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ComparativeHealth Policy Second Edition
Robert H. Blank New Colfege of Fforida and University of Canterbury rrn c'l
Viola Burau University of Aarhus
O RobertH . B tankand V i ol a B urau2OO4,2OO7 Atl r ightsreserved. N o reproducti on, copy or transmi ssi on of thi s p u b Li cati on may be madew i thout w ri tten permi ssi on. No paragraphof thi s publ i cati onmay be reproduced, copi edor transmi tted sa vewi th w ri tten permi ssi onor i n accordance w i th the provi si onsof the Co p y ri ght,D esi gnsand P atentsA ct 1988,or underthe terms of any ti cence p e r mi tti ngti mi tedcopyi ngi ssuedby the C opyri ghtLi censi ng A gency,90 T o ttenhamC ourt R oad,LondonW1T 4LP . An y personw ho doesany unauthori zed act i n retati onto thi s publ i cati on m a y be l i abteto cri mi naIprosecuti on and ci vi lcl ai msfor damages. T h e authorshaveassertedthei r ri ghtsto be i denti fi edas the authors o f th i s w ork i n accordance w i th the C opyri ght,D esi gnsand Pa tentsA ct 1988. F ir stedi ti on2004 Se condedi ti on2007 Pu b ti shed by PAL C R A V MA E C MILLA N Ho u ndmi tl s,B asi ngstoke, H ampshi reR C 216X Sand 1 /5 Fi fthA venue,N ew Y ork,N .Y .10010 Co mpani esand representati ves throughoutthe w ortd PAL C R A VMA E C MILIA Ni s the gl obatacademi icmpri nt of the P aLgrave M a cmi ttandi vi si onof S t.Marti n'sP ress,LLCand of P al graveMacmi ttanLtd. M a cmi [[ani R i s)a regi stered trademarki n the U ni tedS tates,U ni tedK i ngdom a n d other countri es.P atgrave i s a regi stered trademarki n the E uropean Un ionand other countri es. ISBN13:9/8 O 23O 00139 B ISBN -10:0230 00139 4 ISBN13:978 O-23O OO14O4 ISBN10:0 230 00140 B
hardback hardback paperback paperback
T h isbook i s pri ntedon papersui tabLe for recycl i ngand madefrom futty m a n agedand sustai nedforestsources.Loggi ng,pul pi ngand manufacturi ng p r o cesses are expectedto conformto the envi ronmentaL regul ati ons of the co u ntryof ori gi n. A ca t al oguerecordfor thi s book i s avai Labte from the B ri ti shLi brary. A ca tal ogrecordfor thi s book i s avai Labte from the Li braryof C ongress. r0 16
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Pr in tedi n C hi na
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6 12
5 11
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2 0B
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Contents
Lis t ol lir r rc s , F i g trrc s,tri l ' l i l tl c s
IX
I ' r c ft r t ' t , t o tl tc Sc c o ttdF .d i ti ttrr Lis t ol A lt l trc t,i trti o tts
XV
Conr pa ra ti v c H c i rl d r l )o l i c y : An In troducti on I lc elt h c rl rc i rs p u b l i c p o l i c l ' ( . or r r p rrrrtti v h c c :tl th p o l i c v ( , 1as si fi c rrti o n<sl f h e ra Ithc rrrcs v s rc nrs ( . < lunt ri c ss c l c c tc cfo l r s trrc l y , T v pc s o f h c e l th c rrrc ( ir or v i n s p ro b l c rn si n h c e l th p o l i c y ( . ot t c lr rs i < l n s T hc Co n tc x t o f H c a l th C a rc l r rs t it t rt i o n rrl i s t c r p l en rrti o n :: c o l rtr' .rstinq P ()li ti crtl svstcrrs ( lu lt u rrtl c x p l rrn rrti o n s : c trl ttrrel /h i s tori cal i rtct< l rssha pi ue hc r r lt hc rrrc lrirncti on a l i st ex pl rrn rrti on s: 1'rop rrl rrti on,'uvcrtl tlt a n cl ec oll( ) n lrc s ' l' hc c o n tc x t < l f h c rrl thc a rc F undin g , Pro v i s i o n a n d Gc l v c rn a n cc ( . r lnr p rrri n gfu n c l i n go f h c e l th s y s tcl ns ( lr nt r
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The Mcdical Profcssion \(/ho ckrctorsare T 1 ,p c sancl sctti ngsof rnccl i calpracti ce R e [o rnrirrg rrrctl i t:rI prrl r' ti t' t' Prry i n g,for mccl i calcarc T h e o rsani zl rti on of cl octors'i nterestsancli rcccssto thc p o l i c ," p - r()cess [)o c to rs, thc statc rrnclheal th pol i cy
131 133 1.36 t4l t47
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Prefaceto the Second Edition
Wc w ro t c thc fi rst ccl i ti orrof tl ri s bo< l kto fi l l rr gap i rt conrprrrrtti vclr calt h p < l l i c v .A l th< l rrghfherc havc bcen nunrcrous books abottt rhc hcal th pilli, r i, : r r ' c i c s < l f spl cci fi ccountri cs ancl rr hancl ful of books rhrt cottrpr.rre ()rl r ()w rt n l rti < l rrs, rescrrrchi n e vari ct,vof c< l utttri csconr,' i ttccrlus t hr r t e t hc rn o rc i n c l usi veconrl -ri rrrrri vc covcrrrgcl v< l ul clbe hcl pful i n cl trci cl r r t ing i s s u c sr.rncl1-rrobl cnrs surrorrrrcl i nghcal tl r cl rrc. Thcrcforc, w c poolcclour s h a rc c lkrrow l ccl geoi rr cl i verscsct of hcel th ci l rc svsterl s rrtrclw r ( ) t c r r l i n tro c l u cti rl nto thc hcal rh pol i cy oi rti nc countri cs. A l thotrgh i t l vr t swr it rc n p ri rnari l y w rth stu(l cl rtsi n rni ncl ,w c rrregreti i i cd rhrrrthc l i rst cclit i
l l a s e clon rnrrrryfrrvorrrabl crcvi cw s i n j oLtrn,rl serrcl otr i ttpur ir r r t n rvh< lusctl tl rc fi rst ccl i tr or r .r 'vc s c h o l rrrsrrnclfr< l nrtcrrchcrsrrrrclsrLrcl cnts h a v c th
Preface to the Second b.ditictn
xiii
T h roughout the book, w e put he:rl thcare i n a broadcr soci a l cont ext and reveal its interclependcncewith factors oftcn cxcludeclfrom irnirlysis. H e a l th ci rre, w c arl l uc, cannot be separatcd fronr otl .rcr i ss t r est hat the envi ronm ent : lnd i rn p i nge on l .real thsuch as ecortomi c i rtecl ual i ti es, of hor.neci rrefor the el cier lyancl s o c i a lservi ces.Thus, w c i ncl ude anel l yses a n a rr rry of publ i c heal th i ssucs that cunrul rrti vel v i nrpttct or t healt l- t o L l tc omcs morc thal l rnedi crrl servi ces.W c al so expl orc w he t her t hc n re d i calnrocl elancl thc he:rvyernphasi son curati ve rl ccl i ci rrci s t he r nost thc ltcrtlth of poptrllrtiolrs. cffective wiry t() rrclclress O l - r:rpterI i ntr()cl uceshcal th pol i c,vrrnd thc i nrpact of gl obrtl t r cnclsof ancl hei ghtencclptrbl i c cxpcct r r rrgci ng,tccl rnol ogy cl i ffr-rsi on 1 ' l o p r :l rrti on t l'r c ti o n s on thc hcal th systcnrsof cl cvcl opcdnati ons. It rtl s< lcl i sct r sscs i n ' rp o rtarrccof conrparati vel rerrl thcare anrrl vsi srtnclprcsctrtsth c r yp
Prefacc to the SccctndF'ditirtrt
x lv
'fhc d,i-scussion demotrstratesthe corrtinued t,vpologiesof hcalth systetrs' di ffcrcnces w i tl -ri n overal l trerrd s of i mp o rta trce ur tt' u" l ' i :' 1-' l ti fi t l .ns'(' orrl pl exit , v of hcel th s,vste c o n v c rg en ce, as w cl I rrs' tothe compl exi ty cli'stirrctsubil'lto oftctr c1r-rite arisesfrom cliffcrentiatiori of health svstctlls cncotllpassesnlorc than 6erlltl-l ,r,ri"n-,, irnd fr.r' thc fact thrt health carc s y s tc l l l s ' :--..1...--.' ." , col l l parl l tl vc l rttlt lysis T h i s c c l i ti tl n offers rr gcl l ui ncl y cr()ss-cotl l l trv rv h e re w C ll S ..,_" u,t-' .,,.,l ravcw tl rkcdl l crt> sstl rel l tl tttl cl l rri cstl ftrt t r rc s p c c tl Vec()Ll l l tfV arl cl tl rcrrreti ccX pcrti se.Ftl rl tsthi shl tsl l cetl fhct r lt lst thi s has < l i c()tl rscrcqtri rcclr r f r r ir c rc i ti rrg p rl rt ()f ,,,ur.,,l l " b,rrrrti ot.t,l l trt grerrtl Vfecr litt" ui ng rl i fi ces rl pposi tc cech < l ther s h a rc < tfc < torcl i nrtti on. thc sp at ir r l rvhererrs thc fi rrt..l i ti ," ' , rrrtc cth l i s p roccss* t,i i .]* ,,.t]' g '' ' c: 'lcltl l 6rc gl ol l al thi s ti rrl e' t' otttl tlspr frl u rc 9 f 9 ur c.l l l t[.t-ati 1;tt Irl s l .l cl ctl pllr t icforc i tl .ts l l l i l l l v L()l l ti l r(l l l ts'W c arc thcre thrcc c< l t-tl l tt' tet i n q rrc r()ss rvr t Ysit . t f< l r thc cl i i fcrcrl t ru l a rl yg rr rtcful to < l ur fcspccti vc trrl i vcrsi ti cs .f A t thc 11tt1ut1 '''i11 w h i c h th c.v hevc ,r.' n1-" i"J otrr col l aborrrti otr' t llc rt prrrt-ti l l l c rcscrrrc6i cl l rrvshi p frt' t lr A l rl .rtrs ,V i .l a l l Lrrrr. ' l ccci vc.l L rtri v e rs i ty' sl {escl rrchl rrl trrl cl eti tl tl thl l tl )r()V i C l ccl vel Lrl rl l l cspeccir lr t hir ll
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List of Abbreviations
A ( l( . AI III A N' lA I I NI A I'iN,lI ( lA ' l' ( . 1X . ( ll I t l ( . 1) lr l) l llls l) l{ ( is lt l' l{ l: t l ( it \ I S ( ' l) l' (;M(l ( ; l) I I A ( l( l II(.FA I I ( lQ l I I lr r \ I IMO l ll A lM ( . I l' A . lM A M US Nlt I ( . s MOl l M RI N, { S A NHI NHS NI ( lE NI H NZ M A O E ( lD
r \ c c i c l e rrt(.o rn 1 -l c rrs rrti(.o o nrn rrri ssrorr A r c e H c rrl rh l ' ,o rrrc l(N s c w Z c rrl :rrrcl ) A n rc ri c ru rM c c l i c rrlA s s o c i e ti o rr lJ ri ti s h V l c c l i c e l A s s o c i a fi o n lJoclvNlrtssInclcr c ( )l n p r.rfc ri z c c l e x i rrl t< l n ro e t'ephv ( . c n tc rs fo r [)i s c rrs e(i < l rrrro le rtrl l )rcr,' cnti on(tJS ;\) ( . ro rv n Il c e l th l :n fc rp ri s e(N c r n,Zc.rl rrntl) ( lc n tra l l )rrrv i c l c n lf i rrrrtl(S i n g :tporc) l) i s rri c t l l c e l tl r l l o e rrl s (N c n ,Z crrl rrnrl) c li e s n ()s i s rc l rttc rl s r()r.l p s l- . p i c l c rn iectrc lI)rrn rl c rrriAc l c rt arrrl I{csporrses F .u r< 1 1 ' rcIlrrn ni
XVI
List of Abbreuiotiorts
PACE PtrT PHI PH O PH S Pl)O ItIJ A QA L Y QW I] SA ItS S(IH II' Sl l s f(.M L J V II V7 l IO
Prog;ramfor All Inclr-rsive(lare for the F.lclcrly(USA) positron crnissiontolnography pri vi l tc hcal th i l -rsurance P ri rnary H eal th Organi s:rti ons(N cw Zcal ancl ) P r-rbl i cH eal th S ervi ce(I-JS A ) l)rcfcrreclProviclerOreanizi-rtion l { cgi onal H eal th A uthori ti es (N ew Zcal and) qual i ty acl j ustecll i fe years Qual i t,vof W cl l l l ci ng S cvcreA cLrtel tespi rrttoryS vrrcl ronrc s eal th l nsurrr.rccl )rogrrrrn(tJS A ) S tatc (l hi l cl r-en' H s< l ci o-cc< l rronlsrrrtus c tracl i ti orral (l hi nesenredi ci nc ul trrrvi ol ct l l W orl cl H eel th Orsani zrrti on
Chapter I
ComparativeHealth Poficy: An Introduction
t { c elt h c r r r eh a s l rl w a y s b c c n rr c o n tro v c r si rrlpol i cv i ssttc,br-rtovcr thc l ast neti ons. c lec ec lcits h rrsb c c < l rn el ' rrn a j o r a rc r' ro f c ()nccnri n rrl l cl evcl opecl technol ogi es, attcl A geing 1- lo p u l a ti < l nth s . c ;l ro l i fc rrrti < l no f ncw rrrccl i crrl rl l ttone othcr frrctors,havc height c nc cpl u b l i c c rp c c ta ti o n s r' rn ccl l en r rurcl s, c lc v r r t c chc l a l th c rrrcto th c to p o f th c p o l i ti crrlagcncl rr.l ntcnsi fyi rrgprcss ur c s ( ) n po l i ti c e l l c :rc l c rsto n rc c f ri s i rrg prrbl i c cl crl rrtrcl sfor cxpancl ccl s er v ic cc onf l i c t rl i rc c tl y w i th th c n c c c lto constrrti tthcrtl th crrrccosts rtncl t o nlllnlr gc s c l l rc e s o c i c trl rc s o u rc c s .' l' l .rus,cl csl -l i tcnrej or cl i ffercrrces cl cclatrclgovcrnccl , , r lnr ( ) ngc oun tri c s rrst< lh < l w h c rrl thc e rc i s i urrcl cclprovi g( ) v c nnrc n t c< l ntrovcrsy ancl probl erns n( ) h a s b e c n rrb l c to e s c rrpcthc ac c or npr r ny i n gh c e l th c a rc i n th c 2 l s t c c ntury, rrl thoughsonrc secnrto l )c c oping,s igr ri i i c a u tl yb e ttc r th rrrro th c rs . W hy i s that so? ( iiv c n t hc u n i v c rs e l i ryo f h e a l th c rl rc r :rsa probl etn, ()l rel l ust tl uesti on whc t hc r wh a t s o v c n rn re l rtsc k l a b o u t i t - thc pol i ci csthcy acl tl pt- tnrrl < cs rr cliffcrcncc. Ancl if it clocsnrrrttcr,what rrprproachcsrtttclsrrrttcgicsoffer t hc nr os t ho p c < l f rc s o l v i n g o r n rrrn rrg i ngthe cl i l emrl rrsof hcal th care? l) oc s s inr pl v s ;l c n c l i n gn r()rcr1 r()n c yi n rp r,ve the l rcrrl th< l f a poptrl ati on? tl rcsc tl trcsti onsby cxanri rri rrg lf uot , whr r t c l < l c s ?T h i s l ro o k e c l c l re s s cs hc r r lt hc ar c p o l i c v rrc r()s srr c o l l c c ti o rro f coutrtri csthat hrrvctakcn cl i vergc nt appr ( ) a c l rc srrn c e l s ta l rl i s h c ca] v a ri ery of mechani sttrsf< l rcoveri ng the healt l- rneecl so f th c i r;l o p u l rrti < l n s . It rrl so rrttrrl ysestrencl s w i thi n rrncl ir c r os st hc s c c o u n tri c s i u < l rd e r to d c tc rn' ri new hcther ()r not therc i s a c ( ) nv c r gc nc ci n h c rl th p o l i c y rrm o l rl ac l cvel opecltrati ot.ts,as argLrcdby s < lm e< lhs c rv c rs .
