ERHA enters directly intoagreements with these agencies.

Health care provisionGeneral practitioners (GPs) areself-employed, 50% are in sin-gle-handed practices, others inpartnerships of (typically) twoor three. The majority treat bothprivate and public patients, and

enter into contract agreementsto provide services for CategoryI individuals in return for capi-tation-based payments for treat-ment. The GPs have a complexgatekeeping role: individualswho are not entitled to free pri-mary health care may go to sec-ondary care facilities. There is asmall charge for consultations ofnon-emergency cases that havenot been referred by a GP.

Multi-disciplinary primary careteams are being developed andare intended to serve a popula-tion of between 3000 and 7000people depending on wheth-er the location is urban or rural.Between 600 and 1000 primarycare teams will be phased in over10 years, the first 40 to 60 by the

end of 2005. The health boardsalso are responsible for deliver-ing a range of health promotionand public health services acrossthe country, taking account ofboth local needs and nationalstrategies for the general popu-lation as well as specific groupssuch as Travellers.

The public hospital sector in-corporates voluntary and health

board hospitals. Health boardhospitals are funded directly by

Ireland 2004


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35



Nurses

(year)

Physicians

(year)

Acute hospital

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)


the state and administered by theboards. Public voluntary hospi-tals are financed primarily by thestate but may be owned and op-erated by religious or lay boardsof governors. In 2000 therewere 60 acute hospitals in Ire-land, 23 of which were locatedin the ERHA. In addition there is

a small number of purely privatesector hospitals. Hospital con-sultants are paid on a salaried ba-sis for the treatment of public pa-tients. Furthermore, the contractspermit extensive private practicereimbursed on a fee-for-servicebasis.

Public/voluntary hospital bedsare designated for either pub-lic or private use (80:20 recom-

mended ratio) in order to protectaccess to hospital care. Data from

2000 indicate that private use ofbeds is higher for elective proce-dures, at around 30%. In 2002there were 3.0 acute care bedsand 2.4 physicians per 1000population, both below the EU-15 average (table 2). With 15.3nurses per 1000 population in2002 the number of nurses is

among the highest in the EU-15 (table 2). There is an identi-fied need for significantly highernumbers of general practitioners,other primary care workers andhospital consultants to imple-ment planned reforms and com-ply with the requirements of theEuropean Working Time Direc-tive.

Developments and is-sues

Health is a significant sociopo-litical issue that features consist-ently as a source of dissatisfac-tion, particularly among poor-er non-VHI members. Signifi-cant additional resources havebeen invested, with concerted at-tempts to reduce the inequalitiesin health outcomes between so-

cioeconomic groups and to im-prove access to and availabilityof public health and social careservices. However, the propor-tion of the population fully en-titled to free services has beendecreasing because of econom-ic growth. Private patients aretreated more rapidly within pub-lic hospitals, especially day cases.The National Treatment Purchase

Fund, a major initiative intendedto reduce public waiting lists, has

Ireland 2004


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37/6237


European




Israel

Luxembourg

Ireland

Finland

Spain


Italy

Denmark

Sweden

The Netherlands

Belgium

Portugal

Greece

France

Germany

6,1 2,6

4,9

4,9

5,3

5,4

6,25,3

6,3

7,1

7,4

5,7

6,4

6,3

5,2

7,2

8

1,1

1,6

1,7

2,1

1,42,7

2,1

1,3

1,3

3,2

2,5

2,9

4,2

2,4

2,8

Public

Private


Organizational structureof the health systemThe Israeli health system is fi-nanced through social insur-ance and taxation and based onregulated competition betweenhealth plans. The introduction ofnational health insurance (NHI)in 1995 achieved universal cov-erage. The Ministry of Healthhas

snapshots of health systems

Documents