A health system is the arrangement through which health services are delivered. It can be defined to include all the activities that have the primary purpose to promote, restore, or maintain health.[1] These include formal health services, traditional healers, care of the sick at home, and public health activities, such as health promotion and disease prevention. A healthcare system consists of two functional components-financing and provision.[2] In some cases, both are integrated; in others, one entity may manage funds, and other bodies purchase and provide the services.
Health Care Financing
Health system financing is the process by which revenues are collected, pooled, and allocated.[3] Collection of revenue is from primary sources, such as households and firms, and secondary sources, like governments and donor agencies. The pooling of financial resources means that contributors share financial risk. Purchasing is the process through which revenues are allocated to institutional or individual providers to deliver interventions. These lead to the delivery of healthcare services.
Provision of Health Care
The provision of health care is the activities that lead to the delivery of interventions.[3] Personal are preventive, diagnostic, therapeutic, or rehabilitative services consumed directly by an individual. Non-personal services apply to collectives, for example, mass health education, or to non-human components, for example, sanitation.
In some countries, health services are provided by the government; in others they are provided by the private sector; and in some both sectors provide health services. The structure of health services also affects access and how doctors and nurses are distributed.
Classification
Broadly, health systems can be financed in four ways-out of pocket payments; taxation; social insurance; and private insurance.[2] In the latter three ways, resources are paid for before spending occurs, resulting in a pooling of funds. Many health systems are mixed, and the mechanisms of two or more systems operate together.
Out of Pocket Spending
Direct payment for services is the most common way to pay for health services worldwide.[4] In 60% of countries with incomes below $1000 (£683; €754) per capita, out of pocket spending is 40% or more of the total expenditure. In contrast, only 30% of middle and high income countries depend to such extent on this kind of financing.[1] In this system poor people may be unable to pay for their health care or will be impoverished as a result of trying.
Tax Based System
In this system revenues from taxation are the predominant source of healthcare spending.[4] One of the advantages is that it pools risks across a large population. However, the revenues collected may not be used for health alone but may be shared with other public services, so complaints about underallocation of resources to health are common.[4] National taxes are the main source of revenue in Greece, Poland, Portugal, Spain, and the United Kingdom.[2] Part of the tax revenue from the sale of tobacco has also been used to finance health care in Belgium and the United Kingdom.
Social Insurance
Fund raising is tied to the income of members, typically in the form of a percentage of members' wages, in this type of scheme. Premiums are collected separately from general state revenues. In direct payment schemes only the user is responsible for the payment for his or her medical treatment. This differs from general taxation because in tax based systems, people contribute in an indirect way through taxes, whereas with social health insurance people directly pay for their insurance. Ghana, Nigeria, Japan, South Korea, Taiwan, Switzerland, Germany, and France have social health insurance systems.
Private Health Insurance
Premiums are paid directly from employers, associations, individuals, and families to insurance companies, under this type of scheme. Generally, private insurance is voluntary and social insurance programmes are compulsory. The problems of adverse selection and risk selection are higher with this system. Adverse selection is the tendency for insurance to attract only people at higher risk, raising the average cost of insurance beyond the reach of many people.[4] Risk selection is the process by which insurers screen potential clients and try to enrol people who present health risks that are below average. The United States is a good example of a health system that relies predominantly on private health insurance. In many other countries private health insurance coexists with another type of health system.
Comparing Health Systems
Comparing health systems is a difficult task. The toughest part is to decide on what to compare. Should we compare the health indicators of the country under different systems or their outputs or the satisfaction of the consumers? A comprehensive scale that encompasses all may be difficult to achieve. As a patient, access and quality of care may be more important; as a doctor, working conditions, pay, and lifestyle may be more important.