Heafth care as public policy T hc t er m ' p o l i c y ' h a s a w i d e ra rrg eo f m e ani ngsi n currcnt E ngl i sh Ll sage. l) olit ic ians a n c l p a rti c s p rc s c n t th e i r i n tended acti ons as pcl l i ci esto be pur s ued anc lth e y c l c fc n dp a s t a c ti o n s a s pol i ci esto be extended.P ol i ti cal c om m ent ato rs o ftc n ta l k a b o u t i r g o v entntent' s housi ng pol i cy, cri me policy or drr-rgpolicv in general terms, rvhile others clebate tr specific €lovernmentaction. Policy,then, can be used to refer to generalstatements
2
Cornltardtiuc Health I'olit't,
o f i rttc n ti o rr,p a st or prcscnt r,rcti ons i n pi rrti cul ar i l rerrs,()r rr sct ()f sti rncli n g rtrl e s to g ui cl e i rcti ol rs.A l thoLrgh al l orgrrni zi rti orrshave pol i ci cs, rrt l e a s ti rt th e l a ttcr sense,thc focr-rs of thi s book i s on tl rc pol i ci esof govcrrrn l e rrt.' Pu b l i c pol i cy' i s cl cfi neclhere as a cl cci si outrrkcn bv tl rc sovernl n e n t o r < > rtl te h al f of i t. A l th< l ughusual l y vi cw ecli l s r.l ni rcti on, rr cl cci si o n l l o t to a c t c o u l cirrl sobc a pol i cy. A l l hcal th pol i ci cs rhcn i nvol vc a funcl r, t' t' tc tl trlcll .r< l i cbcy a govcrrrnrel rtrl s t< >w hcther to takc rr spcci i i c.rrti orrot' to c l o n o th i n g (seeH ow l ett ancl l trtrl csh, 200.3). ()rl l v rh c q ()vcrrl ncnr hrrs thc l cgi ri nratceuth()ri fv ro rn,rkc cl cci si ons th rrt rtre l ti rtc l i rtsrrtrclcarri crl out i n fl rc nrrnrcof thc peopl c rrs a rvhol c. ()th c r < l rg a rti zl tfi otrs, such rrsnrccl i calrtssoci rrti ons ancl nursi rrgsoei c.ti e s, tl ftc rt rtta k c c l cci si < l ns thrtt rrffccrnrl rnv i nrl i vi cl ual srrs l vcl l rrs thc hcal th c .l re s v s tc l l trts a w l rol c. $fl hi l c thci r cl cci si onsnri qhr i ncl ccclhavc rt bceri l rg o tt l v h rrt thc sovcnul rcl l t ul ri nretcl l ' cl ocs. ther,' rrrcnot bi rrcl i ngl )v fo rc c o f l a w . Al tl rou{-rhthi s book i ncl url es rr cl i scrrssi < l
(.orrtpdrati ue H ed lth P ol i ct, of intcntron) pilst ()r present .tcti()ns in ptrticu\ar i-\rei\s) ()r ..\sct of st..urditrg rules to guide acti()r1s.Althor-rghail orgarrizrrtionshirve policics, rrt l e a s ti rt th e l a ttcr sense,thc focus of thi s l rool
A tt I rtt rt trlt r ct i t t tt
llc t r t lc ler s t < l ' ci rl l i s < l l a ti o l rfr()l r s ' c i a l w cl farc,..rc' pl oyarcl rt, h. . s i' g r r r r cilrrr' i g ra ti " p .l i c i c s . L fa c q i t w i l l bc rrrguccli n ohrr;rter ' ()vcrty, 7 t hat r hc hc alt h .f a p -P rrra ti .r c r* b e a s c rcpcrcl crtol r' i r-,.,r.p,,l r.i " , i t is on pr c s c r ib c c h l e a l th c a rc D o l i c v . ", I ' t r lllic p' lic1 ' c a . h e c .rt.' ,r,,ri r...r i l \ ()l rc ,i thrce basi ctvpes:rcgurat< l ry,, c lis t r ibut iv c a rrc l rc c l i s tri rrrrti v c(s c c L rw i , r966). r{ cgul at.ry p' ri ci cs ir lt l. r osc olls t ri l i l l tso r rc s tri c ti o n so n th c rrcti ons.,fg.,,,,1r,or i rrcl i vi cl ul rl s: t hc y pr ov ic lcr rrl c s.,i e ()n (l u c rw i th s .u rc ti < ,,l , 1.,,,r.k.].1 rrp' by tl re,aLrth< l ri ty , i g, v c r r r r . r t . l )i s tr.ib L rfi v c p .l i c i c s p r< l vi cl cscrvi ccs ,r bcrcfi ts t< l P r lr t ic t t lr t rs c sl n c n t\ ,rf s o e i c r1 ,.( )frr.rr.l i s r ri l tgfi yc p6l i ci cs ar" 1.," r..1,,,, t llc ll, t i, ll . f ;l tl l l l i c c rtti tl c tn c n ts ,r,v h i c h arc rrornrrrl l ycl cfi pcclrrs t6()sc s . . t ls ar r c ls c r v i c c sth a t w i l l b e rc i i t e l l i rrrl i ' i rl tr.rt, tr,,, * tr,.t-, ,i rc .l rl i l .cl y t o bc llr oc lt r c c cbl y r' ' o l trl ttrrrv i rc tso f i n c l i i ,i cl ual s, i rr prrrt 1.,..-.,,.r" tl rcy l acl < f lt c r c s ot t r c es.Irt o th c r w o rc l s ,s o c i c trrl u ,i cl ecfforr i , rr..,c.l c,l t() cffcct.rrtc t hc s c s o< lc lsf o r th c l l o l tttl :tti o rr.l )trb l i cc l rr i tl cl ncntsarc cl el i rrccl6y cach s ' c ic t 1' c lif f c r c rl tl vc l c P c rtd i rrg tt1 .r' . h ' r' v b r
4
Cctmpdratiue Hedltb PoLicl
c i ti z e n s. Of al l arcas of publ i c pol i cy, hcal th care i s one of th e m ost contrcversial Lrecirr-rse it alw:rys entails conflicts, especiailyin the regr-rlato ry a n d redi stri buti ve nrodes. Tl " ri s i s l t()t surpri si ng gi ven the high e m o ti o nal and ccouomi c stakes i rtvol vcd i n any pol i cy i nvol ving liic. c l e a tha ncl huge rrm< l untsof rcsources. In i rd cl i ti orrto thc potenti i l l l i fe/cl eathstakes i rrhcrerrti n rury,p olicies re g a rc l inghcal th crrrc,heal th pol i cy i s di sti ncti vc bccauscthe hcrrlt hcar c p ro fe s si ouIrrs by vi rtne of i ts spcci al i zeclknow l eci gea pri vi l cgccist at us i t. l Jccrrtrsc of thc ccntr alit r - of o f e x p erts i rr shapi ng rrnclc< l l rstrrri rri ng h c a l th professi onrrl sto thc cl cl i veryof hcrrl th crrrc,l t ptl l i cy' crrrro lr lv be s u c c e s s fuli f i r has tr l cast thc taci t sLrpportof thc nrccl i calconrr nunit y. s Iru rth c rnrorc,si rrccrnccl i calproi cssi < l rrrrll argcl y cl ci i nc hcel th nccclr r ncl that r r r e th c n rc rrrrsneccssl tryt() rncct i r, rurt i l ttr:rnptsl ty' rr g< l vcrttttrcrtt rrsk cortcl cr t t t t r t t iot t p c rc e i vcclrrs i rrrl tosi ngc()nstri ri nfs< l n thc pr< l fcssi < l ri J' hc cornpl cri ty ol provi cl i l rg Ircrrlt hcr t r c fro rn tl rcsc kcy strrl < chol cl crs. nrccl i ci ncfurthcr rci nfor ccst hc a n c ltl .rci rrhcrcrrtunccrtrri rrtysurroLrrtdi ttg p o w e r o f thc hcrrl th carc provi cl crsto i l tfl rrcnccthc dcl i very of r ncclicr t l s c rv i c c sancl thus sha;rchcal rh carc pol i cy. oi thc shi ft to war cls Oo n rpl i crrti ngthc pol i cv c()ntcxt, i n pert bccrtr-rsc s o ;l h i s ti catccl curati vc crl reovcr thc seconclhal i < l i rhc l 0tl r ccrrturr ',is t lt c fa c t tl ra t heal th crrrc spencl i nghrrs bccorrrcc()nccntrrrtccli rr rr rclat ivclv s n ra l l rrLrnrbcrof peti crrtsi n l e rrreLi l rL'surti l rss.l -abl c l .l cl crttor t st r r t t cs tl rc c x tc nt of rhi s c< l ncentrati < l ni rr tl rc IJS A , [rrrt si nri l ar prrtt enr s lll Irt s v s te l l l s es cl i vcrsc rrs (l anacl a rrncl Frrrncc hevc bccrt cl ocurrte r t t ccl. for l 7 pcr ccrtt ()f rtll hcalr h l c )9 (r,th c top I pcr cent of Lr\urs.l cL()urrterl c e re ex pcrtcl i turcs;thc r< 11' .5rpcr ccrrf usccl.5.5pcr cel rt;anclrhc tttp l0 pcr
Tabfc I .1 Distribution of beolth expandituresfor the USA lry nngnitttde of expendituresfor selectadyears 1963-1996 l)cr(ciltLtpc()l polttrlatiorrrtrtkcd hy cxpertditrrrcs
I96i
1970
1977
1980
Ie87
l()()6
'1'
t7' l ; 1.lli, .\()'l;,
26' ,\, .l.i'.|i, .i0'L 66"1,
27"tr' .llJ'fi, .5.t'.L 70'1, 90"1,
) L)"1, 39"/,, .t.5'.X, 70'\, L)0"/,,
I lJ'.11, (x) .l c) .5(-:, '.ii, 70"i;,
) 7',)", .l l.i'x, .i.i ',1/i, 69"/,,
L)0')1,
L)()"1'
T o p .5' )1, T o p l 0' .X ' Top .30')i Bottolrr .50',1,
-
.i',L
8u'.x, 4"/,'
lorrrt r,: Acl;r ptctl frorrr l l crl i enrl \l orrhti t (21)0I)
. ri/ ) /r t
n tt/ + /t'
.l'\'
.1"1,
An lntroduction c c llt r - ls ec69 l P c r c c n t. In c o l rtra s t,< l rrl v.l p cr cel l t of payrncnts so to thosc pat ier f s in f hc b .tt.r. h a l f .f th c p < l p ,ra ri . n.' l -h.sc i n thc brtt' ' r.50 pcr c et r t ilr c ur r c c l:l n rtv c r:rs cl tn n u rrlc x p e n c l i turcof $12-2i rr rnecl i crrl cgsts i ' lc ) 96 c onr par c c jw i th a l r rtv c rrtg cc x p e n c l i t ureof for tl r< l ser $.5C ,4.59 i n tl re r op I pc r c c nt ! ' l -h tl s ,th e rn a j o ri ty o f c i ti z cns are rcsl ' ronsi bl c c< l l l ccti vcl y f t lr a v c r t ' s r ll,rl l p ro l .ro rti o no f h c a l th c rrrespencl i ns.Morc.,vcr, fhcrc l .ras llc c r l: t ' r c llt r r r l < a l l l cs ta [ri l i tv i rr rh i s c ()l rc c ntrrrtl ()nprrttcrn over the l i rst t lr r c c c lc c ac lc s(l' l c rk e n c l M o n h c i t, 2 (X )l : l 2). I t is ; r os s ib l c ,o f c o u rs c , th e t rl rc s cfi g u rcs rcfl cct thc f:rct that w l ri l c a f c ' " vllc oplc llc c o tttcs e ri o trs l vi l l c a c h v c a r e rrclusc si gni fi cant resourccs, t hc l' ar c r c plac e c l l y o th c rs i n fo l l o w i n g y cars. A rrcccl otrrl cvi cl cl cc fr< l r.r c lllc r gc llc y r ( ) ()l l s , 1 r,,1 4 ,r..1 e 1 ;J l rIl r, t.r.v s tt :t srtrel l rrul l l .rcr < l f rcpcl .rt rl s o rrrc c s()v cr l t l orrgcr tcrl l . Moreovcr, P lr t lc llf sc ( ) lls t tl l l cs L rl ts ta rrti lrc rl sy s t c r l) at icer la l v s i so i h i g h u s c rs b v M o rrh ci t (2(X ).1)founcl that a si zrrbl c rlr aior it , vol hi{ rh trs c rsc rh i b i t p c rs i s tc n tl v hi gh crpcrrcl i fLrres fr.,1r,.c y c r r r t ( ) t hc nc x t. (.ri trc a l l y , th c h c e v i e st uscrs < l f hcal th c:l rc c().rc pr c c ior r inalr t l v fr< l rrrtw () s r()u p s : th c c l c lcrl l ,i urcl th()sc pcrs.,l s w h' e. llgagcir r high ri s l
6
ComParatiueHed!1hPolicl
a freeclornfrom clcprivation, the cntitlcn-rentto rlt lerlst rr clecentlevel of l ru m a n exi stcncc.The r,vel faresti l tc i s basedto a l arge cxtent otr this nr or c < l f heal th po licy is r p1l si ti vc ri ghts. C )rtc c1r-rcsti on e x p a n s i vc r.t9ti 9r'9f w h e th e r al l ci ti zel s have a posi ti ve ri ght to heal th crl reancl ,i f s9, what it s h o L rl clentai l . H tl w far ckrcsrr ri ght to the i reecl tl mi rorrr i l l heal t h go ir l rc c l u i ri ngscl ci ctrrlprovi si or.rof he:rl thcrrrercsotl rcesto al l ci ti zens?Whr t t l i rl i ts c an j usti fi abl y bc sct on these ctl ti tl ctrl entsto hcal th car c? l- or i trs t:rn ce.corrl cltrcrrtrl cnt bc deni cclto arr i rtcl i vi cl ualw ho crttl scsh is or vr l behrl vi otrrclcspit c i l l h ea l th al cl w fi 9 refuscsto chrurgchi s scl f-cl estrttcti vc w arni rtgs? re p e rrte cl
Comparative health Policy es it t A cl v, r r le (i o n tp a rrrti vcp< l l i cvenrtl ysi shrts bccottrci t {:r()w th i rrcl trstry. ettcl cl i s scr t lr r lll avei l rr[ti l i ry thc crpencl ccl hevc i 1 i < l rrl l rti < l ntcchnol < l gy f r rl rl rl y fi tttc srtl ttc et thc w hi l c l l tl l i cy clcls ti 6 1 6 f cl rttl rl rcrgssc6ustri cs, i n ir lf
ot (l '()\\-L()tl l l tl '\'e()l l l p:l t'i :otl
(l '()l 'L()l l l l )i l l ' i l ti \('
sOci rrll tol i cy, s ccr c. g, . , p < l l i fi c s,scc, c.g., l )cter.s, l .).)l l ; f0r. e0nrl -rrtrrrti ve (.l e s c n, 1999; H errtrei srrtcl l V l rrrl g,crr, I99(r). vc l rcxt i tl
Att lrtlrodttctiott
l],ilt-: :'];
7
('.r'pararivc-pu'ric p.ricvis,rrrcrcf'rc, ir sourcc.f g.rcrar-
i' rtrrrr rcvar.ai'r''r'r r.,crc rsta' cii's Ii' ;i:1"*i: l:J;,ll:'' ;i;il:il';,.. "t In,rtl.litio lr, t . t
I teaitlr;,,,tr.f.,,,'u.r-gcrcc srtsscsrs rrr:rrrhcrcarc slol)rllfrcr)cls i, rhcfirrrrr:rri'rr .f lrcarthp'rici"r, iir.: ,,t,,y".tru", a r r c lec t iv if it ' s ' f ttrrti " rrl ",,.i'rtr,.i l rc a l rl rrtr;;" ,; e rc b ccrrri r)s
,rorc al i l < c.l l rrsccl ()r l il' ( . \ it ' t ilr ; tti ,,rr ,l tr.t.' rl s ,l e l .()s \ i rr tl rrsfr.i :tt,i r,..t .t.1,,' ' ,)L.t.i l L.t(,\, ('l r er r r ic h' v s l< v( r9 9 .i : .i 4 0 ) c ,rrrc .l , ;i r,,, c rcspi tc thc rri r,.crsi ry, c e r csysr cr r s, h earths'srcrrref'rrrs rr,,n"l. r. i' i. , ; lr; ; ; , : ; . . c.fc .hc:rrrh f a 'rr r r r v c r s el out line o r p rrra c l i u rrr, fi ,r h c ,rl t tttrattcirrg,
airclthc UI(, .1"rpit.".1,,it"'.i'rl'",ij"t*-tcrnr stratcgicet';rhases.Harris.n (2002) als' f'uncl c,za/. ..|rcl "''::.,Y,|li': The irrgurrcntuncle.rlyi,rg .,,,ru.;.rr.. ,fr..r.1,is that as countries inclustrializc thcytencrto converge towarcrs thesarnepolicvr.nir(ri'r'ett, l99l). T^c crnverg"n." th.ri'; ,r;;;;; that hcalth p'licy across
,,,,,,,,,se ;; men,,, rn,"ai..lir' ::::;i':'#l?;'l;o'il'i,'il:ff H ;::if; i]:
ComparatiueH edlth Poli cy clisparatccountry environmentshas r.rtendencyto becomesinrilarover tirne as they develop economically.Moreover, sinceall countries f:rcecomparable clynamicsof den'rogr:rphicchangesrrnd the proliferation of expenslve technolclgies(discussedlater),thc pressLlres t
Art Introtluctiort
9
ty pc s of f unc t io n s , fo r c ra rn p l c ra i s i n g p u bl i c frrncl sto pay for rl ecj i ci rl c ar c anc l or garri z i rrr th c c l c l i v c ry o f th c se scrvi ccs. \rvi thout dor_rbt, c c lt r it y / : t c c c s sc.l trrtl i tya n c l c < l s tc < l n ta i n n rcnti rre thc conl l l op ggrrl s 9f l r ealt h polic ic sr tc ro s sv a s tl y c l i ffc rc n th e ra l thsystcnrsanclcoul tri cs. Orrl y tl r c r c lat iv c it t - tp < l rfl ttrcth c rtt i n rl i v i c l u a l c o untri cs attach to crrch soal c lr f f er s( s c eO ha p tc r 4 ). I n c or r t r lr s t ,c ri ti c s ,ri c ,rn v rrte n c c th c rl ri cs arguc thaf thc pnrp< l nents tl v c r s inlplif v t hc p ro c c s s < l f c J c v c l o p rn c nrr t rrclurrcl crcsti nrrrte si gl i fi cant c liv c r gc nc cr r c r o s sc o rrn tri c s(H o w l c tt a l rc l[{ a nrcsh,200.i ).o< l l rvcrgcncc, thc y ar guc , c l< l w n p l a l ' sth e i n rp o rt:.rrrcocf c ( )untr\.-sl )cci fi ci act< l rsothcr th r t t r c c ot r or llic c l c v c l o l ' rtn c l rt,r.u rcnl ro s t s t udi cs rher fi rrrl cyi cl crrcc 9f c() llv c r gc llc cc l< tl l < l tfi rtc li t a p p l i c l rb l ca c r()s stl rc b< l erclthus , rrl l rl w i 6gf< l r cl iv c r gc llc eir l o tl rc r e rc a s . F L rrth c n n o rc rn r()st stu(l i cs thef Ir:rvc fotrncl e v ic lc r r c cof c oll v c rs c rrc ch a v e fa i l c c lto rl c n ronsl ' rl tcthat i t i s appl i ceIl c rl c r os sall c lor lla i rtsth , trsa l l < l w i n gfo r s i { :n i fi cantcl i vcrgcncci n othcr rrrcrrs (lilar k a. c l 13t rrrr' ,2 (x )6 ). T -h c rc f.rc , w h i lc.rc car scl ccti vcl y fi rcl cv ic lc r lc c< lfc t lt r v c rg c trc ci,t i s [ry rr< n l rc l l n sc c rtl ti n, i ncl r-rsi vc or c()l rsrstcl rt a t t c l hr r slr ( ) t lr c c c s s :rri l ytre n s l e tc c li n to s i rri l ar hcal th p< l l i ci csor pol i cy tl i r t ' t r ior r silLl' ( ) s sr' o rrn tri t' r. A lt hous h c ( ) n v c rg c l rc eo f h c a l th s y s tc n rsl r as bec< l rnce focLrsof schol _ rrr lv c lellat c , t lr c L rl tc l c rlul rq c ()n L c p ru .li r.,r' r. * ,r,-k of thc strrcl i es of heal th p o lic l' c ( ) l) v c r s c ttc ertrc o fte tr v e g u c , rc l y i n u on cl i ffuscv:rri eti tl 6s9f ' sgft clc t c r r lr ir lis r ll'( F i c l d , l ()' )c )).w l ri c h rl s s u n rctl rrrt corrparaIl c c.l ncl i ti < l ns p n r c luc cc onr pa rrrb l cp ro b l e n rs w h i c h rc s rrl t i n conrprrrabl cp< l l i ci es(cf. .frt c < r lr sI,t ) 98; S a l trn ' ,n , l ()L )7 ;f< l ra s i rn i l a r-rrrgunrcnt i n rcl ati on t< l pg6l i c n r lr ni' r gc lr elrrt ef< l rn ],s c c l )o l l i tt, 2 0 0 2 ). In o fl rer cescs, pol i cv c()l rvcr_ g c r lc c is oit c lr t h e l tv -p ro d u c t o f s tu c l i c sw h ich rre cl r.ri trrt.rlr,r errpl ai l ;rolic y c liif c r c r r ce srl c ro s sc o u n tri c s (c f. F rc crnrrrr,2000; I Ial r, | 9971-t). Su c h s t t r c lic sf r c c l trc rrtl lb' u i l c lo rr rr l r()s t s i rri l er crrsccl csi gnusi ng vrrrrcti cs o f ins t it r r t ir lnal i s rnrrn c la s s u c h rrrc rro t a l l v rryst.r;i ri 1.r1.re1l i or rrnal ysi ng p < llic vc ( ) nv c r . g c n c icrr i ts < l w rr ri g l rt. Irre s p c cti vc(;f w hcrc thcy 1-rutthc e tr phas is , c r os s-c o u n try e ()n rp .rri rti v es trrc li esof hcrrl th p< l l i cy l argel y rrg r c c( ) lr t he c oer i s tc n c e o f p o l i c v c l i v erg c n c c rrnclcOnvcrg.,nce (cf. Fi el ci , l 99c ) ; 1. ien, 200 .3 ; Mc c h a n i c , 1 9 9 9 ; I{ i c . c t t1.,200.1). H .w evcr, thc co t lc c pt t t ir lf t r z zi rte s so f h c a l rl r p o l i c y c o l rv ergcl rcenrakcs i t cl rffi cul t t< l crlpt llr e t his c O c ri s te l tL r' i nrl s v \fL -n tJ ti cw i l y . T ' lr ec or lc c l' rttl f c o rtv c t' g rn c ci s i n rp o rtrl n f for heal th pol i cy becausei f i t i s v ic wc c l as ine ' i trrb l e th a t th c rc w rl l h e .rcc,rnpl ryi ng pressLl res ol r ;r< llic ym al< er st o c o n v e rg e i n rrre a sth a t m i g ht be c' r-i rterpr' cl ucti ve t< r th e uniquc nec c i so f th e i r p a rti c u l rrr c o u n tri e s . In other * ,,r.dr, thcre rs a cl at ger t hat ir bel i e f i n p .l i c y c o n v e rg c n c eb e c . rnesa sel f-ful fi l l i ngprophcsy ,pos s ibly t o t h e d c tri m e n t o f h e a l th c a rc prol i ranrmcsi r-rmi rny countri e s . c . . nv er genc eth e .ri e s a l s . b e g th e q u e s ti on .f c.n' crgencc to w hat: p ri v at iz ed healt h c a re , n a ti o n a l h e a l th s e rvi ces,or soci :rr i nsurance?
10 ComparatiueHcalth PolicY Al th o u g h tl ri s b99k i s n11tcl csi gl cd to test thc convcrgerl ce thL-( ) r ) ' d i re c tl y , i ts currel t pr6nri trence i n thc l i teratLl rc cl i ctatesthat w her e l atcr (espcci al l y(.hapter 4) ancl be :rddressccl a p p ro p ri i l te i ts assr,rntpti ons countri cs l l c ex;l l oreclnl ore ful ly. th a t i ts e x p l i rrtl .l torypow er acrossthcse
Classificationsof health care systems ' [-l tcttl tl sr < l l lviA t i ts b rts e ,h crtl th pol i cy i s, of c< tttrsc,rr ;rol i ti cel l l l i l ttcr. o u s c l i l n c n s i onof thc p< l l rti calc()ntext cotnpri scsthc i orrtl al i tl sti ttrti or r s th rrt h rrv el )ccn crcl l tc(l f< tr nral < i rrgpubl i c pol i cv cl cci si orts.fhc rrl sti tr r ti < l p rrls c tti n g i n w hi ch pol i cy nrrrki u!l trrl < espl rtcc i s fcrttrcclthc prol icv rl rc n l l , w h i c h i ncl ucl esnot onl v thc forrnel pol i ti cel i nsti tttti orl sstl cl l rls l e g i s l tttu rc s ,cxccttti vesr' rttclcottrts bttt el s< l rcgtrl af< l ryrructl ci cs,sctlliconttni ttccsrtrtclcotttttl i ssi rl tl s.fhcsc i l l s t ip u [rl i c b < l c l i csrrrrclspl cci el i zccl i l l l l ()l l g th c tu ti 6 l s c l c fi n ctl rc cl i stri buti orroi p()w cr rtnclthc rel rtti ortshi l -rs p < l l i ti c a l p l a ycrs by sctri ng tl tc rul cs of thc sruttc rcg,i tr(l i rtgacccssrl r lcl or cl i srr t li n tc ra c ti o n w i thi n rtrcl trl s..,\ssuch thcy gi vc cl i sri nct:tcl vetl tagcs r< l ttrl cl crstrr t lcli ntporfrrttt F-cl tral l y i n soci ctv. v rl rtl rg c st() vrrn()usl l roups hrlvc rh:1t strttcrttl -t:s rtttcl prrrcti ccs i n g p u b l i c p < l l i cy,thcn, rrrethc i nfortnrtl trec lifrerncrvork.' fhcse c v < l l v e cwl i th i n a parti cul rl r i onrrrl i nsti ttrti tl rtal cott t li rr ertch l < l gi c ti < l n srrrrcru l l c s < l fthc {renrccl cfi rrca cl i i fererttp< l l i ti cal l l l tercst try .' l ' h e y rrr c i rl s() cri ti cal t() the cnvi rotttttctrt w i thi rt w hi ch g ro L l p s ,p < tl iti calperti cs, burcl .rucrl ttsartcl i rtcl i vi cl trelpol i ri ci atl t vi c i o t ' i n fl u t' rtc t'()v (' rp()l i (y. ' R rg c th c r t hesc i rl rl ral rncl i nfornrel pol i ti cal i rtsti tttri < l tts shrtpeh ty p o l o g i e s i s ccntral to thc col l prtrrtti vc turn i tt ptl l i cv rl l l i rl vsi sancl th el' to conceptl ral i zethc (i nsti ttrti onal )col rtcxti n w hi ch p
Art lntrodut:tktn
tl
( 1990) welfa rc s ta rc re g i rn c s ,w h i c h i c l c nti fycl i sti nctw cl fare statc l ogi cs; anc l l. ijphart' s (1 9 9 9 ) rrn c lIl l o n c i c l ' s(1 9 9 ())rypol ogi csof cl enrocrati ci rncl s t at c r c gintc s . (l ro s s -c o u n tr), c o r.n P j rj q11n l l t:neratcsan abundance < l f ir r f or nr af io n ,a n c lo rd e ri n g th i s i rrf< l rn ra ti onthr< l uehtypol ogi esi s ccntri rl t O t t s ing c o tttp rtri s o trt< l b u i l c l , rc v i c ' u vancl revi sc cxpl ani rti orrs ab6ut polr c y c lnc rg e u c c ,p o l i c y ma k i n g rrn c lp o l i cy cycl cs. Des pit ew i c l c s p rc rrcvlrrri rrti < l n ru n ()l rgh crrl thcrl rc systcms,rrt root thcy r c pr c ls c lltv a ri rtttts< l rc o tn b i l tl .tfi < l nosi rr li nri tcclnrrnrbcr< l ftypcs. A s w i th polit ic : r l s y sten rs , th c c o rn p rrrrrti v c:rn rrl r,' siof s hcal th pol i cy often uscs t y polouies o f h c a l rh s v s tc n rst< l l rc l p c i rp trrrethc i nsti tuti < l nrrlceptcxt 9f hc alt h c r r r ertttc lc < l rrtri b u teto c rp l a i n i n s heel th pol i ci cs rl crosscl i ffercl t c ot t t r t r ic s .W h i l c ty p o l o g i c sc a n b e i ' a l tre[rl ci n si nrpl i i yi ng rr r.nrrl ti facctccl s c t < lf c r < ls sc tl tti l tl i c l i rrre tts i o n s .()l rc n ru st bc cl trrti ousu,hcrri ntcrpretl ru t hc t t l lt ec at ts cfh c \, c l o rc p rc s el rt i c l c e lty p e s of spcci i i cnri l cr() i nsti tuti < l 1rrl c hr r r ac t er is ti c sA. s l v i l l b c c l c n ro l rs trrrtccl i n thi s book, rhc rcel rvorl cl < l f hc r lI t hc r lr c s v s tc l rs i s c o n s i c l c ra b l yrri l rc conrpl i catccl . lJ c c aus co f rh e i r i tl p o rtl trtc c i n th e l i tcratrrrc, s...veri rl ti ' p< l l ogi cstl ret lr av c lt c c r t trs c c lto c l a s s i fy h e a l tl r c rrrc systcnrsi l rc sunnari zecl hcrc. T hc init ial ty p o l o g y c l c v c l o p c d b y th c Otr(,1) (scc Fi gurc l .l ) i s a c les c r ipt iv cc rrc g o ri z a ti o n o f l ro w h e a l th crrre i s < l rsrrni zccli 1 cl i ffcrerrr c ount r ic s arrc lre fl c c ts i ts s p e c i fi c o ri g i n s i n appl i ccl pol rcy arral ysi s.A t ( ) nc c x t r c lnc i s th c p o tc n ti a l fo r rr c o rrp l ctcl y frcc rnarkct systcrn w i tl .r llo s ( ) v c r liln c n t i n v o l v c n te n tr rv h i l c a t fhc othcr cxtrcrrc i s a trrxs uppor t c c lg()v t:n rn rc n t rn o n o p o l y o f p l rovi si onl rnclfrrncl i ngof al l hcal tl r c r r r c s c r v ic c s . T h o u g h i rr rc rrl i ty n e i th cr of thcsc cxtrenrcs exi sts ancl public inv ol v e rn e n t i n th c fu n c l i n g a n c l provi cl er rol cs rrrry bc rrt vari anc e, : r long th i s c < l n ti n u u l n rrrc fh re c c < l rcty1-rcs < l f heal th crrrc sysrcms t hat < lpc r : r tca c ro s s a l l c o u n tri e s . A s illr - r s t ra tc ci rr l F i g u rc | .1 , tl re l tri tttttci rtsuroncc(or consumer soverc ignt y ) m odc l i s th rrt w i th th c l e a s rs ti rtei nvol venrenri n the di rect funding or pr ov isi o n o f Irc a l tl rc a re s e rv i c e s .'l ' hi stype i s char:rcreri zecl by the pur c has cof p ri v rrtc h c a l th i n s u ra n c efi n anccclby ernpl oyersancl /or i ndi v idual c ont ri b r-rti o n sth rrr a re ri s l < o ri e n recl .' fhi s system i s al so l argel y bas ec l pr i v a te .w n e rs h i p .f h c rrl th c i r rc pr.vi dcrs ancl the fact.rs.f 'n pr r oc luc t ior a r ,l rh o u g h rt m i g h t i n c l u c l ea p u bl i cl y funded safetyner for thc m os t v Llllt c rrrb l eg r' u p s s u c h a s th e p o o r , the el derl y the y.ung. Thc 'r Private Insurance Free Market I System
Figure1.1
So cia l In su r a n ce
N ati onal H eal th S ervi ce
I Government Monopoly
Typesof health care system by prouision and funding ,\o r r r ce : OI:( iD ( | 9 ll 7: 2'+ ).
t2
ComParatiueHeabh PolicY
b a s i c a s s u mp ti o nofthi sappr< l achi sthatthefundi rrgandprtl vi si on< l t h e a l th e a re i s b e st l eft t() nl Jrket fttrces' as to state irtvolvemcrrt is the The seconclbasic type of health systcm g' i J-" ..k) mr.,ri r. A rthough there i s si gni fi cant va' ' s o c i a ri n s u ra n c e(rr u'-t tut]ttpt of s
jt it it l; n " rt t t. l9 c )7 ;S c o t t '2 0 0 l; Wa ll' (sce,c.1;.,1." . n ' , " , i, -. ' typtl l < l gv i ntcrcst.i tltl eo-i nsti tuti orl rl l i sl rlthc
l i l g c tl -rc rw i tl -rt hc m< l ur.rti ng of thc hcrrl thsystcl l l:1sthe i l l stih a s b e c rra fa c il i tat.r-t,,r.ri ti ." l rrnal yscs p.licics arc cr.lreclclcdarlcl l.r.w tl-rc tr-rti.rralfrrrr'ew.rk i,l'*i l.ft health shapchcrl tl -rpol i ci cs (erl clpol i i rs ti tu ti ' rrs .f he:rl thcrrre(atl rol tg< l thcrs) th,etypol ogy tl " l t,:]f,l er i rrttl e ti c s ). S c o tt (2 0 01), ft" ": " ." " tpft,' rrscs rol cs' ancl i rrterfrrccs i n hcal th crl rc w o rk to a n rrl ysenui ri i . " n.l ' p.i u" r. x;l l i ci tl y on rvhi l e l l rl rn (1997b) focttscst]l ore e i l c ro s sc l i ffc rentcOL,r' ,tri es h e rrl thrc i o rm . c()llll'l1olltl'rcir corrsiclcrrrtiotlof Howcvcr, thcse analysesrrlso l.rrlvein of herrl thcrtrci tl acl cl i ti orlto tl 'r e O th c r rrs p e c tsof the i nsti ttrti on,tlc()l l tcxt (2000)' for cxer.npl e'e rpl i ci tl y ty p o l o g y o f herl l th systcl l l s' Freet.uatl by w hi ch l rcal th crrrc i s coorc lii n c l trc l c si r-rh i s rrnal y' ' " ttt trl cchani strl s i ncl usi orlcl crl rl y cl ct' ttorl strrlstethl lt n a tc c l(h e a l th crrreg' ,ru.r,-," n..;.Thi s hrls als
a a a a
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of t he phen o m c n o n a t h :rn d , w h i l e a v oi di ng the pi tfal l s of conceptr" ral fi t. Thc l i terature l s t r et c hir - ran g c la p p l y i n g th e c o n c c p t to c rrscsthrrt cl < rrot thi s tetl si ott by acl cl i ng, p o l i c y h a s rrc l c ' l rcssecl h e a l th on c om par r rti v c ro the dcfi ni ti on < tf the alt hough m o re o r l c s s c x p l i c i tl y , n c w rrttri btrtes hc alt l- sr y s t e rn . A n < lv c r l a p p i n gs c h c rn cu s e c to l c a tc g ori zehcrrl rhcrtrcsystentsi s based ( ) n t hc dir " ne n s i o n of fi nertci tl g.A t one extreme < l fth c n rc tl ro c la n c ls ()L rrcc t l p rivrrtc sotl rccsof frrncl i ng,rrnd i rt r r r c t hos c s ys tc msftrl l y c l c p c n c l e n()l t hc ot hc r ar e th o s c frrl l y fu n d e d b y p u b l i c sourccs.l Jascclon thi s cri teri on t hc r c ar c f ou r mrri n ty p c s o f fL rn d i n g : a a a a
cli rcct tax/gcrrcrtrI revcnucs s < lc ir ror l s tl ttei n s u rrrn c e pr iv l- t t ci n s u rl rttc e c lir c c tpa y l l l e n t l )y u s c rs .
W it hin c r r c h ry p c , Ito r' v c v e r,th c rc a rc l tteny potcnti rl l vari arrts. I" < tr ilr s t r r nc et hc c l i rc c tte r n ri g l rt b c l c v i e c lb y thc certtrrtlg()vcrnmcl tt,by sr" rbr ur r it ss uc h r ' rss tr' rfc so r p ro v i n c c s , o r b y a contbi nrrti otlof govcrnl rel l ts. s y s tc n rn ri g ht l rc bascc]on a si rrgl cnrtti < l ttrrl S int ilar ly ,t h e s o c i rtli rrs u rrrn c e s c her r r e or on n rrrl ti p l ci n s u ra n c cs c h c n rcsrr()rc ()r l cssri gi cl l yrcgul rrtcclor c ont r ollec l b y th c g ()v e rn n re l tt.F trrth c r rtt< )rc,thcrc i s a w i cl c array of rrnclthci r vari rrrrtst[rat rrrcusecl c or n b i rrrrti o n sb o th o f [rrrs i cty 1 -l cs 1- r os s iblc of t c n wit hin rr s i n g l c h c a l th c a rc s y s te l n,sttch rrs i rl the IJS A w hcrc ottl y . c o rcl i ngto A ppl cby,' al l hcrrl th crtrc t hc elc ler lylre v c s o c i rl i n s u rrrtrc cAc s y s t enr s ar c p l u rrrl i s ti cw i th re s p c c fto fi r ranci rtg(arl clorgani srl ti on)w i th l th c r th rrtra l rothcr' ( 1992: l 0). t elr c lenc ictso ()n c n re th ()cra mcthI n ac lc lit i o nto th e w i c l ev rrri c tyo f c o rn bi nati onsof thcsefr-rncl i ng i n cl i ffcrcnt w ays. oc ls in er r c hc o r.rn try ,c l i ffc re n t c o u rrtri c s rtppl y thcrr S or r e, s ilc h rrs th c L J S A(rrn c l ,to l r trrtc h l esscr cxtetrt, A rtstrrrl i a),user gener al t ilx e ti o l r fo r;rrrrfi c u l rrrl 1 ro u p ss ttch rts thc poor rtnclcl cl crl y,l tut c lc pencor l r p ri v a te i n s u ra n c eo r d i rc c t p aynrcntsfor the rerl ai ncl crof tl re c of heal th bctw ccrts1-rcci fiforms populr r t ior r.Oth e r c o u n tri c s c l i s ti n g r-ri sh c r r r c . F or ir .rs trrn c eN, c w Z e e L rn c l fu n c l s h< l spi telcrtre through gerterrrl t ax r r t ion but u n ti l rc c c n tl y re l i e d h c a v i l y ort cl i rectuscr pi tyrnel ttfor nrost pr r inr ar yc r r rc le x c c p t i o r s p e c i fi e ccl a te g o ri csof p:rti cntsstrchi rs chi l cl rerr . e n c ra m ini rtg heal th crtrepol i cy, then, i t whos e c ir r c w a s s u b s i c l i z c c lWh basedon these is c r it ic : r lt o c x a n ri n en o t o n l ),' h o l v l rc a l th ci trc i s fi nrrrrcecl t y pes , but r rl s o u n d e r w h a t c i rc u rn s ta n cesi t i s ti rrgeted from p:rrti cr-rl ar soLlrces. A s im iI ar c l a s s i fi c a ti o n o f h e rrl th s ystems, haseclon a di sti ncti on am ong ins t i tu ti o n s re l a te d to th e g o v e rn anceof consLl tttpti on,provi si on and pr oc luc ti o n i s o ffe re c 'bl y M o ri rn (1 9 99,2000) w ho constructs four dif f er ent t y p e s o f h e a l th c a re s ta te s ,th re e of w hi ch are especi al l yrel evant
I4
Comparatitte I t ealth I' olicy
hcrc. ln cntrenched comrnttnd druJ ctmtrrtl health cAre stiltes, thc govcrn a n c e o f c o n sumpti on consi stsof extensi vepubl i c accessbascd t.trlcit iz e n s h i p a n cl extensi ve control of resource i rl l ocati on througlr a d n .ri n i s tra t i venrechani sms.l n contrrl st, i n thc corprtrati st hci rl tl .rcar c s t:rtc ,fu n c l i n gtl rror-rghsoci i rli nsurancecontri buti ons mrrkesfor dc fact
Table 1.2 Public funding ctsd percentdgeof health exltenditures,19 70-200.), ranked by 200.| I e70 LJI( Swcclen .frrp a rr N c w Z e e l ancl Frrtncc ( rC ft)) ll 11 |
Ita l y A u s tra l i a N eth e rl a nds U SA Si n g ,a p o r c
So r r r r ' cs:l) r r tr rlronr ()t.(.1) (2006), erccpt S i rrgrtporc S i ngrrporeMi rri strv of t l tel th (2(X )( ' ).
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l.t
in public Box | . I The Singaporesystem:low tunaing, high on indittiauatresponsibility
i rr as rcfl ct' ted uttrtsttal .l i s e tts s chdc rc 'Si n g l p o rcis tnosl , t ) f r r llr ht ' s y s tc n rs regrsters main reas.trthat Singa;rore ;r il;; i;;i.',f putl;c f'nding' The a crlmpulstlrysavings it institrrtccl 19I]4 i, t]...,u,.,in lrlr'vpublic ftlrrclirrg fr.rn thc state rcsp.'sibility financing schenrcthat s6iftcdp''i;;;;i;t.,ith au i ndi vi dual i rt dcoosi tecl th c n. s .i rl , 2 0 0 4 )' Iru n d sa re t o inc liv idu i rl (l thcrrbc clrawnon to ca'r whicli saviugsirccountin t"tn'tt'i"tii-,;;t;;;t;t;"t; or itlcttrrcclby that pcrs()11 pay for hcalth insura'''ttt't hospitalexpcllscs tax a of forrn thc is c0tnpulsorv.irt farrrily.wtlit" ,t.r..r.t'lcntc irisintnrccliilte t. bc it ii c.rrsiclcrc'cl tt;t;;;;;-it t'; iti"ntt fi]l:'-ttltt" becrrttsc it.tc.tt.tc, utric|te rt on t,.,"tl iJ ''r iinzrnccd.J'his hcrlth .;;-;;;.1;, "t::'i-':t-::tti:ll u':"']::1
sutrlltlic1. basichcalth carc thr.ugh gover'rrcnr rccerve rccirs irfforclable rn to wish thcv sLrbsidv of lcvcl 't,f' the i;;i;i,l;;i; .,;,r^.i"' trlut"c tr.nor low is * n,r,I fa'cy warclthc subsidy ,"frir. n,rtpr,.t, if tntf
ia":I.:1:iii:;:i;l1til*::"il; ifth"iu"h'rales'' i,;i;;.;,;;il.,.as arc cxpectcclto pa kcy principlc is that plrtiellts lcvel of * h"t i h t y 't l t " 't n n d a service sth at t hc y , t ", ; ; ; ; ; ; * t it t 'i g h c r servlcc, 1 of llcalth (2002b)anclIlern (200 )' N4irtrstrv Singaporc Sorrrr:cs:
tool,trtltrlftrllrcprcsetrtrrtiotrofrcrrlit'v'llvellirrthosecrtscswhcrctl-rc irr ,,,.r.,f t6c tvpesiclcrrtified l',,u Scrrlthsvsrcrr.,f .,.,;,,;;;'ir.1,,,,ri,,",..r " th cscrlt
s y S t c lllc lc p c rl c l s .l rl .rrrttl l ti tL rc l e tl ffl rc ttl rsi ncl ucl i rrgthcptl l i ti cl l l syS tcnl ' t l- r ec r - r lt ur rrl t." ,r,.* t" k ,t1 ' " tl " n .tt' g ' a p h i ccontcrt' thccl i sti rrcti vchi sttl ri c lllbilc l< gr t l .rn d ' s p c c i fi c e V c l l ts e rrc l s < l ci al stl tl cttl rcsi tthererl tttl tltlrat llle g o i l l s ancl pri ori ti cs devckrp ovcr c ount r y ( s c c (.h rrPtc t Z i ' St" i " ' " 1 are i l r-ri d u " lut" .w hi ch thcr.l rsel ves r r nd s h, r pc r tl l s o c i i l l i ' ' t" i i t" i t' n t " " tl changerlblc. ru-rcl
countries selectedfor study pol i cy, c ro s s - countryanal ysi sof hcal th I n or c lert O p rOv i c l ea c o n s tru c ti v e r v ehlt r , es e l e c te d n i n e c o u n tri c s fo rp ri rr-rar,v..,u" ." g.i rrthi sbook(w i th for F ra u c e ancl l tal y, w here appropri ate' t he ac ldit io n o i e ra mp rl e sfro m
16
ComPdratiue Health PtilicY
Britain New Zealand Sweden
Na tio nal
H eal th
Figurc1.2
GermanY Japan Netherlands (Singapore)
United States (Australia)
Social Insurance
Private Insurance
Typesof health caresYsten,s
Thc c< l recountri cs w cre sel cctcclto gi vc t he r eacler i l l u s trati vc pr,rrp< tscs). (sccIr igur c 1. 2) . cxposure tO thc ful l rarrgeof heal th systcl l rs s y s te l .narrc vrrryrng r.rloclel-irl purc this rrwiry frtlnl ,ttit-l.rugn irll thrce hrrvc t.u
foctrs ,, In thc follor,ving, refer to llritrrrrlor thc tJK \vc oftctrspccificrrllv \vhcn.nve
i rl l :rrgl errtl ' ci l re i l s thel 'cxi st o lt thc ()rgi .i l i l zi 1tt()u l tntl l t()l i ci cs of hcrrl th s1'sterr tsi rr the foLrr 1990s thc hertl th l- OllOw i ng pol i ti crrl dcvol uti 0n i n thc l rrte ()\Lr\i r' \V ' \(' r' (l ()l i l l l $'l \\ l r:rrt .l t'i .'l ,r1.e,l rrr tl i l i t'rt'rrt L r lllntri L.\ ol fl r..tl l (
[]a g gott,2004).