In 2000 the World Health Organization ranked the performance of the health system in each of its member states.[1] France took the top spot, and Sierra Leone the bottom. The UK was ranked 18th and the US 37th, only two spots above Cuba. Australia was at 32 and Japan at 10. However, the criteria used, the method for ranking systems, and shortcomings in the data have been criticised.[5]
In a comparison of deaths in 19 industrialised nations that should not have occurred with effective health care, France and Australia were in the top five and the US, the UK, and Ireland in the bottom five (figure 1).[6]
 | Figure 1. Deaths that should not occur with effective health care, 2002-3[6] |
Another comparison of six countries by the Commonwealth Fund, based on long, healthy, and productive lives; quality; access; equity; and efficiency, ranked the UK first followed by Germany, Australia, New Zealand, Canada, and the United States ( Table 1 ).[7]
The Netherlands came first in a recent comparison of 31 European countries on 34 quality indicators that focused on patients' perspectives. The UK came 13th.[8]
Clearly ranking health systems is difficult, and it is worthwhile looking at systems individually. Indicators such as infant mortality rates have been used as a measure of health system performance for many years, especially in developing countries, because they relate to quality, effectiveness, and accessibility of healthcare services in the community ( Table 2 ).[9]
Australia
Australia has publicly funded health insurance, called Medicare. Established in 1984, it covers the entire population and is funded through taxation known as the Medicare levy, which is currently 1.5% of taxable income.[10] Poor people are exempt from the levy. Rich people who do not have private hospital cover pay an additional surcharge of 1% of income.
The government's lists the many services covered by the scheme and the fee applicable for each items. Medicare covers 75-100% of the fee depending on where care is received.[11] For instance, Medicare covers the total cost of treatment for people admitted as public patients in public hospitals if they receive care through doctors nominated by the hospitals. However, for private patients who choose the doctor who treats them, Medicare pays only 75% of the fee. If the fee is more than the benefit amount, the difference must be met by the patient as an out of pocket payment. These additional costs may, however, be covered by private health insurance, if the patient has this.
Australia encourages private insurance to supplement public coverage. Private insurance covers 43.1% of the population, and spending by private health insurance accounts for 7.1% of total health spending.[11]
Most doctors are self employed. However, a small proportion of doctors are salaried employees of the state. They often have the right to treat some patients privately and charge accordingly. An intern doctor in Queensland earns a base salary of about $A54 000 (£26 000; €30 000; $39 000) a year.[12]
Japan
Japan was the first non-Western country to introduce social insurance.[13] Japanese health insurance falls into three categories-society managed health insurance, government managed health insurance; and citizens' health insurance.[14] The benefits, however, are the same for all plans.[14] Private health insurance is rare.[15]
A national schedule lists fees for all residents regardless of their health plans and where they receive care.[16] It lists all procedures and products that can be paid for by health insurance and sets their prices. Billing the patient for fees not covered by insurance is prohibited.
Patients can choose any doctor or hospital. Most doctors practise privately, and many hospitals are privately run, however, most large hospitals are owned by the national or local governments or universities. Hospitals are concentrated in urban areas, and rural areas lack facilities.
Hospital doctors in Japan often complain about having a high workload and little pay.[17] In a survey in 2006, 44% of doctors surveyed said that they worked more than 56 hours a week.[17] The average annual salary of a hospital doctor in June 2007 was ¥14m (£95 000; €110 000; $140 000). A doctor who ran a clinic earned ¥25m, and a doctor who worked at a clinic earned ¥14m.[17]
Doctors qualify to run a clinic if they have finished a two year mandatory medical internship in a hospital. But many young doctors opt to work in hospitals for longer to improve their skills and because opening a clinic takes a huge investment.
Nepal
In Nepal the private sector offers treatment at a high cost, and the public sector is inadequately resourced to fulfil demand.[18] Health insurance is almost non-existent, and about 70% of total health costs are met out of pocket by patients.[19] For this reason spending on health is a big cause of indebtedness and impoverishment, particularly among poor people.[19] There are limited free public services for poor people, but the criteria for access are unclear.