Art Irrtrorlttctirttt
T7
l ' .rcl rrcl ccl cl cntrrncl s. s 1- r opr r lr r t ir l lnvsi th s i n ri l rrrl e v c l s o f c x p e c t ati ()r' lartcl Mi cl cl l c l l rl sr rl rl cl A si a, thc f r < t r t rt his an e l l ,s i s i l rc c rts c s fro rtr Ai ri ca, l l i l l i orl pcopl e. w h i c h c < l l l e c ti v c l y rc p rcscl l t ovcr.! I r r r s t c r n F - u ro 1 -rc A lt houeh ir r c l u s i < l no f a s c l c c ti o no f tl rc sccotnrfri esw rttrl cll tc i l l trrrti rtrtting, it r v oLr l c,tl l s < l rc u n w i c l c l ,v,rttc cl o tttpl i crl tcthc l cvcl < l f anal ysi s.Orrc i rr trv i rtg l { ) L ()\( r L ' \(' ll l l i l l ( .,rtttl tri t' s i s tl rrtt i t i s l tot of t lr t ' t lr - r t w l rrte l .s s l f atrr' ortc tl f thci r hcrtl th crtrc p ro v i c l c r tl rrl ro trg h a n rrl ,v s i< t < l 1- r os s iblc tl tc ol l i ccti vc oi thi s l l tl ok i s tl tcrt, s 1 :rc c i fi c c < tu tttri c s , A s rc g e rc l s s v s t c ut s . l trttl t< t prtl vi cl c l t t o bc r t n int ro c l L rc ti o nl.t()t l r c o n rp rc h c n si verttrrtl t' si s. l i r rhi s cttcl ,rcrrcl crs c ( ) nt c x t wit h i rr w h i c h t() s tr.tc l vi n rl i v i c l u e lcoutttri cs. wit h en ilt t c r c s t i l t l t p l trti c trl i trc ()r.l l rfrvo r cotttrtri esshotrl tl tttl rl < cttsc of t hc ( ir r ic lc t o Ii u rth c r Itc e tl i n g ,i i t th c e n rl of thi s l tool < rvhi ch shtttrl tl l i rt< l ' ur,l ctl gc pr ov ic lc a v rrl rrrrb l cl rrrs i sfo r b rri l c l rn g()rr tl tc i < l ttrtcl ,tti ort,tl , c (i u i r l c to W ebsi tcsprovi cl csl i rrl < strr oif er c c lin t hi s b o o l < .l n rrc l c l i ti o nth l trtc lc l e te()l l tl l csc c()tl l l tri cs. t hc t nos t r c c c rtfi ttf< l rrrra ti o tr
Types of heafth care hc.rl th p< l l i cyrcl rttcs A r r r ; t hc r{ is t i n c ti < l n th e t i s c rtrc i e l i rr ru td crstrrtrcl i rtg ' l rtl tl c l ..l c l cscri l testhfcc crl fc!l ()ri csthi l f t o t hc t y ' 1' rcosi h c rtl th c e rc . I ar gc lv c lc f in cth c rrrn g co f rrc ti v i ti c sn < l rn r,rl l fi ttcorporrttcclttncl crhcal th c er c . A lt hor r g ,hth c tc rrn s trs c c lt< l c l e fi rr cthcsc crtrcgori csvrtt' v,l tri rrtor| ( Lt r ( ' .( t t r Llt iL ' t,tttt' d i c i ttt' r' tn dc l trts rti t' t' r tt' t' at' crtsctl l l crc. I)ri rl tl l ry cl l re 1911elly c nc ()n rp rl s s cvsi s i ts to g c n c rrtl prl rcfi ti ()rters (( i l )s), errtl tttl rrtory c r r r c r lt c l her tl tl rc rl rrc a ti o nc ffo rts , a n c l i rrcl trdcsi t str()l l s hcrrl th pr()tttot ior r / dis c r t s cp rc v c l tti ()l t e l c tttc trf tl i s c trssetli rl (.hrrptcr 7. Itt c< l tl trrl st, hcal th carc c ur r t t iv c r ne c l i c i n c ,rv l ri c h rc p re s c l tts th c corc of trl < l cl et' tl ()n i tt hosl ' ri trl l srrrrclrel i cs cr.rrc rrcute dis c r r s s c cinl O l re p tc rs .3to .5 , c e l rtrc s th< l sc to actrtcl v ill. s rc s f( )rc hcrrl th on s 1- r c c ir rl i srrn ts tl te c h rr< l l < l g i ct() (r, c l tr< ttti ccrtre c()l rsti tLl tcsthe l vi cl e F inall. v ,r r s il l rrs trrrtc cilrr Oh a p tc r rrrtclh< l s1' l i cc r engc < lfs c r v i c c sp ro v i c l c tlt< l1 ' rc o p l icn l o trs-tcrtttrcsi cl crtti rtl
Tabfe 1.3
Categoriesof hetrlth core
Pritttclr|c,trt
( )ttrtt i t,t' rttc Lli c i t rt'
( ', l t r o r t i t - c a r c
( ienc r al pr rc ti ti o n c rs W ell- pat ic n tp h v s i c a l s A nr [ r ulat o r-v c a rc Hc alt h pr o u ro ti ()rr rcven ti olr [.,cl u cati o n/1-r
AcLrte/hos1'litrlca rc ()Lltprlf iertf cli rtics Technologl' [rrrsccl Spc c ielis t s Intcnsi'"'ecrrre
[-ons-tenr.r i aci li ti es N ursi ne hol re l l ospi ce llesl-ritccare H onre crrre
18
(,o nt p ttrtrtiu c LIe,tltb Pril i cy,
fa c i l i ti c s,hotrtecrrrerrnclso forth, r' ni rnyoi rvhi ch have si gni fi crrn tsocir r l rtsw c l l i l \ tn(' (l i ci tltl i rrrt' rrrr(} rrs. A l tl ro u gh the herrl tl rpol i c,vof any coLl ntryw i l l conrpri scrr nri rrt r r c of th e s e ty 1-rcs, therc i s consi cl crrrbl cvari ati on i n rhc r.vei ghtgi vcn to cacl'r c l i n rc n s ion cl epcncl i rrgrl n thc l l ssLl l rpti ()nsrrrcl goal s of thc po licics p ttrs trc cl ..Aisl l ustratcclby thc sc()pcof c()vcrrl sci n thi s bool < ,hcrtlr hclt r c ttl c l a yi s cl otri nl rtccl[ry currrti vcnrccl i ci nc.W hcn one rhi nl < srrbout hcalt h c a re , h < l s1-l i tl rl s hi ghl r,' trl ri nccls1' l cci rrl i sts, i t i s thc l etcst rcchnologics l rncl th rtt o ftc rt c()l rc t() rni ncl .,.\srrotcclbcl ow i l r fhe cl i scrrssi <
Art Introductiort
l L)
Growing problems in heafth policy l) c s pit c v r r r ia ti o rri rr h e a l th c rl rc l rc r()s sc o u ntri es,thcrc rtrc sevcrrrlfrrctors enc lc r nict o al l c l e v c l o p c cnl rrti o n stl ra t rl rrk c hcal th pol i cy cver nr< l rcpr< l [rlc nr at ic . I n t h c w a k c o f fa l l i n g n a ti o n rrl i nc< l nrcsrrncli ncrcasi nsl yscarcc r c s ( ) r r r c c sf or s o c i a l s p c n c l i n g ,a l l c o u n tri es. l r() nl rl ttcr h< l w rrrrch thcy v r r r y polit ic r r l l y o r s < l c i rrl l vfrrc , cs ro w i n g cl i fi i ctrl n,i n thc fi rranci ngancl c lc liv c r y< lf he a l th c a rc . -h [rl c 1 .,1c l c rrrl vtl ernonstrrrtcsthat w hi l c counr r ic s c lif f c rc o l rs i c l c rrrb lavs to th e p c rc c n ti l l l col thci r sr< l sscl onrcsti cprocl uc t ( ( ; l) l' ) t hc v c l c v < l fct< lh c rtl thc rtrc .i rr r i r turrl l i ,rl l crrscsi t has i ncrcrrsccl r t ppr c c iablyo v c r th c l rrs rth rc c tl c c rrc l c sl.l r j s nrcrrnsthrrt hcel th crl rc c()sts lt r c inc r c lr s in gi tt ri ttc sc rc c c c l i n gth l l t ()f c conotni cgr()\\' th,l r l l l rttcnr fhttt is not s us t r r in rtb l ci n th r' l rl rrg rtn r. T hc inc r c r rs ci rr h e .rl th c rl rc c ()s fsi s n o t bl ' i tsel l .r probl ern. r\s l )rri l ( 2( X )l) poir t t s()u t. i l n c rp rrrrs i o n< l ts p c rrc l i neon othcr gootl s i s u' cl c< l rrrcd as c < lnt r ibLr ti n gro c c o n < l rri c w c l l -b c i n g ; w hy, tl rcn, shoLrl cli ncrcasccl c ( ) ns t unpt i( )no rt h c l tl th c l rrc b c l r p ro b l c nr? Ii urthcrttt< l rc,cvcrv c()untry s pc r r c ls100 p c r c c n t o f i rs (i l )l ' ()n s ()nrethi ng,so i i countri es s1' rcntl c or r s ic lc r r t bllyn ()rc()l rh c e l th c e rc th a t i s th ci rch< l i cc.' l ' hcrrrrti rrrcrl s()nw c s hoult l c r r r c r rb o rrt s ro r,v i n s h c e l th c r' l rc cxpcncl i rLrrci s thrrt thc cxtrrr s pc r r c ling, r nir:h t l ro t b c p ro v i c l i n g rrs n rrrcl rvrrl rrcrrs i f tl r< l scfLrncl sw crc ,1,.,. t t s . ' , .l,1r t ' , . ' t lu .' .tti ,,nl ,ro rrs i l tg .t' r' tv i l o r' rru t ' nt.tl 1i ott ot' otl tr' r' [rl i r:tl t' 1.11 r r r lr r r lr licc ( )n s tu u p ti ()rro r i n v e s tr)l c n t(FLrchs,2(X ).5:77\.l n cconotni e t c r nr s , f hc ' ( ) p p ()rtu n i tv c ()s fs ' n ri g h t b c to o l ri gh rvhcrt exccssi vcntoney g( ) est ( ) hc altl r c rrrc rrrrc li s th i rs c l i v c rtc clfrorrr nrorc cffecti ve spcncl i ng,
Tablc 1.4
Health exytenditure Ltsct Pcrcentctgeof GDI', 1970-200.3
A rrstrrrIi rt F r lrnc e ( ic rnrlrn y I t aly . f apan Nc t hc r lanc l s Ncr,vZealrrncl S ineapor e Srvccle n LJI( LJSA
\ o i r r c c - s :l ) r t t e f l o r r ( ) | ( .I) ( 2 ( X) 6 ) r r n clSin u lr p o r e\lin istry ol I l u.rl rh(1t)l )| .rrrtlJttrl r.1.
20
C ttmpartti uc H crl th I' ti l i t1'
for thi s concern ovcr hei ghtened spend ing on a re a s . A nothcr rcas< l r.r rn e c i i c :rlcare ccntreson thc cri ti crrlrol e of thc strrtci rr funcl i ng i t b ecr r use g o v c rn m ental sper-rdi ngdoes trot respond ttt normal rnrrrket for ccs. A tt.t rapi clrrcl vanccs fi n a l c a usefor cl ccpconccnl i s that agei ni ;1-ropul rtti ons, ancl clet nr r ncls rn e d i c a l techr.roIogy,rrnd crpancl cd publ i c cxpcctl rti < l tts p ro n ri seto exacerbrttethc probl enrs.l l .ecerrtrcfornr cfi orts i rr vi rtur r llyr r ll c o r-rn tri cs rel rcti ont< l thcsc nrrrj orforccs rrrrclrrl thotr ght hcr e rrrc l rrrgcl r.' rr i s v rrri a ti on by cl cgrcerl cr()sscountri cs, thcsc trcrtcl srcprcsettt< llt t it t ot t s s i g n s fo r the funcl i ngrrnclprovi si < l nof hci rl tl rcarc i n thc corrri rrgclccr r clcs.
Ageing populations As i n c l i catccli n Trtbl c 1..5,cl crl og,raphi cpro j ccti ottsshow thrl r l tt() stcoult < l vcrt hc t r cxr tri c s rv i l l cxpcri cncc srrbstanti alrrgci rrgof thci r popi rl ati < l rrs .3 0 ,v c r rrs.A l though thc:rgt' i ng l )r' ()ccs\i s rrtki rtg pl rrcccrtrl i cr rttt clt t t or c ra p rc l l yi n s< l n' rc corrntri es,el l l vi l l cxpcri cttccrr.' l ' hc pri rttrtr,vcrttr sct lf t hc rrg e i n g< l fW cstcrn soci cti csi s thc prcci pi touscl ccl i rrci n fcrti l i ty rrr t cssince -l ' hi strcrrclis er : t gth e l g T0s thrrt has i ncrcrrsccl the proporti ort of cl cl crl .v. g c re tc ( l bccrrtrscthe sharp uptrrnr i rt bi rth retcs rtftcr W orl cl War ll p ro c l u c cclrt bl oarcrl l rgc c< l hort i rr tl rc brrby boonr gcnct' rrti on,t he l'ir st w a v c < l f w hi ch i s now rcrrchi rtgrcti rcrrrcrttagc. I-.vcrti f l i fc crpcc t r t r r cyis rrn a l tc r cclthi , s rvevc of egci ng,baby boonrcrs,el < l rrgl vi th cl ccl i rti r t qicr t ilpr()p()rfi ()rrof tl rc cl cl crl y. i ty ra te s,gurrrrurtccs rttt i ncrcr.tsi trg -l ' h c scc< l nd f,rcr< l r corrtri bLrti ng to thc egci rrg of l ttl l ttrl a t it t t t s is In the ycars l ' retl vcctt 19.50 artcl l c)80, lif c i n c rc a sccll i fc cx1-rcctrrncy.
Tablc 1..5 Percentage of population agetl 65 dncl ouer te60 ,\ trs t ral i a Fre rr cc (rCl-lllilllV
I t ir ll, . fapr r n Ne t hc r l a n c l s Nc r v Z c a l r t n r l Singa p o r c Swc d en
LJK LJS
I eu0 l ee0 2000 2020 20.i0 2010
I l. I l,+.| l.t..l 1 0 . . r 1 . 1 . 2 14.9 r).1 l 2. l .5.7 9.0 I 1..5 ll.8 L).7 I l.l u.7 6.0 1.1) n/rr 8.t I 1.6 10.8
I I .l J I t .7 9.2
9.6 1.1.9 t.t..t
t).2 1.5.9 l(r.li 17.6 16.7 I .1.(r I t.7 7.0
1.t.,+ 19..t 2t .7 te.4 20.e I u.e
I li.2 21.8 2 t.8 ll.e I1.0 2.1.0
19.7 D.7 27.6 )1.2 D.7 24.8
| 5..i
lL).4
Zl .L )
I u . . s le . 0 2 2 . 0 16..1 t7.u r 7.r .i 2 0 . 1 J )t . 7 2 2 . . 5 1.t.0 I 1.2
| .5.7 I .t.7 I 6..1 12.4 r2..1 | 6.2
tL).) I 9..r
20. 4 I 9. 8
(S i rru.rP ort\l i rl i \tfr of l l crl th, 200 l ) \( ) //r .( ,- \:I)rtr tronr Ol :(l l ) ( 198S )krr rrl l btrt S i ng:tP or-c
A n Introducti on
21
the Box 1.2 A warning: 'profoundconsequences'as EU grows older to ri sc t he sh l rc o f th e e l d c rl yi rrth e i .,ta l p oP Lrl xl i l lins expected l- . U- wide, rrse predicted to irre [J0+ Those 20-50' frc>tn2L"l, now to around 34"1,by peopl e 37.mi l l i on 2050' B y l 0 ' Z ' ' s o m c (r<-tm to p o p u l a ti o n 4' h, of t o d a y ' s risesin the big thcsc says F'urttstat n.i,r14.nitrians+' ,u'b" are expectccl systemsfor socialprotecti()11 elclcrllwill have 'profound collse(lLrences' emplclyers. ancl rv.rkcrs 6v rn
el rcl(' ,.0r' crtrsf< l r cx pc c t . y t c yat lt i rtfi i l c rc :rs c c l[l r, l i ..5 ,v c a rsi 1;r i cnrrl cs i ecttl rs. hcrrl th nt elc s . - l' hc s c s i s n i fi c e n t g rri n s rc fl c c t i tD pr< l vcclsoci el t t,Itrl l i tt' el l cl s n tc c l i c i n cto rerl ttct' i rri .trl ttl h ebit s anc l t hc , , " u u .,-,1 r.c i ti cOf grri rrsi 6 l i fc prrst i rr thc thrl t l r()tc t() i tl .tp 6 rtrrttt ex t c r r il t |c lif c sp rrtt.l t i s c< l trl cll l c cvctr thcrc thef rrc a r ti trg ex ' ec t r r c y l. r . u .i[.,c .rrtr' c l c re ' s ti ' l rtc 6 , cotl ri l l g cl ccrl cl cs. the i rl sp:rrl l i fc rt r r lr c s ier r if ic rtn ti n c rc rrs c si rr rl v c rrrg c cx1-l cctrrrrevi rl l i fc N{ ( ) r c 9v c r . s t ll ts trr6 ti :rl c l i fi c rc rl c c s i rr i rvcri l ge () r gr t nis r r t iot rf < l r l l c o tl o t.l .ti c(,o ()p t' ri l ti ()tlencl l )cvcl opl l l cl l t (Of' (l l )) t rrt frrrthcr grri nscotrl cll l c rrrecl ei tt c( ) Ult t r ic sir t pl- c s c l l ts tro n g l v s U l l ,g c sth stcps,t()gcthcr , c s c h c rtl th-i rtrpr< l vi trg r t t r unt lt c r< lfc < l tttrtri c sl.r< i l ri c rrl l yth agci l rg c xi rccrl )rl fe c ()u l c l rrttc s , P < l pttl l l ti < l tl fc rtrl i tv wit h c ont int r c c ll o w (l l o x I' 2 )' p ro b l c n l s e nc lc onr plic ar ci r' rrrc l i rl s i rl the T hc s c r r gc in gt..,.,.1 ie rc rl c c o l n p rrn i c cbl y tw o cri ti crl l changtrs ptl puol cl cr torvrrrcl s trcrl cl s o v c rrrl l t r u c tu re .l ri rs t,rv i th i n th c 1 - r opr r lat i<sln prcsc.t A t tl etttscl vcs. i " , i, r , r , is t 6e a g c i rg , t6 c s c e l c l c rl ,vp r" l rrti.trs 'i i s thc coh< l rt rhc r nos t r epic l l vg ro w i n g s c g ,l n c l tto f th c c l d crl v p< l ptrl eti < l rl , , u .' ..As i l l ti s tra tc c li rl T rl 5 l c l ' 6, thi s pr.' .rti ,rt i s cx1-rcctccl agec lll0 " , t . 1( ) \ (.t. i0 tl rt'l '40 L ( ) tllllt 'i t's.,ttttl l )('r Lul l t i l l t() t,,..lintl, P1 .1 .cr ' tr l itr n t( ) \l i rrc P rl rti cul arl l ' srgrl i fi cal l tf()r hcrrl th .f . r pr r n,bv 204 0 . l ' h c ' s c i rrc rc rrs c s l -rcal thcrl rc' p. , li. u 1. , . i. . , , r "th o s e < l v c rl l 0 e re l l v i rl r th c hcl rvi cstttscrs< l f col l l p()si ti orlof the scx the to rc l rrtc s T hc ic c < r nc tl r c ttc l w i th i rl a trc rl c l cxpcctrtl l c\' 'w ol l l cl l l i i e l o tl qcr c lc ler lv 1- r < lprrl rtti
22
C'nmparatiuc H cdlth I' olicl'
Table 1.6
Shareof uerYold Persons(80+) among the elderlY, 1960-2040
Ar-rstralirr F ra n c e (i c rrl a n y' Ita l i ' .frrpan N c th erl a rtcl s N e w Z -cal arrcl Sr,r,,cclcn Lil( L IS
1960
2000
2040
t 4..1 l7.2
23.6
. tl. u
.l,.)..)
n/ir
/- 4. -')
14.6 12.6 1.5.2 l7.l 1.t.9 | 6.4 1.5.2
22.2 22.0 2.1..5 23.ti 29.0 25.1 26.4
i 4.6 2L).9 .10.(r
41.r .10.0 30.5 .l | ..t )9.1 .t.i..1
,\or r r r r ' : l) .ttr l r otr r ( ) l i ( .1) ( l ( ) 0i )
rl g , c?lt w h e t c l ocs i t tl t:rttcf tor hcal th cl rc i f tl ' rc l .rtl P Lrl rrti < l rrs. hcelt h < l f sl rrl rc cl i sprOl ' r< l rti tl tr;l tc e l n i l ttc rs b ecrtusc 1rt pl -cscl tt i l l tl str:rtct l ir r A s 80. ovcr rc s o u fc c s gO tO thc cl .l .' rl y, perti cul rrrl l ,th< l sc ' fa l tl c 1 .7 , rrr nrOstcOurttt' i csthtl sc ovcr (r.5rrcctl tttttftl r rtt l east tl
An I ntrttductittrt
Table 1.7
L.)
65 or of heatth expendituresand personsaged l'ercentag;e more,2003 and'estimated2020 and 2040 Proit'ctiltns "lt 6.\ +
A t r s t r r r li e l'ntncc ( icrrurrtt,v I t r rly .frrprttr Nc t hc r lr trrc l s Nc',vZcrrlrrrcl Sr'vctlcn TJK I]SA .\o l rr't':
l )rttrt lr olr l ( ) l:( ll)
l2.u 1 6 .i l l J .6 18 .2 1 9 .0 l .l .l l I l .c ) 1 7 .) 1 6 .0 | ).1
,,/,,I'.tdl t,xltt,rtJittrre
40.) .l0.0 .14.1 .)+..)
4).4 4t.) 4).1 5,+.1 '+1.0 48.li
2020
2010
46.4 .5(r.0 . l. r. u 4 l. l 4L).4 46.fi .t.i .9 (r0.I ' + c).6 rt/rt n/rr 59.6 6.1..1 .+5.6 t,+ .I 6).1) 56.9
40.0 l l J.c) r2..5
( l( ) ( ) ( ' ) '
for ht' al th ptl l i cy' o f tl -rc fu l l r,trrg c o f i rrl l l l i crrti ()l l s r r t r t r r r c lc r s trtn c l i rrg gcl l crcxP encl i tttres ()l r i ncrcrtsccl thc , r ir r , . r , , gre- ,ttc rti ,i r h c rc h e s fo c u s c c l lr r c c llt v t hcg rtl l v i rl g l ' " t.,p t" ti t" ' o fth c ,c l d crl v' thcrci srrl sotl -rei ssr' rcthet thr-rsrei st' i th e p ro c l ucti vcscctor cl ccrcrrscs' , . t r - f . , p" f 'i''t rl l arl cl s.' Thc cl e rl cw " r i ,' ,,t, " g .' a tlc t: to sLl pp()rttl l c inq c ( ) lt c c r l ltl v c r th c a p e c i tyo i s o c i e t,v i l rc r cttscclcosts i rssoci etcclw i th the abilit v of r rtl y c o ttrl trl i ttt fi rl e rrc c 1-r,pttr c rc l rrti vcsi zc ,f thc l sl p ()l th , . r ; " i' t ; p, p' l a ti .rl d c 1 x :rrc L l vel l rrs es ' r,cl typc), r' rcti vc s.r.c rrrti ,s,f b v c l c p c ' c l c rc -v lr r t i< lr(rus u rrl l ,",' .,." r.' i r.,.1 A, tl.r. w
24 CompardtiueHeolth I'tilicY Medi c a lt e c h n o lo g ya n d h e a lt h p o lic y l A n tl tfi cr f6rce i ntpl rcti ngon al l hcel th s]' stcl l tsi s the ra;l i clcrprt t . t siotoi avr r ilmc c l i caltcchnol og,v.S i nt;rl yptrt, tl .rercl rrc l r l ot tl orc tccht.tol o gics r lr e vcr v i rl tl e tocl a,vfor i tttervcttti orl- atrcltrl ' ttl v < l f thesctl cu' tccl trl i cl tr es pr
Art lrttroductiort
Box 1.3
2.5
The cost of technology
After helping to develop some rf rhe horresr new drues, Menrorial sloa'Kettering cancer doctor l-eonirrd Saltz lras c.me d.wn with a bad case of sticker shock. T'he price tag for rrcarin{r pirricnrs lras increasecl.500-fold irr th e last d ecad c . Ten y c ar s : r go, doc t or s c ould e x t e n d t h e l i f e o f a p a t i e n r wh o ha d fa iled t o r es pond t . c henr . t her r r p' b 'i l r r l v r r i r g c 1 1 . - 5r n o n t h s using a combination of clrr-rgs that cost $-itll.lin roday's clollars. Now, new dru gs:rre ab lc t o ex t enc ls ur v iv al ( ) r ir v er ilgct .2 2 . . 5 r r r . r t h s , b u t a t a c r s r of $2,50,000, not includinc Ph.rrnrrrcvnr.rrkups, sirllries for c.loctorsancl nu rse s,a nd th e c os f < lf inf us ing t he dr ugs int o p l t i e r r t s i n r h c h o s p i t a l . T h a t kind .f co st is r ns Lr s t ainable.' s . r ner . r lat e' t h c b L r [ r [ r l ci s g . i . g t . p o p , ' a ccord ing to S alt z . - lhc c lues t i. n is s inr ple: H o w n r a n v $ 2 0 , 0 0 0 c r l n c c r drugs ca' s.cietv rcally aff.rcl t. stack ()n top of .nc an.ther? 'Alrsenr a tho ug htfu l n at ional c lis c us s ion, r ht . ens wer i s n
vi c lc lwhr r t nr igh t b c j u c l g e cal s n rrtrs i n a lb c n e fi tsrcl rrti vct< lthci rcosts (sce Ii r x l. . l) . ' l' hc ir npr r c t , f tc c h r.l .g i c rrl rrc l v rr.c e sw i l l bc hci ehtc.ccl by thc i n c r c r r s c in t hc v c ry c l c l c rl y s i n c c a c l v a n c csi n tcchnol ogy cnrrbl c thc p rolot t er t ior t of l i fc fo r p c rs o n s w i th i l l n c s scsthet urrti l rccel rtl v w < l ul cl h rlv c lt c c r tLr r r t re l tfa [rl- c b trt rrt h i g h c o s t. M o r covo, w ,l ri l ccrrrati vcrrcrrtl l lc llt lllilv lt c lt c n c fi c i e lto i n c l i v i c l u a p l a ti c n ts,the rnrrrsi nel grri ni n tcrnrs o f lc ngt lr of s t r rv i v rrla n c l rl u rrl i tv o f l i fc i s c l i fti cul r ro j rrcl gc.l ' hi s Lrncertrt ir r t yis c < lr t r pl i c rrtcbc vl th c i rtc t tl rrrt rrro s trn ccl i calpr< l ccdurcshrrve66t l l cor s t r [ t jc c tt o co n tr< l l l e crrs i s c s s rl c nto t c l c t crrrri rre thei r cffecti vcrress 1r p rr r t ic ular c ls c s e rrc l h o w th c y c o n l p rl re i n < l rrtcorncto l css crpcnsi ve rtlt c r r r r r t iv e ir ppro rl c h c s A . c c o rc l i n gto [:c l c l v(1991), i n thc IJS A al onc tl .rc cl if f c r er r c cbc t r , v c c nth c a tti trrd eo f ' w h e n i n c l < l trbtcl o i t' rrnclthrrt of ' w he n i rr c loubt s t op' c o trl c la c l c lrrp t< l $ I0 0 b rl l i o n rnnr_rrl l y,. l) c s pit ct hc f ec t th rtt n rc c l i c ate l c h n o l o g vrsg l obal arrclcontri butesro cost cs c r llr lt i< ltint lr ll h e rrl ths v s tc l n s th , c rc i s e v i c l cnccthat pol i ci csacl < l ptecl l rv count r ic s c r r n hrrv c rr s i g rri fi c rrrrt i rl p a c t < l n th c use of l rcw tcchnol ogi es. Alt hoLr ghall c ou rrtri e sfc c l th e i rrrp a c to f n e $, technol ogi es,nri l u\,,rry ro l i n r it t he c lif f us io no f e rp e rrs i v cn e w c l ru g sa n cl ccl ui pnrentby i nsti ruti ng cont r ols ir nc l r eq u i ri n e p h v s i c i :rn sa n d h o s p i tal s to w ork w i thi n fi xec' l b r r c lget s( F uc hs , 2 0 0 5 : 7 6 ). Mc C l e l l a n a n c l l (essl er,for errrnrpl c, fonnd 'cnormolls differcncesin how cluickly and rviclelvtrcrrtnrentscliffuseclrnto n r c c lic : rpr l ac t ic e '(l 9 L )c ):2 -5 .3e), s p c c i a l l vtl ro s eh i gh-technol ogvrreatnrcnrs
()l AJql 'Jlcllsso cl,lJAot lJ ll, \ \s lt t t t t l iJ t t lI I t l] Pt oAt l PL I t ]'1 \ l t t l ( ] 'l L l - 'l ) A ( ) l - \ L t J l r J t ll o l P L t t r- t l 't r t l c l l t r r r l r l o c l l l t 'm ' l1usl-r 1 rsV 'sltlJnllls t lol J t J Lll J ( ) s Pt t t r Lt t J P Jq P[tt] slLlJlr-]tlstl():)'llJt[] slsJ-rJlttl isoLll ol itJPlol'lJClI'rr irr-11'PJlrJlJ-JJ e r t r r s 't l s 1 1 r 's t t o t - ] t l r e c l r : r o l ltltl,rr, r - , r , , r , - ' , 1t 1, ' c ll< 11 1t : lnlt lt l s l l l ; r st:;11 cl rl rnq'rll::t:t]'r-'-r'toil 'rql os ilLro ,,,ql,^ .ql llcprcl iursr,t lo lxJlr.t():) llP :tttt 'JlJsll All[tllLLttuo:) tlllA\ JLll lLt'riitr 'iltrtl ')LlI sl slu.ull q:)tls Jr-l()Jtl.rol .lr'nt
puP s u o llP ] la d x alllq n d 6 u rs t 5 spuP LUap ',tiio1oLttlrel ltlsLtl L l() ls t lJ , llP. lt ll ( l- lt l: )( ) l PJ t l; ^t s J Ps l t r t l
97
Art lrttrodttctictn
Box r.4
;;;
27
campaigns for treatment denied
suffcrcrsarc furiousand go to thenedi:rwhen In the UK, ntultiplesclerosis cost-effec(llinical F.rcellencc,thc g.vc.rnntent's if-'. X"ii.,""f l,rstit.,tef.r th,at at grounds th-e on clrug trelv a ban iiu"n.r, agencythreatensttl rel i rti vebenci ts for ttsi vc xpe e to o s i mp l v i s i t p a ti c n t p c r d 10, 000per y ei rr press as in the tltr.ted is of twt.rchilclrerrwit| the clisertsc firr.'iln"',.,.',ui1.,.,. saying :'Myc hildr c r r lr c t lepc nc lr ' t lt . ( ) l1nlc , - l t o l v c l l t l v ( ) t l p t l t : l p r l c e ( ) n fL r r r Jt h c d r t r g f o r t h c s e y o r t n g th at? l'Sh..ld r hc gov c r llr f lr t s t c p in. r n. l do so contc frotrl? Meanwhilc' to thc will *hcre .-t-rit.tr"narrcl,if s
' I hc c r pc ctrrti ()n srrrrrlc l c n trrn tl < s l i th c p trl l l i c f< l rhcrrl tl rcrtrcrl rc p()tcl l l y .e l l l ecl i cali rl cl trstrythrrt hes rrrtrch t iell" - ir ls at ir r b l crl rl c lth c l ' e rc ftrc l l c c b < l i rl l ccl i ci rl c'H. erl l th crrrc t o gein lt y t hc c o rrti n u e lc x p rrn s i o tlo f fh c scol -rc c < ls t s hlr v c ir l c rc e s c c l p a rtl y l l c c l ttts c c i ti zerl scxpccterttl < l ftcrl cl ctl l l rttcl ()i i tl t crvctl ti otl , l cvcl s t' 11{ 1-1' 1111t hr g, herr r ilr l h i s h c r l c v c l s o f rl 1 c c l i c rrl l csscl cfcrctl ti rrlrrttcl , " u. r " l . lc c a. l c i rl g ,. M < l re ,v c r! p a ti c l l ts h rrvcl l cc,t' c l rl tcrl rct rl rl clthe ttl ccl i rr thc nr < lr cinir lnr r c c lrrs t< l th c i r OP ti o rrsth ro tl gh ' fh i s era g ,g c rrttc cvli c w of hcrrl thcrtrcoi tctr i s trtrrtttrecl ( . S c otct t r ll. , 2 0 0 .5 ). sr ri ghts oi i rrcl i vi cl tralt< i' , , vpolit ic iatts w h o p 1 " ." h tttu y c tl p l u s i s orl thc i s il evcry frl ct that h. ' a' lt hc lt r c w i th i c w l i rl ri ts . l t a l s . rc i l c c ts thc rl eccl rrl i ght i rrrri l y rl l c n tl l e r.l l .,,]1.w ho rtt rrtryti nrc ' crs,l .t 1- r < lt c nt irprt lrti c n t< l r a l l thcrc l ' rasbccl r ' l shi ft hc r t lt h c ar c . F n rth c fl n ()re r s i trc e w tl rl c l w ar crrrc th.l t pl accs l .l l l l orrl l t owr t r c lst hc n o ti < l r-t,,f1 ' ,,rri ti u .ri g h ts to hcrrl th l l cccssrl ryto cxcrcl se tnosc c lut y O n s oc i c tv t< t p ro v i c l c th c rc s o ttrccs tl l ' rrc stl phi sti cver oi ctl trtext r ight s . ' T l. r cl rtn g -tc rrtrc fi c c t, w i th i n th e bcctl nl e prol l reshas l i mi ts c , ic . l t . c l. ln ,,l ,,g i c a lo p ti o n s , i s th rtt s c tti l r!1, hcal th crrre ti rl < cs s iv ely nt . r e .1 i i ' i i .u tt p .l i ti c rrl l v rl s th c ' ,pr-rl :rti tl ' c nt it lelllc llt sfo r g rl l rl te c l . lirnit thc rTrcdicirl one sl.ror-rlcl thrrt pr
28 Compdrdtit,e Hettlth I' olicy Table 1.8
Views of the elderly about their health care systems(o/o) Australir.t ('ttnrtdtt
Systernworks rvcll N e e d sfundarnentalchi rrrge N c c d scornpl ete rebtri l cl i ng
34 3rl 24
3ll 40 Iti
NZ
U/(
U,SA
22 4,5 3l
39 44 l.t
2.5 44 26
,!or r r r ' t' : l)r ttr r l - r or n Sc hr tc tt r 'l r r /. ( 200( ) ) .
v e ry l i t tl c rctLtnt i n ternrs oi prol ongi ng rhe prrfi cl rt' sl i fc. l rl co t - t t lt r ies or col l ccti vcl y grourrcl cclcttl tttres,thi s nrrtxir lr r r list w i th l r6 re c1;rrrrrrurrrrl thc ptrl tl i c l esscl i sp r r r '. r gir lg c rrp p rg rrcht9 hcrrl thcl rrc i s nr()rcl nrl l l err[rl rrrtcl 6 f l i rl i t s. l )1fi i c opi ni on stucl i cs.for i trstrrrtce,hr' tvcf< l trrrclthrrt pt r lllic y cr() ssc( ) Ll11th cr.rrcsystcnrsveri esc< l nsi cl cr:l l l lrl c s u p p ()r t i or s1' rcci fihcal sP cl l toll lr calt h thc r.ttt)ottl l t w i th tri c s e l cl sccl l s to hrrvcl i ttl c corrcl rrti ott fectors at t t l velt t c cttl tLrt-al rrt the c a rc (T rrbl c l .t3). Onc rl ust l ool
An lntroductictn
29
w hct] tl nc' s< l w tl heal th i n thc or y s llppof t s th c n c c c lfrtr c o s t c < l n trti n n l etl t, of herl l th .r t1at , , f i, iu" . l 9 1 c i s rrt s trrk c ,c o n s tra i n tso n the avai l rrl l i l i ty " g< l vertrrnetltlt et:cl st' r cl trc r c s or t r c c sllr C v i e We c la S ttu fa i r:' l l < n tl w t hC rrn cxpel l sl vel l ew co trtr < t lher r lt hc : ] r ec ()s tsb u t n < l tw h c n n l y c h i l cl ncccl s trrl w i l l i rl gto trl rrkc rrrc o fi i c i el s c l c c te c l I t ' is lit t lc wo n c l e r rh rrt rl l rru v .l r,-,13. A grri rr' i t i s val trcs' hcl d .l ..i ri, r , t , t l. r r r tjc < l p a rc l i z cth c s c c t.tl ti .rl e l l l l vorki rl g t< l forces g l obrrl l n rp or t r lt t t t o llot c th rrt rrl th o trg h th c rc rrrc l l l sol l l e \tr()l l gcr rrrc c lc r' l rrrl s rrrc l c r' c c trrti o rl s , th cse i ,.,.lr . , r s e t hr t t r it t o th c rs . co u n t r ic s' ublic crtrcfeci l i ti cs s n olt s c rv c ctll te t rrtl n l .l ttu f ttl $ h rrt cxtcl l t hcrrl th It l- r r rbec cl cl tt' l tl cl((' s Lrncl i i f rtrcex pr r nc lc ctl,hc rc w i l l rc n ra i rrrl s te l c l l ' 1 ' l o ool f tl l l l l l ct of sotrtcoffi ci rrl s.thcrc ru rc M l c ( lar t hV , 199 4 ).l )c s p i tcth c p O l i c ys trl tc rl ) crl ts ttro trct' rrl orl cu' i l l resol vcthc rtttc l l i l i ti c s i s l i m lc c v ic lc nc ct ha t a c i c l i ti o n efrrc c6ttl l tri cscl cvotcstthstrttl h crr lt hc lt r c c r is is( l l 9 r I..5 ).A l th ()trg hw c rrl tIi c r scrvi ccsthrttl prl orcr h crrl th s ri e l l y highc r pr olt o rfi < tn so f th c i r rc s ()rrrc cto thc s < l trl l l rl t e; i l l stcrrcl , ptrbl i cL()l l l cs .,,r. , nt . i. 1rt hc , lc lc nre n dfo r s c rv i c c sc l < l ctl l l y ci ri ztrl t ttl i rl rrrgi rrctl to c x pc c t ' 1rlc v c l 9f l rc tl i c e l c rtrcth l rt c ()tl l c l l ()t .l l e rl rc l l l ct, l "rr, if il, , , . , . r rc . t r r r tri c s .M< l rc .v c r, rrsl tt()rc< tf thcsc expcctrl tl ol l s tlcnrlrtrclftlr cxpandcclhcrllth scrviccsrlcttlal| \' cseillrltt'\'
Box 1.5 Does more high-technology medicine improve health outcomes? health care fror-nvarious stuclicsct>nfirmthc notion that US Fir.rclings care coltrparing a stttcly usc of technoloey.h'orir-rstrrnce, ntakes'cxtensive. past dccaclc.showccl,that' frlr hcart atticl
llf
ContpardtiueHealth I'olicy
Concfusions H c a l th s vstcmsof al l counn' i csfrrcctraj or pr< l [rl cnrs as regardsthu isst r cs ra i s e c lh c r c. \r)Thether heal th crrrcrcprcscntsrr cri si s i n a;l arti cul rrr coLlntrv c l e p c r tclot.t s one' s perspecti vcbrrt certrri nl vthcre i s nrtrch vari rrt it lr rin -l i r r vhlt t s e v c ri ty l t cr()ssnl .tti < l nsol l l nore < l bj ecti vcl l crl surcs l ts " vcl l . c x tc rrt rrrcthcsc cl i i fercnccstl rc procl uctof hcal th pol i ci csof rhc cotrr r t r i, : s rtrtc to l w het cxtcnt arc thc probl cnrs bcr,onclthc cl i rcctcontr< l lof policv tttrrl < c rsI)rrt ? an< l thcr r,ver'w , het srcps cl ur g()vcnul tcl ttsrtrl < c,i f rr lt r , t o ttta ri ttti z cthc chrrnccsof frrrnti rrg, srrstl i nebl chcel th crl rc systcnrstl te t clr n w c a th c r thc agci rrg 1-l opul rtti on,tl rc;rrol i fcreti on of tcchrrol ogi cs,r hc h c i g h tc n cclptrbl i c cxpccfrl ti ()nsanclotl rcr forccs cl ri vi ni : up thc cost s? W h a t shotrl clbc al rcl rcl l ' cvi cl cntfrotn thc cl i scussi orr so far i s thrrt r hcr c rtrc s i g rtii i crtnt cl i ffcrcrrccs rts to l t< l rv rvcl l corrrttr-i csrtre cl ,,i nt in c < trts trrtirti trg c< l sts,provi cl i ng,uni vcrsal ertrl cl Lr,rl i tl ,crtrc rtnclprotc cr ing th c p u b l i c hcrl th. l t hes vct to bc cl crnonstrrttc(lconvi nci ng,l l ,l vl 'r ct hcr tttti v e rs rr lsl , ol )al forccs rrrc rrrovi rrstl rc hcel th pol i ci cs oi i ncl ustrir r lizccl c o tttrtri c sf< l w rrrclc()nvcrscl s rcc.Irvcrti i thar i s thc crrsc,i t i s i nrperrtt r vct o c x rttrti ttccl oscl l ' thc vari eti orrsrtnclsi nri l rrri ti csof thc hcrrl tl rcrrrcs)'st cnls o f c o u tttricsenclto epprcci rrtcthc i rrrpl i crrti orts i or thc provi si orroi h calt h (.heptcr 2 bcgi ns thi s tesl
Chapter 2
The Context of Health Care
l- hc hc : r lr hpol i c l ,o f e rrr,c ()u n trvrtt rr l )i l rl e ul rtt' l .rtti ttti rt ti rl rc i s thc procl ol n' hi ch rrrc cl i spl rr,vccl r r c t 6f r r r nt r lt it u d c o i frtc to rs .th c tn o s t i rrrl ) ()l ' trl rtr l. soe i el ..trl ttrrrtlrrrttlP rl l i fi n tl i nsi e in I r igur c |. l ' h c s cf,rc to rsi n c l rrtl erh c rl ic r t l ilr I r ic of r r c o trn trr' ,i n c l u rl i n g i ts s o c i rr lvri l ttt' s ]l (l \tt' tl ettl l ' es,ptl l i ti es c r l ir r s t it ur ion s ,tn rltre tl i ti o n s , th c l c g e l s v sterrr,trrtltl te el trtrrteret' i sti oi rl trtl tori n rl ri ght it s hc elt I c r r r cc ()p rn u rri tr' .Iro r i l rs trl n c c ,p ol i cr' -trtrrl < i rtg bc highly c c r rtre l i z e c l o r l v i tl c l l ' c l i s p c rsctl rtcr()s\ rl rtl l ti l .rl c l cvcl s. l\ , l6r c 9v c r , in s o tn c c o trn tri c s rrl ti < l n se rtcl /rl rc()rp()ri l tc strLl cttlrcs rl rc s t r ( ) lt g f , t c t 1; rsi rt tl c tc rrrti rti rtgs < tc i rrlp o l i c v erl cl rl l i ght' i rl etfcct, hrtvt' rt \ , et ( ) p( ) wc r ( ) v c r l )r()p ()s c cpl o l i c t c l rl rtrgcsrttl ttl c l t1' tl tc g< l vet' tl l l tctl t. i rttl tl stryrrrrclrrl etl i crrlassoei .rti ,,tl s l. ilic r v is c .t hc i rrfl u c trc co f th c rrrc c l i c ,rl rrs c l o e stl rc p o rv c r o f th c i trsttrrtttccprovi cl ersi rl sl repi rl g v , r r ic s r , r , ic lc l \,, hc elt h polic r ' . ' l' hc r r r r r c t i c c< l i rtrc c l i c i ttcrtl s tl c a tr b e str()l l gl v effccrctl by thc l cg,el s y s t c nrenc l it s ro l c i n c o rn l .rc rrs rrti ocnl rri t rrs,rrtclthc cl cti rl i ti orlof l cgel r is I t s t 6 hc , r lthc l trc s c rv i c c s .\,{ o rc o v c t,i tt sttttt. e,rtl tttti t' . tl l t' eottrts crttl c lt ellc ng, c , r t t c lc v c tt l tc g rl tc g ()v c rl l l l l c l l t l l ol i ci cs. l vhi l c i rl others fl tc g( ) v c 111c 1t is s rrp rc rn t' rrrrci ts l c l c c i s i o n si rre fl tc l rrrv.S rl ci alvrrl ttcs,too, i rttl i l ' i tl tralri !.:,hts r r r c ir r r p1lr t r lrtf()rc e s ,rv i th s o n rctra c l i ti o rrscrrtl thesi zi rtg s tr col l ccfrvc or ar r c lc lt it lc nt el tts rl n d o th e rs p trtti rrg ,h c ,rv1' crrrphrtsi rl rl rtclw l l at s to rv l r rrti s rt' ptrl l l i c' 1i < l tl cl c 9r 11r r r 6it vg< l < l c l .' l ' hbco L rrrc l rrri crrs s hoLr lc lt ' c t t t r r i tti rr th c l tri v rttc s p h c rc rl l stl i tl l prtcts ol l hcrl l th pol i cy. ( . < lt r r t r r ies . " r ,i tl t l n q c rs o c i e l i s t r()()tsrl rc l i kcl y to cl cfi nc ptrbl i c goocl s s tr< l tl sotl l c r r r r csl c r v ic c slru c h p r< l rcb ro rrc l l yrrn c li n c l u cl ctrtti t' crsrl c()verrl l l c. rl y ' s ti l p l 1 e t,srttt i trtportrrtttrol c i rl hcal th crrre, l s 1; c ic t ic st ,hc c x tc n c l c cfrrru i rl l portrl l l cui l l r , v hilcip 6t hc rs c v c rr th c n u c l c rrr fe n ri l l ' h rt s rt cl i rrti rti shccl t hc c lc liv c r vof h e rrl thc rtrc . of a c()tl l ttry,hcrrl thptl l i cv i s ln adc lir ionto th c v e l u c srrn c li n s ti ttrti < l tts rrttcll l -vcl crrl ograpl ri c l nl f i ts 1 -ropttl rrti ort r r ls 1;s I apc c l b v th e c o rn l ' r< l s i ti < < pllt t er ns . l{ c t c ro g e n c Ou s , n ru l ti -c trl trrral pOptrl ati < l ns rccl i ti rc tl rtl re th rrrt trto re h o rl l o getl cotl s()l 1cs.l .i kcw i sc, < l l cl cr c < l6plc r hc r t l tl -rs ,v s tc l tts r ones. [l eel th pol i c,varl cl h a v e c l i ffc rc l ttl l c c c l sfro rr v o ut' rge 1- lopulat ions rrl sorefl ectthe cttrrcnt d i s tri butccl rrc rc s o L rrc c s n tc c l i c a l in r , v h i c h t he wa1i1llclclemancls erpectrrtiotls ptrlllic the arlcl strrte of rneclicrtltechnologl' length arlcl altor.rt of attitucles sLlrve\r a thrrt acconrpirn,vit. For crar.r.rplcr Irl tern:rti tl nrl l LJK thc by c lualit v of lif c a n to u g a c l r-rl tsc o n c l r-rc tccl
3l
32
Cynpardtiue HcctltbPolicl' B i omedi cal Technol ogy - i ntensi ve/curati ve - hi gh cost - w i del y di ffuse
Demographic Factors - ag e i n g p o p u l a t i o n di v e r s ep o p u l a t i o n s - s tr a t i f i e dp o p u l a t i o n s
Legal System
Poriticar system
Social Structures ( f am ily ,c o m m u n i t y )
P ubl i c and
Mass Medi a
I
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H eal th C ar e S ec tor
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fr
So ci al V al ues ( in di vi dual ri ghts,
C ul tural Factors (di versi ty, confl i cti ng
co mm uni tari an, te chnol ogi cal fi x, life prol ongati on)
vi ew s of heal th, rel i g i or.rsd i fferenc es )
Figurc2.l
Heabh policy context of deucbped natictns
l .o n g evi t1, (,cntrc i n 2002 fotutcl si g,rl i i i cantcl i i fcrcnccs bctwcct l t he F rc n c h. tl .rcA rtrcri crrnsrrrrclthc l l ri ti sh. W hi l c 64 pcr ccl l t ()f Alllcl'iLr r lls a n c l .5 .5l )cr ccnt oi thc l l ri ti sh w antccl to l i ve rts l ()rl g as p()ssi l) lccvcr l if tl re t c ntrri l cclpai n, ncrtrl y tl vo-thi rcl sof thc Frcrtchtl ptcclto l i ve r l sh( ) r t cr l rci ng i rt l tei tt or cl epcr lclct lcv th l rl everrrgel i fc i f i t nrcrrntcl .vi ng' uvi thout o n o th ers ((.arvcl , 2(X )2e). ' l ' h e rnassntccl i rrand i ts !()\' Lri l gL' ,rirrrecl i crtl st()ri escl crrrl y inillr cr lcc Ito w n tccl i ci ne ancl heel rl t crl rc pol i c.v i l rc percei vccl bv the pt r blic. the l l l ( ) r cscllsil (l 6 u rrtri csw i th' t;rl tl < l i cl ' tracl i ti ()us rrrcl i kcl y to el ttphrrsi zc trrtclit iot t s: t r c i ttvesti l l rrti ve those l vi th nrorc ti e n a l aspectsof nrerl i ci ncr.tncl
Thc C'nrttcxttf Ilcalth Cdrc Table 2. 1
-33
Public satisfactionand percentageof GDI' spent on healtb cdre \ ,\,tt i sl,tc t i, trt I t' t' t'l
l s Ir c ttr $r 'l l , rl (.)r)l n l cl l srlr ( ' ( l l) \\f:lt( lIr ' nt,' ( ) iltlr cr Vlr 0lr ,fhclr tlr ltltc i l r c \\s tc tl l r r ol | ( ) 9O) ' tltr tl.L if * 'or l l l c tti t'( l i l er r tl or l ,',,,7. .tp rl 6 rrl y 1 tir r ,,r ' clt,t1gt, ilr ( ltcc( \\ilI\' 1o or lc r v s r tti s l i c tl 'u'i tl r thLi r l l tr l tl r s r s l tttl I9 9 6 i s l )o rc ( nlr r gc sr r ir r g tht,r ' u,t' r c' fr r ir lv ( l l l cn rl o rr r'1 .r 1., l0( ) | ) . rr)t:rrrilr tblt' n /r -
\ i / / / r ( . . , - \ :l ) e r r r l- r o n t( ) l:( ll) ( 1 0 0 6 ) ;lilcn tkr n ( ,/,//.( 1 990);l i l cntl orrr'1,r/.(l ()01).