Doctors can be employed by the public sector or in private hospitals, or they can work independently. Rural areas of Nepal lack trained staff, and Nepal is affected by the "brain drain" of doctors emigrating abroad.
Every year an average of 400-500 non-Nepalese doctors who trained abroad come to work in Nepal.[20] Many are affiliated to international aid organisations, and some come on their own to work in rural areas. The adventure of working in a setting with limited resources and the satisfaction of contributing in an area of need is tempting for many doctors.
Nigeria
In Nigeria health is financed from multiple sources-tax revenue, out of pocket payments, donations, community financing, and recently health insurance, after the inception of a national health insurance scheme. Federal, state, and local government have responsibilities for providing health care.[21] The state and local government are responsible for all financial aspects of primary and secondary health care. The federal government sets overall policy goals, coordinates activities, and ensures quality.
Doctors, nurses, and other health workers in Nigeria face challenges such as poor pay, lack of facilities, and lack of opportunities to develop professionally. In Nigeria most doctors earn less than the equivalent of £500 a month, which has led to strikes by doctors.[22] Many Nigerian medical students and junior doctors leave the country soon after graduation, largely to developed countries of Europe and North America.[23]
United Kingdom
When the UK's National Health Service (NHS) came into existence in 1948, it was the first health system in any Western society to offer free medical care to the entire population. It provides care on the basis of need and not the capacity to pay. The NHS is centrally funded; aims to provide quality care that meets the needs of everyone; is free at the point of need; and is based on a patient's clinical need, not their ability to pay.[24] Charges from patients comprise just 1.3% of total NHS spending. The remaining 98.7% comes from central funds, with 90.3% from taxation and 8.4% from national insurance.[25]
Primary care trusts are in charge of primary care and control about 80% of the NHS budget.[26] The system relies heavily on general practitioners, who are usually the first point of contact. Secondary care is provided through NHS hospitals and specialist centres, which provide care to patients referred by general practitioners or in emergencies.[27]
About 11.5% of the population has some form of private medical insurance, and this has remained reasonably constant since this market grew rapidly in the early 1990s.[28] Perceptions of long waiting lists in the NHS is one reason why people buy private insurance, which allows them faster access and a wider choice of specialists, facilities, and timings for treatment.[28]
Hospital doctors are employed by the NHS. General practitioners are self employed under contracts negotiated with the NHS. Ambulances are provided free by the NHS. Junior doctors earn a basic salary and are usually paid a supplement based on extra time worked beyond a 40 hour standard working week and the intensity of the work. Junior hospital doctors with a 50% supplement earn £32 793 in the first foundation year, increasing to £40 674 in the second foundation year.[29]
United States
Health care in the US is funded through private and public insurance. Coverage of private health insurance is about 67.5%, most often employment based.[30] People can also purchase insurance directly from insurance companies. Among the publicly funded insurance programmes are Medicare, for old and disabled people; Medicaid, for poor people; the State Children Health Insurance Plan, for poor children; health care plans for military personnel; and other state specific healthcare plans.[31] However, 45.7 million people (15.3%) lack health insurance,[30] making the US the only wealthy industrialised nation that does not have universal health care.[32] This is despite it spending 15.2% of gross domestic product on health, second only to the Marshall Islands among all United Nations member countries.[33]
The US attracts medical graduates from around the world each year. International medical graduates account for about 25% of the doctors in the US.[34] However, at anytime there are 5000-7000 international doctors who are unemployed.[34]
The average annual salary of a family doctor in the United States was $172 000 in 2007-8.[35] Doctors in specialties such as orthopaedic surgery and radiology can earn more than $400 000 a year.[35]
Capabilities and Needs
Each country has its own unique health care system based on its capabilities and needs. For instance, the US market based system results from a belief in freedom of choice and personal responsibility, and the NHS in the UK reflects a belief in state intervention and universal access to medical care (Box).
Source : http://www.medscape.com/viewarticle/703712
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