lik c ly t 9 l9< tl
34 ComPortttittt' H ealth P olicY LJS Astrbstanti allYhighcr i n th e hi ghest, r,vi th ()f coursc son' rcl i kc the (Mu s g ravectctl .' 2()()2).S i rrceal l tl frl trrctl tttl trl csarccl tri tesi rl lillr r ir l r r c( ) lnbithrrt cl i fi crcnccsi n spcncl i rl g.rcfl cct w c i rl th, h.u,cvcr, w c sr.l l l gcst bc t hc rl l i ght W cal t6 frrctors. rri rti .rr ec.rr< l rrri c,.ui ru." trrrrclhi st' ri cal l.rc lllttst 'f thrtt t.l.latlV
political Institutionalist explanations: contrasting systems r l r c i c l c r l t i c r r l tr tl cl e r l ch Alt hO t r g h t h e p
Tha (ttntcxt of'Hctrlth Carc
t.5
. c N cthcrl al l cl s,A trsfrrrl i l rl ncl c ount r ic s anc lS i n g a p o rc ,l v h i l c (i c rtttrrrtyth thc LI S A r t r c c r a n rp l c s o f th c fc c l c re lrtto c l c l. A n< lt hc r it r s ti tu ti rl n a lc o n fi s u re ti o rt fh e t r cl rrtcscl i rcctl ,vt< l thc col tri rt< t f p< l rvcrr' vi thi rrcrtch l cvcl of s rh c c l i s tri l ttrri < l rt t uunrof c c r r t r e l i z .:tti < li n sttchl ts N cl v Zcal l trl clarl cl gov c r lllllc llt . lj< l ri tts tl l tl c c rl l l l ' tl l vc l c ttt< l c rl t ci cs' t hcrc thc tl i sti rl cti tl trl l ct\vcctl thc t lK , c ( ) lt c c n tr:ttep ()w c r i l r p rrrl i rrn rc n \v c r c c ut iv c anc l l c g i s l e ti v c l :ro w c r i s o b s c trr cclor vi rftrel l t' tt()l t cxtstcl tr. M< lr c ov c r ,r t lt h o u g h rn l tn r,' p e rl i ru l c n tl l rvs \' \terttsl tl tve trl l l l cr rrttcll < l w cr i rr thc LII(), i n hous c s ( c . g. ,t h c Il o u s c < l f l .o rtl s a n tl IIo rrs e of (.orrrnr< l rts l to tts t' s l < tu ,c r i tt s ts th c c t f c c t r r r < lsttr ) ()w c rc r I r r s t r r r l
ljrt'tl
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t ion c har gc s f o r th c c l c l e rl y ' o rtM e c l i c rre w hcrc al tl l < l stcvcryol ' l cagrcccl
UK Singapore New Zealand Concentrated
Figure2.2
ttaly
GermanY Japan Sweden France
Australia Netherlands
USA
Fragmented
lnstitutional pouer in political systems
36 Comp dr dt ittc H ealth I' oli cY aftcr ()vc r t wo s o m e th i l tg must be cktne, l i ttl c l .rasbeen acconl pl i shecl and the LJSAar c y e rrrso f iol i ti cal w rangl i rrg (A branrs, 2002)' A ustral i rr ilrc clr.riteclivcrcarc hcalth t. b.th federrrlsvstcrlrs,l-t tii.i.:rppr.achcs i rl A ust r alir l rcfortrt g c n t. Al th ough not rrs stati c rl s ti l e LJS A ,how eveq rrcighbouring of thllt iru.. t1.,.y.,.,ri h,.,,6ccrrver,vnrerrs'rcclc'rttpirrccl t() N e w Z c al ancl . hl ghl y i rl crct'nct lt r r l, l n (i c r nrany hcrrl thpol i cy nrrrki ngel so tencl sto bc bl ockaclcs"As to rh e c x tcl tt thrrt hcal ti r p,,l i cy i s oftcn l ockccli nto' rcfornl r lor lpOw ers,rr. Jl i rl ' ," rr.clrttl l otl srr nrtl l ti ttrdctl f rl l ai l rly c l e c i s i < l n-nrrrki ng r r cr t lss orgrrtl i zati rl l rs) provi cl cr rrrtcl s trttc r.rc tors(tl te i nsLrrancci utl cl s clir cct l i ttl c q()vcfl l l l l ent hes fe c l c ra l ,strttc tU rcll Ocel l eV cl s,tl re fecl crrl l ' l hi s i s parti ctl l ar-11' of c r r sc i rl thc pcrti rl cnt i n i l r-re n cc< l n hcrrl tl r cri rc. ' l hrorrgh thc scl f-i l cl rl ri rl ist r ilt ior l i oi rl t rn e c l i c .rlrcforrn (l i urerr, 2()()l ). lt t t cl e()vcrtl rl tt CC' cl rl C tgrsrl rc i tt tl l e heert 9f hcl l l t[ fLrrtcl s, w i t[ i rrs r.rrttrtcc l r r t clical erl cl thc rel ati rl rrshi pl l ctl vcctl ccol rott' ti c i t i s c i i fi i cul t to acl .l rcl ss rrrti < l n r rl i ty. pol i ti cel systel l l s\vhcrc c()l l l pcti l l l l polit ical M < l rc0vcr,i rr frrtgntcrrtccl i s rl rorc l i kcll't
Ge r m any USA
Australia Ital y
France Japan Swecten
N etherl ands New Zealand
Str o n g
Medi um
Weak
N one
Figurc 2.3
UK
'fhe strengthctfiudiciol reuiew Sol l t'r 'r ': l 'i i phr tr t ( l 99t) : 126)
Thc Context of Hcalth Care
)-
inv alidat ing n ra n y l a w s o n c o n s ti tu ti o n a l g rounds, thr-rscarni rrgthern the l: r bel< r fbeing a n ' i rn p e ri rrlj u c l i c i a ry '(F r:rnck, 1996). I n c ont r r r st,th c N c th e rl a n d s , N e w Z e a l ancl ,the tl l ( and S i ngrrporecl o l1( ) thav e s y s tc l rs o f j u c l i c i a lre v i e rv .l n th esecountri es,tl re w i l l < l f parl i :rnr c nt is s upr e n rcrrn c lc rrn n < l b t c c h a l l e n g e dor overri cl cl enby a hi gh coLl rt. T I r c r c n' r ain i n gc o u trtri c s h a v c p r< l v i s i o nsfor j rrcl i ci alrcvi cw br-rtfor rr v r r r ic t y of r er rs o trsth c c o rrrts h a l ' c e x c rc isccltl rci r p()w cr l vi th rcstrrri l .rt (.otrrt of I Iunran R i ghts i s r t nc i nr oc lc r rrti o n J. ' h c ro l e < l f th c F .u ro 1 - rcrur lik c ly t o inf lu c n c c h c rrl th p o l i c v i n a l fe c tcrlcorrntri csbrrt i ts p()w crs i rrc s t iI I nr et ar r < l rp h o s i n g ,.
Legal systems liigt r r c 2. 1 al s o s r.rg g c s ts th a t th c l c g a l frr rrnew ork c,rn l rrrvcsi gni i i cent inf lt r c nc cor r h c a l th c a rc . l t c rrn c l o th i s i rr n rrl l ryw :rys, rengrng i rorn l csulet ir r g t hc nr c c l i c a lp ro fc s s i o n sto i n fl u c n ci ng thc cl i srri buti orrof herrl th c r lr c r c s ( ) ur c c s ,t() c o n s tru c ti n s l i a b i l i ty systcnrstl rrtt i nrpact < l rr b0tl t. V f lhilc s ( ) llc c ()u n tri c s h a v c ()p tc c l f()r n < l -farrl ti rcci cl cntconrpcnsi rti < l n s y s t c nr sr ur c lf< l rs rrn c ti o n sb v rrrc c l i c abl o c l i cs,()thcrstunr t() thc c()urtsto v r r r ious c lc gr c c sro c l c tc rrri rrc l ra b rl i tv rr ncl the al l ocati < l n < l f nrecl i crrl r c s ( ) ur c c sr r nclro p r-rrri sw h ro n g c l < l c rsi n th c nrccl i crrlprofcssi ons. Not s r r r pr i s i n e l yu i v c n i fs c rn p h a s i so n ncsrrti vcri ehrs,thc LIS Ahes thc I t t ( ) s tc x t c ns i v c c i v i l l i a b i l i ty s y s tc l r i n re gi nabl c ancl hcrtl tl r crtl c i s rrtr c x c c pt iolr . M a n y s tl l tc s i rrc c o n s i c l c rc rlto h:rvc rt cri si s rvi th ntccl i crtl t t t alpr r r c t ic cin s u rl rn c ea fi < l rc l a b i l i ty()r c vcn rrvai l abi l i tl ' ,rtnclcl < l etrrrs in s ( ) t t t cs t ir t c sha v c h a d rv o rk s to p p e g c s< l rs l rl rvcl ow ns()r.rtof pr< l tcst(l tci ss, 2( X ) . 1)I.ns ur r rn c erl rtc s f()r th c ri s l < i c s n t rc cl i crrlspeci rtl i ti eshrrvesl < yrocl < c t c c l wit h r ur ttu l tl i rts rrr.rn e uc ()v c ri l g L i ,,r < l bstetri ci l ursavcrl tgi rrgovcr $2 10, ( X ) 0ar rc l i o r g e rtc re l s rl rg c rv $ 1 7 .5 ,(X )0i n l i l ori cl rt for i nstrrr.rcc. ( , ons c c luent l y p , l rv s i c i a n sa re l e a v i n g th c strttc t() precfi se erl scl vhcrcor lc av ing,r nc c li crrc i e nti rc ly ( Itc i s s ,2 (X ).1 ). ' l' lr e r nr lpre c ti c c c ri s i s h a s b c c n b l a n rc clon l arscr cl ai nrs l rncl rnorc laws uit s : t hc a v c ra g c i trry rrw a rc l i rrc rc rrserlfrorr $700,000 t< l ovcr $ l, ( X X ) , ( X ) 0ir o u r l 9 c )c )to 2 0 (X) a l o n c (l N S W orl cl , 2()02). The cl octors' r lr s ur t lc lt t is t h a t n re c l i c a ll i a b i l i ty l rw rrrc l sf< l r rhe el usi vc cetcg()ri es()f pr r in r r nc ls uf fe ri n g , a n c l ;rrrn i s h rn c n rrw t a rds, w hi ch oftel r rel rch tcns of r r illions of do l l rrrs ,n rrrs tb e c a p p c c l(a u s u rrlfi grrrcgi vcn i s $2.50,0(X )) as t hc v hr r v ebc e rri n (.rtl i fo rn i a , w h i c h h e s e scrrpccl tl rc cri si s.H ow cvcr, tri rrl lr t r v v er sr t t t c cl o rts u rttc g r ro u p s a rg u e th rrt th e reel probl cnr i s thc fai l urc < l f t hc r nc c lic al; rro i c s s i o nto c l i s c i p l i n cb rrc lc locrorsanclthat i rny attcl npt t() lim it ewar c lsn u rs c ()L l n tc rto th e ri g h ts o f i ncl i vi cl urrlt< s l rccl ressw r()ngs r r gr r ins t her n i n r.rc o u rt o f l rrw (PL rb l i c(.i ti zcn,2003). A l l si cl csi rgrec, r hot r gl. rt,hr r t th c c rl rrc n t s y s te mi s i rre c l u i tabl eancl unsustai ni rbl c:rsnrost pilt ient s lv ho g o to c o u rt l o s e a n c l g e t a b sol utcl y n< l thi r-rg w hi l c i n sorne
38
Oomltaratiuc Hedlth I'rtlicY
rccei vchl ttt ttl t' lt let ar v c a s e sp c rsonsw ho havc sufferecll i ttl e or no h,rt' t.tr s c ttl e n rcnts. cotl tri butcs h eavily thrtt the LISl i abi l i ty s-vster.n T h c rc c:rn be n9 cl 11ttbt offer strbstar lt iallv si cl cs tw o thc rrl thor-rgh ro i u fl a tc cl hci rl th crtre costs wrrl's' J'htl clirect itl tr'r'tl costs thc to cliffcrcnt cstiltliltcs.Thc systcrll rrclcls i tscl i . rl lost 9t i tl sttrrrtrcc col l c fr11tttthe c< l st1l f l tl rl l practi cc c o s t i n c rcrrscs prl vcrs..' fhc' i rlciir cct l v h i c h i s pl rsseclol t t() prl ti cl tts rrl l (l thi rcl -prrrtv cl c' isit 't lis tl l ccl i cal vi rttrrl l l t' cvery i n tp a c t i s cvctt ttr< l rel l rtl i tl trttcl l, l ccrrtrse l i ti grl ti on ' This n trrc l ew i thi n a l cgal col l tcxt etrclttttcl crthrcrrt< l f poterrti al t' t'ntcdi ' ' i rtt' trrrcl cluvhich f ttt l crtcl st< t w hat i s tcrtrtcclLl t't:rtsi c n v i r< rn ttte thcrepctrfi c l l l cr 't s[ lr cs' rl ttcl tcsts cl i rl grl tl sti c c l < l c to rs< trcl cral l avrti l rrIl c pi l ti (' l l t' i tl t tt-tl ct'fo l't vcr t t() i l l l crl cfi t trtl or c v c n th () sethrrt l trc of rtrl l rgi rl l l < l r,i i str ccl,t
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Thc Ctntcxt of Ilcrrlth C'trre 39 c< l rl trol l i rrgnrecl i cal s t r t f c lc v c l r lr c rc s p o l l s i b l e fo r l i c c rl s i rl g cl < l ctors, speci al i sttrrrrrl i rrg' c t hic s , or gr r n i z i rrgc l i s c i p l i rrrrvp r()c c s s c srr rcl < l ffcri rl i l , ' f hc c ha' r ll' , cr,,,,]cp u l ' ,1 i .l ro c l i c src g trl rrtc i by l l :rrv (Moran' 1999)' l i l l l i trl ti < l rl sof tl ' ri sl l ppr< l :rch'l tr th c s h o rv s I l< lr , v c v c rtl, tc c rrs c< l f l l ri trri n Li l \(' \ ()l ' rrtt' tl i tl tl r ( . L( ' lt [\ ( , ilt \ . tl t(' rr' l t:tv t' l ,t' ttt .l l tttttl l t.' r' ' rl l l i ql r P | ()fi l t < l rgatl t i rotl t rctl r< l vccl nt elpr r r c t ic .e ()n c rn v < l l v c cel 1 -rrrth o l o g i$,l st l o hrrcl t' rrtttl i ttrtti tttl tw i th< l ttt t 6c it . c lic s , i c l c e c cl h i l c l rc r c l u ri rrgp ()s t-l l l ()l ' tel l l rl (i l ) w rrs c.tsc. Itt rrtt.ther it - . ' "f . i, , , . c or s c rr .f p e rc rts (l l .s c l e i ' . l (X )l ). sttbsccl ttcl rt rr thotrgh , .5o f l ri s c l rl c r' l r prl ti cl l t\ c r lnv ic t c r l < lf n tu rc l c ri trg 1 200 r.cutl ccl e l e t tl re rrc ttt,rl ttttttt6tt' .t r i cti rl l s i, - , f , , ir u s r ! { ! r,c s tc cth tht' eS i l i tv.f thc ( ( ir r r t c q Z f liiZt. l i ' r1 c rrs c ss tr.rts l ' tl rt' .* i ttt, tl ttttl ' ' t ( ic r r c r r r l N4crl i c a l(.()L rn c i l((;N l (.). th e tl oetors' pr' ol -cssi orl rtlbotl \" t< ) i r.rl r thc \l .tl rl trrl q i r.,rr r' c .l i .l e l r..rl p .rrre t i ce. profcsrl l etl i crrl ' rr' \stl rc tl l c u' i thi rr i rrl ttl ,ts rrrrrl g. . , ,, ' r (,)u. t c.c, t. , ',r, r. f, ic .ts th c l tU l tl i c , rrs i l ' e l l (. tl trrrci l . rctl trtti otl i tt i rl cl trcl i rl g rc i o rri l s o f th c , i, , , l, l. . l t O s u l -,s t,tn ti rrl I fi tttess-tr l ' rl ' ,l tti tel tt' occtl ttrcs s iz c , inc r eas cc ll a v tl l c n tl ters h i l -r,ti g l .rtc rl ccl l)). i \t thc.srl rl l t' ti rl re' (l Jatt,v,2(X r.u ,ti i .l rti .. i' t r . c l trc ri ,rr,ri e. c l t hc N eti ,rral ii, , ir ilit . uc lr r i ttrsi . th e tl l ( h e v c ri s c n s h :rrpl v'A cc.rcl i rrg:t]..' l ]t i :rcc tl rrrssi vcl i abi l i ti cs rotrl l l i rl g, A r r c litO f f ic c , N l l S h O s l -ri trtli ns L .rl g l rl rrcl -[' h c rrrtc ,i f ,' .r" c l a i rtrsrrs c 6v J) ytct' ccl rtbctw cc' l c)c)0 I , . 1. 96illi. r . cl rti rrl soi cl i rl i crl l rl cgl i r r nc ll9c ) f J r, r n rl .rrsO i M e rc h )0 0 0 , rl ro trrl cl2.1,0(x) val trc'of settl crrvcrrrgc T' hc l ). 2 (x ) l o < tc l n re n , *. , , . . , " . , 1. ()U ts ti l n c l i l tl(w ccrcS rrrlprl l s\ rrtl cl cl ettrrrgc 5 r ei rt lr ' . , r r i, . ,1. 00 0 rv a s I,U 7 ,0 ()0 ,c x c l trc l i rrg -l ' hc rcport rl l i l l i orr. I 1, thl rrl lV hc r c c ( ) r t r tsh rtv c l tt ti n rc s l w ,rrc l c c ltl l
C u | t u r a I e xp |a n a ti o n s:cu |tu ra|/histor icaIfactor s shaping health care ctl l l bi rl arr cl i sti rrcti vc I t is ar guc c lh c rc th rl t c rtc hc tl tttl trVb ri rrg st6 hcrrl th i l l cxpl rri rl i rrgi tt his t< l ri c a lrrc l c L rl t.rrrl fa c t' rs th rrt rrre crtrci rl l t i. r ' . i i s thc conl pl er of bel i efs, pr oc liv it ic s rrrrccl h :rrl c teri s ti c s .l )o l i ti c rrlctl l tLl rc the proper r< l l c of v alr r esr r nc lrrtti trrc l c sh c l c l b ,v th c p trl l l rc ctl tl cerl ri tl g to a prlvatc op.pos.ccl as pr.rlllic ll cr'rrc is hcalth llovcnlutcltt. Trl rvhrrtcxtcltt servi cesl l c heal th s6.trl cl g r.trncl s g < ).d ,.t-l w 6 a t [ u, r . l , ' , ' - , . 1i f, ;r p L rb l i c state rrs th.c r.l c.f pcrcci vecl . iis t . it . , ut c ct,,, 1 i n .l i u i c l i i a l s ?Wh rrt i s t6 e inflr-rrvhich cultr-rrc tlf on thosc clet.ncuts opposecltO the citizctr?To f
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Germany ( ic r r nenv hr r s rr s tro rrg rrrrc l i ti o n o f v o l rttttrtri srrr.scl f-hcl 1tarttl l -artri l y suppor t r c nt bc c l c l c c li rr (.h ri s ti rrn s o c i rtl terrehi ttgs rrrl .l thc i cl crl < l i 's Lr bs idier it l, ' . -l ' h cIl J 7 .l s o c ra lIrt' a l thi n s rrrrr r.t' . f hr' l i f\t of i ts l < i ncl l.rtri l t olt t hc s c t r lt c lit i < l n sru ttl i trc rl rp o rl rtr' ctll re n r i rt i t \t;tttl t()l -\svstcl l lof s< l ci al s t llic l. t r it y '.l' I e c 6 l s c rr,rrti y e1 n !l q ' p rn n i rtu soi thi r r i si ort of srtcrrrlsttl i c lr r r it yc onr r ilst rv i th tl te e g rrl i tru ' i ;rno ri e n trtti otrsel trtr' .tetct' i stiofe N r' u Zc r r lr r r r cer l r c lS rv c c l c n . l ' h c o rq ru ri z rrti o no f hc.rl th Li l rc i tt (i ertttrtttv ts c o n ti n rri tr' e n c li s s h rrp cclbv rt tttttttl ' tcrof 1' rri rrei l tl cs, rr r ar k c cby l pr
The Netherlands ()u rtrrvi s tl rc N cthcrl arrcl s,w hi ch A r r ot her c r r r ntp l c o f r' re o n .rr.n u rri trrricrtrt ( ic r n ra n v i n th rrt tr)ri v a tci n i ti a ti v c has bccn e gtri cl i rtgpri rtci pl e r c s c r nblc s . u tc h s o c i c r l -l -rastrecl i ti < l nrtl l vbeettorgrrin t hc or geniz e ti o u o f s < l c i c tyD niz ec lin s c pr t r i ttcs c g n tc l tts< trp i l l e rs th a t rc p rescntcl i ffercrl trcl i gi Ousancl polit ic al or ic n trrti o rrs . Ac c o rc l i n g to th c R tl trtr' rtr(l athol i c tt< l ti on of s u[ t s ic liar it l, a n rli rs l )ro te s tru rtc o tl l ttc rp rtr t of s< l vcrci grl tYthe c]i ffercrl t l provi cl efor thci r metttl ters s c glr c nt s in s o c i c tv s h o r-rl cbl c e rn p o w e re c to ( lljdr k nr au r r r tcO H 6 w c v c r, th c ' pi l l ari z.ati on' of D r-rtchs< l ci 1 9 9 7 ). l k rl rr, i ntcrventi ol t i rt herrl th care s trltc c t , v began t o w c a k e n i n th c 1 9 6 0 s a rrc i inc r eir s ec(lM r r r rrs c ,1 9 9 7 ).
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Japa n Al th o ugh frl r ptl try W cstcrtl crs.faprtl li s rl ttctl i gl l trr,i ts hcal th cerc c( ) llt cxt llccr lt t sc b o rro w s trrttchfrottl (i crtrl rrttyarl cli s si rl l i l rl rto thc N cthcrl erl cls' ct t lt t r r c crtcrl tl ccl -frl rrl i l y-[as ccl It i ts basc.frrpel htts rt .t,l tttl l tl l l i tl ri l l l , ttlc: r t lt t hr r t hr' rs thi s carc, hcrrl th F9r w i th vcl ereti .()l t f9r thc cl cl crl y. givcll' r l a . s soci rrl l y i l cccl -l tccl covcrrtgcfor hcal tl r crl rc i s w i c[cl y tu n i v c rsrrl illr lr ily, thc \vi th rcstcr-l e l th < l ugl rl ong-tcrtrtcarc has trrl ti l rcccrl tl v l argcl v trr r clit it lr el p a rti c r;l arl y w ()1tc11.l l ow cver, cl ul i ng thc l est hrrl f ccrl ttrry < l f Wesf cr t l, r,vi tht[c i rl i trsi tl rr J ,,p " r r.r" val rresl trrvc ctl tuc i rrt1;c< l rrfl i ct i .rg .l v A rrrcri crrrr,i .cl i vi cl urrl i sti c c.l t.re, tl ttts crtttsi ttg sigr lif icar lt rl l l rtrl escP o1' r111;11i 1 r 11' c l i s i r css,P .l rti cul rl rl )'rl l l l ()l l sthc < l l cl cr.f rrccl i ci rrc i l rc rl tt rttrtrl l grt llt r r t i, t lt 'i < l f As,r i csul t,.faparcsc vi cw s (.,rri trci err rrl tl S hi rl r
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c lat ir g lr ac k t' tl re l T th c c rru rv ((i l e n .grrrcl ct al .. 2005). T< rw .s arcl c it ies elnpr l o v c ccl l o c t< l rsto p ro v i c i c p u b l i c' hcal th care r' rnclnrunrci prrl i ti cs I t ls o < lpc r a tc cllro s p i trtl s Il . r rL rra la rc e sth c ccntrrrlstatc pai clphysrcra' s t< l pr ov ic lc llas i c c a rc . S ra tc i rtv o l v c n l c n t i n hcrrl thcarc w as c< l nsol i cl atccl i' t lr c r r ic lc llc < l f th c rg tl r c e rtu ry w i th thc crerrti < l rr< l f c.u' ty c.unci rs, wlr r c h hac l p ri n rl rrv rc s p o n s i b i l i ty i o r l rc.rl rhcJre. H .w cvo, e c< l rsi cl er_ r r blc c x 1- r r r ' s i ...f h c rl tl r s e rv i c c s ,rl r.,< l ccrrrrccl i rr rhe 1-,' st-w l rrpcri ' cl , pav ing t hc w a v fo r rh c L rn i v u rs :rl h r,,rrtherl rcsvsfcnli l s w c kl r()w i t t< l cl ay. - l' hc lr is t < l ri c a l l e g ,a c v< l f l ttrb l i c i n v o l v crncnt i n hcel th c:rrc i s col nbi recl wit h t hc ; r r irrc i p l co i c t;u rtl i tr' ,w h i c h i s c l ccpl vcrp6r' cl cl crl i . S r,vccl i sls.ci r c t y ' I ) c oplc h a v c a ri g h t ro h c rrl tl rc rrrc resrl rcl l ess,f i ncorrrc arrd w l rcrc r hc y liv c ( l L i l < a n s s o na trrl N o rc l l i n g . l c )97). Il rc ri eht to hcal th crrrc i s p: t r t of pc op l c ' sc i ri z c rts l ri PrrrtrlIro t rrrri n ri i vi cl rrrrl lc,rrnc.i r cnti tl crl crt, rrs it t t he c es c < l f (i c rrrte rtva n c i th c ' N e th e rl encl s.I,tri ,l i e fri ncl i rrerrnclprovi s i< ln< lf lr c el th c rl rc rrrc k c v fc rrttrrc so f th t,hcrrl tl rsvstcr)r i n S u,crl crr,es i s il s t r ( ) agc r r p h a s i s ,rr p u b l i c h c a l th a rrrlc rl rc..r-, l rr errrrrfr.
New Zealand A lt lr O r r ghit s n a ti o n e l h c a l th s ),s tc n rc ()l nprrrcsrnost cl osel y w i th thrrt.f t lr . ' t lK iln (l i rs P.l i ti r' :rl c rrl trrr-t' r. ,.l t,rrrr,nl i l nl i ...,i ,,,r...,.l i t, ( lot lll. t lot lwcrrl thh c ri ta g c , l i l < e S w c c l c l r,N cw Zr.rrl rrntlhrrsi r srr()19trrr(l i t ior l of c gelit :tri rtrti s rtt.' l ' h w i srrsc l c rrrl l ,rc fl cctccli n tl rc S < l ci rrl S ccuri tyA ct of l9. if l t lr r t t p ro rtri s r.crll rr,)p r.n -e n rl c (l l .r .9vi si 9rrt9 al l ci ti zcl s l tasecl6n nc c c l' lt is r ls o c l c l l l o l ts trrrtc c[ry l th c s tr()ns l rcl i cf rn tl rc ;l u[rl i c c< l l srrl tl r t i" pr . c es s a ' c l th c v i c w rh rrt.ffi c c h .l rl ers,r.c l ,< ,l cl .j rs,f the pubri c t r r ls t , l' l( ) tr lll o v c i t. N e w Z e rtl a rrc l ' cs g a l i teri arrfouncl rrti op i s al s. i l l ust r at ec i b1' .t hc ' trrl l p .1 -rp r,'b e l i e f w h i c .h r r.l cl s thar pcrpl c ," h,, g., ,,,., s t r c - c e' s s f ul wc, rrl th y o r p < l w c rfu l rru s f l rc ctrt back t,i si zc,.N cw Zcal a' ci p. lit ic ians c rrb rrrc c c lfh c rrc w , ri g h t, rra rkct-ccl rfrccl pl ri l < l s.phy i n thc 1980s r r nc l 1 9 9 0 s , l ru t th c p L rb l rcrc j c c tcclattc' pfs t. rcstrtrcturc thc hc a. lt hs v s t el , i r w a y s th a t w c rc s c c l ri rs cl cstr.yi .g i ts egrrl i tari rrnf' urrc lr r t i. ns .T hc rc s u l t l ra s l rc c r rr s e ri c s ,f rathcr t-,.rl .i ' " tt" ,r-' pr, l -,i l j ,,u" rn_ llle' llt s< lf bot h Prrrti e sto trta k cI.n rt j < l rc h a n gcsi n thc hcal tl r c-arestrLrcturc, olr lv t ( ) pull b a c l < fr.' r r-n ' rc e x trc n rc a ' c l rr' p.pul ar tacti cs orcc thc pLrblic f c lt t h rc rrtc .e c l a n c l c l c ma rrc l e ci r rerLrrrl to:l l r()rc cgari tari rr'
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Britain lr c . r npar is r n to s w e d e n , Bri t.i n n .t.n l y has hi rcl i r rnuch shorter his t . r v pub l i c i .v .l v c m e n t i r h c a l th c a re, but the a;rpr.ach to col l ec'f t iv e ac t i' n ha s ty p i c a l l y a l s < r.b e e np ri rg ' nati c ri rrher' than prrnci pred ( . f . hns . n ir ' d c )u l l e n ,2 0 0 0 ). T I-ri sa l s . h el ps t,, cxpl ai n ,.,i t.. l forl cl -hy
44
Cornlt dr tttiu e H ea lt h P o I i c1'
Wa r II i r uni versal heal th servi cew as i ntroduced i rl uvhat w i rs tradit iona l l y a l i b eral state rcgi me. H ow evcr, the N H S di d not rcsol vethc re r t sion a gcner ous b e tw e e n l i l i ssez-fai rel i beral i sm rrnclcol l ccti vi sm ancl i rrsterrci pror ision servi cc rati ol l ecl e n ti tl e rn e nt phi l osophy hrl s co-exi sted w i th (Mrrra n , 1999). of thc N [-l S ent iT h e N H S crrj g,vshi gh pr,r[l i csuppofr. Thc gcr.rerosi t,v rl c rn en r p hi l osophy contrrl stsw i th botl -rtl rc fai l trrc of thc carl i cr N rl t ior r ir l l l ri tai rl , arl cl it is rrttc]thc rl trstcri ty6f p< l st-' ul ' ar Il rs u ra l c e rtrrl l tge11tcuts N ot strrpri si rl gl y,rcforrl l s hr t vc tni l rcl . ptrbl i c' s i rt the d c c p l ,ve l l tfencht:cl thc cxtc llslvc evctr rttrcl servi ccs, hcrrl th 6i f6 c p s c c l6n thc orgrl ti zrl ti ol frl ccclw i th t lr c pre (.6rrscrvrrti vcs w crc 19l l 0s l ate i n thc c h rrp q c suncl crthc wit ll r r tol l cthcr LJrri vcrsi tl i snl , rts s u rru rcc' thcN l l S i s srri ei n < l ur hancl s' . h calt h tl l at c e n tra l i s t p< l l i ti cal svstcl rl , al so gcrl cretcs cxpccteti < l ns the coL lnt r y. s e rv i c e s erc thcr srrtrtc (6r at l cest c< l nl parrrbl c)across (l < l l c c rrrs rr[r< l uti nccl rri ri esi rr.l ccu\s rtt' cprottti ttcl l t al l cl arc rci l tcret l ir l c l c b l tte srr bgut tIe ' 1' l ostcocll cottcry' ,' uvhcrcl tvscrvi cesvrrr,vsi grri ficr r lr lt ' fr< l n ro n e l ocrrl cto thc rtcrt.
USA cty.A l thotrgh i rrt liviclc T [c tJ SA i s thc prgrorvl ' rcof rtn i ncl i vi cl ual i sti soci cxetl ri l l cclhcrc, ir l t hc trrrri < ttts tu rtlri g h ts hl rvc sonrc cnrphasi si n rrl l thc of sttprerl trl cv()vcr col lcct ivc L )SA i i g h ts hrrvc bccrr cl cvl rtcclto tl strttr.rs i n tc rc s ts .M9re1;vcr,!y ri gIts A nrcri crrrtsl ttcrtl tl l cl ]rl ti vcri ghrs, r' ttlcl.r t sr t re s u l t, th ev rrrc l .rcsi tantt() sacri fi cc pcrcci vccli ncl i vi ci trrrll l cccl sfo r t hc Lrrl i versl l c()vcrrl l llcl rlt t r ls
Tltt, (\tntcxt of Llcalth (.drc
4.5
c x pc ndit ur csfo r a tt i rtc l i v i c l rraplrtti e n tc
Box 2.1
Heafth care in the USA
It is sonretirncs saiclthat the USAl.rasthc bestmedit:alsystcmbur one of the worst hedlth c.irc systclnsamonli developcdnations.The heavydependence intensiveand expensivediagnosticand life-savingint.iu"'rtio,.,s 'n has resulted in a sysremwhere thosewith adequatethird-party coverage hav e quic k a c c e s sro a b ro a d ra n g e o f technokrgi esi ' d speci al i sts unmatchedin any other country.It has,however,als{rspawneda system for which the control of cosrshasbeenelusiveand 4,5million peoplehuu. no healthcarecoverage. The extren're contrasrsof the systemareillustrated by the expenditureof $5 million over34 daysto rreata 69-year-ord patient whc lin t he e n dd i e d(v i .s l o w ,2 0 0 1 ) b u t the fai l urero guararreepre-natal carefor pregnantwomen.
46
(ktmp oratit,e H attlth PolicY
for cvery < l neperf1l rmcd i n.f apt lr r th e U S A carri cs < l ut fottr i 1peri rti < l ns (l )ra k c , 1994: l 3tt).
Australia thc frrr S outh l )rrci fi crtrl cla si rl l i l rrr llr it ish A l tl -r< tu gh.r\ustrrrl ishrrrcs r' r l -rc ri ta s ew i th N cw Zerrl el cl , thc tw o ctrl tureshevc cl i vergctlsi rrc eir r clci " r' I rtl or c cgr lw i th N ew Zcrrl rrl .l o1-r1l 11q ;," n .1 .' t,."i rr the l gth ccrl ttrr.v, i ta ri ,rl rtrrclcgl l ccti vi st pol i ti cal cul ttrrc rrnclA trstrrrl i rrecl tl pti ng:r t t t t t cl. t rl o rc i l cl i vi cl gal i sti c,LIS -tvpcrrppr< l :rchto cl cfi rl i rl gtl .rcscopc 9i pr r lllic g < l o c l se l l cl thc r< l l e oi l i ()vurl l l l l ul l t i rr P r' < l tl toti l l gccl tral i t-v'A trst r : r lia's i i n i .1 u " wcl frrrcstarc pl rrccsi r i r rr S v6ri clcetcg.ry val uc-w i sc,th' tr gh t 6c l l i th i ts str()l l qpl i rrtc c( ) lllpoA ustrrtl i :rtrhcal th crl rc s,V stcl w frrrg i rre rrtccl ( l{ir t 'l n c n t i s c l oser to thc Ll S A then i t i s to i ts nci ghl ror-rrN cw Zcel erl cl rcf lcct sr t svstcl rr hcal th cl cl i vcrl A trstr-rrl i err rl l .,2 0 0 .5).' fl rc cl cccntrrtl i zccl rl cctl cclto sttrvi vc i rl rl hosti l c ctl vi rtl tl tt.tct lf( cvct l irrcl i vi cl trrtl i strl rr-rg g c cl th o L rg hA l strrrl i rr i s tt1;wthc rrt< l stttrl l rl rttl i c()tl l l tri cs):l s tl l t' tcl las ir cl11cs p6l i ti cs. tl -rci re g , rtrel tcrlfccl crrrlsystcl l ltl ret cl ci i rrcs.A trstrel i rtrl ' l ' h rrs.w hi l c tl rcrc hrrsbccrr,rn i rrcvi trrbl cl l ri ti sh i rtfl trcrl cei rl A tr st r elir l t() i thc fi rst pri s< l ttcrscttl cl l l cl l tserrclthi s c()l l tillt lt 1s s i rrc cth c l tegi rtrri rriof t
Singapore O i e l l thc courrtri cs, S i ng,eporei s thc rrrost cl i ffi ctrl t to cl ,l ssi fv r ls t o c U l ttrrel ()ri cl l trrti ()l t,i n prrrt bccl rusc,rrnl i kc othcr A si arl cotttl tt 'itt , it s h i s t.ry i s sl ri ;rt rrpcl i t i s thus rr trni tl rre nri rturc < tf scvcrrtl bl cr lclsof c u l tu rc , Il tst and W cst. S i ngrrporchrl s ri scrl i l l fhc l ast 40 ycers f r ot l r l cotl tl i ttot lst
r*n]11ffi&_
Tbc Contcxt rl Hcalth Cdrc + / r S ingapor c ' sa p p ro rrc hto h c a l th p o l i c y i s a cl i sti ncri vccotrtbi rtrrti ttlof (l .i nr, I99tl ). l ts i r c c - r t r lr r l< cpr t in c i ;l l c s l rttc lc rrc ftrl !l o v e rl tl l lcl l t col l trol i trtt< l vi tti vcprcvcl l p h ilos < lphvis t o b u i l c l rr l re rrl th y1 -r< l p u l rtti
Differentapproachesto defining health A c r it ic al qLr c sti ()nfo r h c rrl th c rrrc p o l i c y ' i s w hrrt i s tttcrttrtl ty the terrrt 'hc r r lt h' . ' T - l. r c rl rrc e s c v c re lc ()n rp e ti n l ltn < l c l e l s, crrchof w l ri ch has i tttl -' op' Iht: prevrri l i ng tr r nt im plic llt i( )l l s fo r h o rv w c o rg a tl i z c l - rcrl l thci l re . W es t er n r t r c c lic rrlrtro c l e li s p ri mrrri l y fo rrn c leclon cl cfi ni ng heal th rrs thc tlt s at t c cr f Llis c rtsocr i l l n c s s .Pe < tp l ca re h e al thy trrl cl ertl -ri scl efi ni ti on i f Tl -regoal of curati vc thel, ar c n< lt s u ffc ri n g fr< l tt a n i l l n c s s < l r c l i serl se. hcal th < l f the pati eut' the re s to re n t edic ine is t o d i a g n o s ea n i l l n e s s a ttc l i vho by def initi o n i s u rrh e a l tl ry .In l .re re n ti n nrecl i ci rtei s thc cor.rti nual
48
Ctt ntp arttt it,e H cttlth I' rt li c1'
r r t r t gt ', r f e x p a r rsi onof categori csof di serrseto rrccountfor rr brorrcl etri ng rrsr r clisclt sc c o n c l i ti onscl cenrcclunheal thy.S uch l abcl l i r.rgof a concl i ti or.r h rrs tc ncl cclto i ngrai n i n rrccl i ci nethc noti otr that cl i scl rsci s th c enent y (Sccclhcruse, 1: 13). I L)L) A conrl -rcti rrg cl efi ni ti on of hcrrl th i s thc t' r.rpi l grrrocl clrvhcre l- r ealt his c s s c nti rrl l l ' errabi l i tl ' to rtcl rrptto thc prol tl orts l i i c gi r,' cstrs. LJlr clert his or ill st r bc hcrrl thy cvel t i f thcy are cl i scesc cl s d c fi rri ti on, i rrcl i vi ci ualcrtn l < tn gr.rsthcv hrrvc the pcrsonrrlstrcl l i j th rtrtclresi l i cttcct() c()pc lvr t h liic. ' I' h c t cnsi on w i rh thc l r()t-i l l theorf i s nrrrrri fcstccl i n a c()nccnr t hat t hc l vi th tl rci r i rttcnt al st at cs l rtttc r i ntcrfcrcs i rrcl i r,' i cl turl s' abi l ito t,"copc " vi th rrn c l cnvi ronl ncrrr. Il nLl cr thi s cl cfi ni ti on 1' rc< l plw c i rh< l trr i clcr t t if ialt lc c l i s c rrse or i l l ncss.rfc sti l l trrtheel thvi f thcv erc ttl tal )l ct() c()l )c. T h c thi rcl cl ci i ni ri orrof hcel th, thrtt of thc W orl cl H cel th Orsit r t iz. r lt ior t (\(/F l ()), cl cfi rrcsi r rrs' rt sfrl tc ()i cornpl ctc phvsi cel , tncntrrl rt ncl s
T h c ( 'r t t t t t r l
o l 'H t 't l l l t
( ,trt,
49
A lt houglr i n c l i rti c a l te rttts p n e u l ro n i a i rr b< l thcasesi s tcrrncclrr cl i serrsc, t hc am big tri ty o f th c c l i s e a s cl a l re l rc cl Lri rcscl ari fi crrti on of the sncci fi c c ' ollt c x t . I r l c rc a s i rl { rl vi .t i s e v i c l c n tth rrt l rcal tl r l l rusr cncol npass,r,,r,,,rl 1, r he phy s ic a ll rrl c lttre l rta la s p c c fso f p c rsorrrrlrveIl ,bci ng l ' ,ut,rl r,,thc s11ci al ( llalr c oc k a n c l l l c l o m i , l c )9 4 :2 0 9 ). l) t r t t ir r sh c a l th i rtt< lrh i s [rro rrc l ccr ()l rrcxfel so rai scstl rc cl Lrcsti on of w hv wt ' r lt lt r , . ' l rr.:tl thi n i ts n :trr,)w \L .n \(.;1 ,l r.t.t.tl ol rr l r()nt (l t\(,i l \(..r\l rl t,,tr.ql r healt h s ho trl c lh c h i g h l y v rrl L rc csli n c e i t i s ccnrrrri ro thc c6r1pl eti 96 6f ollc ' s plr lll < l f l i fc , h c rtl th i s l tc ttc r v i c rv cclrr\ i l nrL.,rn\to l )ro;111r1.g< l ,rl s rrrtl pt lr p( ) s c sir l l i i c . (i o o c l h c a l th i s n o f e s r rbsti tLrtc tor e q()()(ll i fc, rrpclg< l < l cl lr c r r lt ht loc s tt< l ts tl l rrl l rtc c rt g o < l rll i ft' . ( i ootl he.rl th i rr i tscl f crl nn()tgui rrat r f c cac lr ic v c l l l c l l to f < l ttrg < l e l s g, i v t' u \ l l r(' rl \()l rto l i vc, or nr,tri prrz.. .rtrr. pot er r t ielt o th c h i g h e s to rc l t' r.(i o o rl h t.rrl thi rr rl re P hr si c.rlscnscbrrt 1vi fh ( ) t lr t llc oth c r th rc c c l i ttrc n s i o rrso l l rt' rrl tl r.fl rt,n. i s rrni i kel y te cpsrrr.c e()lll(lltlll('lll.
( ) r lr ' ltt' t' lt
itt r r lr i.lr
tlr t.r ' itl, .tr
l .tkt.l ol rrt
r. i rt rr'l r,tt i r,,l t.n
r c r r nc c l' rlt r c rn rrti i ,c 'o r' h o l i s ti c ' rrre rii e rn e.
Cultureand traditionalmedicine A lt h< lt r r ] . hth c W c s tc rrr rn e c l i c rtlrrro c l c lcnj ovs cl < l rrri rrrrrrcc i rr al l 9f thc c ot lllt r lc s c ra rl l i rl c c ll rc rc , trrttl i ti < l rtrtlv a l ucs c()l tti nr.rc t() shrrD chow i t i s pr r lc t is c c l.- [' l l c refo rc , e l rl ro u g h n r()s trrttcnfi t,rrrrrrhi s l ' .' ,,t,1< euntr-cs o11thc r lr r aly s isoi th c s i rtti l rtri ti c se n tl c l i ffc rc rr ces < l f rhcsc c< l rrntri csw i thi rr rhrrt llr or r c lc rf r rl l l l c w o rl < ,i t i s i tl p c rrrti v c to crrrrrrntcfci tturcs that rni ght l tc t llll( lt lc t ( ) r ()r l tl < l rc c l o trti ttl ttrti n , p a rt i crrl er courrrri cs. ()rrc rtrc.t tIrtt of f c r s t t s c f trI i rts i { -:.hits s fh e c rfc n t to w hi cl r r,' eri < l Lrs forrrs of trrrcl i ti onal r r lec lic illcc o tl ti ttttcto [rc p rrtc ti s e cel l < l n g si clnrorl c crn W estcrrrrttccl i ci l c. I Llt il lll7 .5 , rv h c rl \rV c s tc rrt rrrc rl i c i n cb ccrrnrcthe < l ffrci alf< l rrrroi rnctl i c ir t c ir r . f ap e n , l < l tn r1 ' r< rtnl rl rrc rrl -l tu rc ture w cre cl onti nl tnt.l (antl -l ol l rei uts ' l{ r t r l M c t ho c l ' i rr b c c e u s c i t rvrrs rht.(,hrrresr' q' he i rrtrgcl gcc; fe p a rrc s c t hc t r s c of h c rb rtl p r< l c l u c tsfo r rn c c l i c elthcrrrpl ' cl rrri ns tl re 7th te 9rh ec r r r r r r ies : rt th c ti rn c o f th e H a n l )r,,n a s fr,.-l he .fa;xrrreschcel th crrrcsysrcp.l r elr llr it lsllt l ,l tl l ,tl t.l rttttl rti oonf n ro c l c rnW cstcrrrnrccl i ci nel tncl trl tcl i ti onal llas t c r r l P r ll c ti c e s ,rtrttl k a rn p o i s s ti l l rrrr i nrpol trrnt fr..rtl r' c()i rpccl i cl rl pr ac t ic c . - [ h c e rc e r rn rrj o ri tv e p e rrcscphl ,si ci ars (72 per ccnt of i rl l ' f .f \ wes t c r n- s t1 ' lccl o c to rs i n e 2 0 (x ) s rrrv c ),,) usc;rf l cest sonrc kanrl .roi 9r.1rulr lc ir l t llc ir p rrtc ti c c .Mo rc < l v c r,e l rn < l s ta l l pl rrrrrnrrci cs heyc staff tr.ai l ccl ir t t r ac lit ior r rrln tc th o c l so f Pr1 s s 1 l 1 1 1 1,.rrrrl rtrost herrl th i nsurrrnccc()l l D r.r_ orr nic s r c c < x lr i z crrn c ls u p p o rt i ts u s c (l (e n ncr; 200 l ). I-r' nr I c)74 to 196' ) t lr c r e was a 1 .5 -fo l ci lttc rc rts ci rr k a rn p o n rccl i ci nalprcparrrti onsi n ct,6rprrris on r v it h on l v 2 .6 -f< l l ciln c re rrs ci n th e s a l esof nrrri nstrcanrpharmrrccgti c r r l pr . c luc ts i r .J rrp a . (w H o , l c )L )6 ).A cupurcture arcl < l thcr l -rol i sti c pr r r c t ic c sar e rrl s o i n tc g rrrte cill rto th e .frrprrncsehcal th svstcnr,i n parr a r c ilec t ion of i ts Sh i n to /Bu c i c -l h iro s ro ts .
50
Comltardtiue Health I'ctlic1,
S i mi larl y,w hi l e srngap< l re' hcal s tl r crl re servi cesare bascd .n wcsr er ' rrte c l i c i rre. i t h;ts l rt' r' rt(()ttl ttt()rtP ri l cti c('i .l tr' t()nt tht' vrrri orrscthni e gr ( ) ul) s to c o n t act tradi ti onal practi ti oners for gencrrrl ai l merrrs. A l t hough 'Westernn'reclicine is thc urrrin forrr-rof hcalth cllre, il varietl, of traclitionirl p ra c tl c csc()l l ti l tucto serverrsconrpl erl entary forrl s of nrccl i calce r e ( f er i mp l i c a t i ons of thi s cl ash.f ' cthos' , see Qurrh,20().1).(,i vcn thc lar gc p ro p o rr i ol l of (l hi ncse i l r S i nerrpore,frrrcl i ti onal(.hi nesc rnccl i ci ne( TCN, t ) h rl s l l c c tt < l fspcci rtli trportrtncc.T(l M i s rrr.ri nrportrrntpi l l t of S i rrg apor c's h e ri frrgc rrnclcnj ,l ' s consi ci er:r[rl c1' roprrl ari ty. A l though i ts pr.rr ct iccis c o n fi rl c clto otrtl ' l rtti cntcrl re. rw o i rcupuncturccl i ni cs are affi l i ete clwit h p trb l i c h ospi trrl s.l hc\,' l i ni srr-r oi H crrl rhesti nri rtcsrhatabout l 2pcr cclr trl tl ;rrl r ou11' r.11i 1111 .tttr' rttl rtrrtt' ts tl trotrgl t | ( M Ip11L1i ti orrt,rs. rl rt. nr . r jor i ty o f w h,nl rl rc rrrri nccll ,cel l i bv spcci al i st' l ' (l N ,l school s (si n g. r p, r c Mi n i s try of Il cal th, I99.5). l n i ts report, rhe Mi ni stry concl uclcclt hat th c rc s h < l rrl cl l tc rto f< l rcccli ntc,qt' eti ort of ' l ' (.M al rclW estcrn rnccl i cilear r cl th l rt o n l y those pcrsons pr< l pcrl r,' trrri ncclro prrrcti scT(.M sh ).ln199. 5, th c Atrs t ral i rtnS tarcof V i ctori :r.i rr rcrponscto fl tc' rrrpi clexparrsi o nof t hc p ri l c fi c c tl f arrclcl cnrerrcl for l ' (.M i n thi s cour)try' r crcetccla Mi pist cr iel (l < l rrtrl ti tfccorr Trerl i ti onal Mccl i ci nc (V i ctori arr l )cpartrrrcnt of Hunr r r n S c rv i c e s ,1996). l rr l 99l J,the (l < l nrnri ttcci ssLrccl rurcxterrsi vcrcl )()rton t hc ri s l < s a rl cl l tcncfi ts < l f T(l M rrnrl rr r' vi cl crrrnsr.oi rthcl rrrrc lit ional e p p r< l e c l l cstrsccli rt A trstrrtl i rt,rtnclrr consi cl crrrri orr of thc nceclfor r cgulr t tt< l tt. r\ r tl rtj or rec()rnl nel rdrrti onof thc (.< l nrrri trce t() rhc A rrst r eliel H c a l th Mi ni ste r' s r\cl t i sorr' (.orrnci lw as thrrroccul .l rrti onrrl rcgi stra t ionof tl te Pro l t ' ssi ,n ol | (.\l l l .' ' ,,...' .1 :l \ i l n),rttt' r'or ul l r(.r' r(\' :{V i ttor i: ln Mi n i s tc ri rtl A cl vi sori '(.ontnri rrce, l 9c)8: | ). As i l l A trstral i rt,< l ri crrtalnrerl i ci nci s rvel l cstabl i sl recl i n N cw Zcr r lancl w i th s c hool s of rrcr-r1-runcturc, J' (.M ancl hol i sti c hcal i rrg.Mrrny gener r r l p ra c ti ti () l tcrsarc trai nccli n rrcul ' rr.rr.tcturc, rtnrl the usc of herbrrlpro clgct s, i n c l u c l i rtgN ew Zcal anclnati ve trrl rrnts, i s c< l rnrr.ron. ,\l though (i l ri nc se: r lcl o tl .rc rAs irrrttracl i ti orralapproachesarc avrri l abl e,the nrost uni ctgcinf llc n c c o rl N ew Zcrtl anclhcal th pol i cy conl cs ri .r Mrrori rrntl P .rci fi cI slalcl
fhc Ctvftt'xt ttf Hcolth Ocrrc
5l
hrrs llecn clircctecl rt cr,rlture s. (lo nsic lc r r t blc c f f t t r t ( ) \ r c r t hc pr r s t c l c c r c l c s tli hcaltI rlncl hcrlth rtccog lttiltg f
Functionalistexplanataons:population' wealth and economics ftl tts' T lr t , t hir . t l ( . \1 rl i l tl i l ti ()nftl r ..,,U | ttr.i .l r)ttrt ttl tfr v:tri :tti tl tti s.tt' rtttt' tl ri sti cs (l tl rrl l ti ti ' tti vc chl rrrrcte t c c tl trc sol l t ionr r lis tor strtl c tL l rrl l i sbt c c a r" rsi e hi ghl y rr st.nrrl l s uc h es c lc n tO g rrrp h i c srrn c l w e :rl th . P r
52
Con4)dratiueHedlth Policy'
Population size and diversitY irrfiucl;;'l Not surprisingly,hcalth policy catr be signifierrrtly, fl":|"' l l ccl tl sc t| l (' scLnilr . rc()V C r. tl f i l L(} | ' l l l rrVM(}
' ;ttt;, .1 .' rr.,g r.l p hi c..l .' l ....r.t.| .i sti Ls sttch:rs tht agci ng..r thc cl i versi fi c;rti'r r . i i rc te ri s ti c sc hange,," ;; hcal th systel r nl ust rl cl l r ptt o th c p o p u l i r ti ,rn thr,r.,i l .l i rnmi grati orr'the eff< l rtsof cotttl tri cs < l vcrt hc th o s c c h a n gcs.Ttl r,r,' ,.' ttttt" t, the rcfortl l rleccls represcl l t r.rtrcrl tprsto cl crrlw i th charrgi rrg, l rrs t s e v c rr rl cl ecrrcl cs espcci al l y trcncl s, 1-ropttlat iot . t b rrl r-rg h trr 6.ut i ,' 1-r" .tbr cl enrog.re;ri ri c ir r rcn' es cl i i fe thc of O nc rrl i ghi .rp" i t. tht" l tt" t" thrl t sotrl c chrrpt cr s fol l ow i rl g thc " 1 a .i t.,g sc eoutl tt-i es cl escri bccli n h c rtl th p o l icl rl l l tol l s tl -re ptl p t llir rcspccti vc si zc of the c rrn l tc trrr cecli ,l p" r,-,,, rl i ffcrerreesi rr the tS ci r cl egrcc< l i s.ci rrl stratiiiclr rtrtcl cl i ' crsi ., ti < l rs . t6 c i r egc rr.cl .,i ' r,l i . ti o rt i rt te n l l s cl i stri bttti ottoi l verl l tl l ' ' th l l l c 2 ..1si ttl l tl l rtri zcskcy cl cnl ogrrtphi cr" l ri rtbl es rtcrossotl r c()tl l lt r lcs' si zc oi p< l pul rrti ol r.l t i s t lot MOs t < l b vi ous i s thc u,rra.i i fi .r.,tcc i n thc rvrl rl i abl c hcel th sr stctlt f t r r ri s u rp ri s i n g tl .rrrtthc LJS Astrrrggl cst() dcvi .se (,el i f.rrri rr rrl .trc, rvi th.vc r 'i'l :rl n ro s r.l 0 0 rni l l i .. 1-,f,,pt. i tl .," S ," ," ,f cxrttl l i ttcclherc' (i crtrlir lly' n ri l l i o n p copl c, i , r" rg.| . th" l l hal f thc.cottrttri cs otl ght t
Tabfc 2.3
Populdtion chardcteristics'2005
I ', 'l t t t l l t i , t t t
,'1,
Nc/ grott.,tlt rrtigrdtittrr
(r't
t'Ltt('
Au s trel i a F re n c e ( rCfll)ll11)'
I t e ly .faprtrt Nc t hc r l a r t t l s Nclv Zerrlrtrlcl Singr t p t t r c 5rvcclett
strttc.[.,trge1tt' ptrl ' tti otlri zt' tl rt, ir s y . s r c r il,wir h i l l i l t' i l (jU S c rtv ,,r rt ,ttt,tl l deci si onmaki ng rn i ght r r ls
c l c t t t o t lstr ltft
slll:lllct' t' ' lt( \
( ) f ll' ( ) \\' th '
rl l rtl i l l \ut'tl el l 's
ei l sc l l el l l '
of tht' i r Iopttl rrti otl s' zcr o s r owt h ( lirr ).);. (.0 rrrb i n c rlu ' i th th e e gei rl g rl rrti rl trl rrl i tl cri s sti tl g sl .rctl tl thc s c i< lw gr o$, th rrrte :ss i g n rrltl i ffi c trl trc si rl .tr thc shri rl l < i rl sP l ' (' l )()l ' ti ()l l i ,. , gpat t c r , . , ,wit h .u t i ' rc r.:e s i ' g th c ta r l .rtc l tl t r r t is ( ' llt l) l() \ ' ( ' tl . ( ) r lc r v ey t lf c < l tttttc rl rc ti rl g l tl l v g rtl w tl rri l t csl S t()l l l crcl tscl l l l l l l l grl l (l trtl v, (i crrrl rrl ry,rncl the ti( ) lt r llt c s , which e t l e rl s t x rv c rrrl c o u rrtri cs pcr l ,()()()rerl ge.sfrt' tl t Nc t hc r I lr r lc ls ) lrp p c l rrt< l l l c c l tl i rrg .N c t l rl i g rl rti < l l r A gl ri rl ' i t i s i nrportl l l l t t() zcr o it ' t f epelr to rrl n l o s t 2 7 i rl S i rl g l rp ()re' esti rl reti rl g thci r r ' < lr c c lc ta i l s rr5 9 u t th c i n rn ri g rrrn ts bci orc kr ' w i rr lpec t t lr lhc lr lth ;l < l l i c y .A r.c tl rc y s k rl l e d tl rtrrl ski l l ccl ,cl csti ttrtc< l r O f c < l rl rp rrti bl cctrl ttrrcs rrncl rel i gi otl s or r,v c elt hy ?A r c th e y ' .r..,.,.,,1 .," ., th e c ri sti ng cotl rtrrttl l i ty?A l thotrgh c c ti o n w i th th < ls c lil< c l, vt ( ) c r.u .l sfri strel l l l thct.tcotttttri cs i rr thc c liv c r s cc ult t r r r :se trc lc th n i c g r()u i )l l l q s c rrl l hcrrl th rrrl clsoci rrl servi cc tlrr l ot lg r t t t . t ,t hc l' c rrrl p L l t s e v c rc p re s s tl re s
Box 2.2
Policiesfor older people in Sweden
grow th-ra.tesof tl te T ouc t herwit h l o w rJ tc s ()f n c t tttrg ,ra ti orntnd l ow of old people' percentascs highest ;;.; one of the ;;;j;,,;'i;;;" hed for.copi ng t' f a.tc' t s o n rerl ri ng S w c d e n T os et her .t hc s t.fl c to rs n r:tk e of t' l ' l er pc,pl c S w edc' o f crrc rrc a In th e i n g ' e g e ; ; , T ; ; ; . r t , . . il.r,s .t,' r of decentrtrlizati'n'serviccinte'gration with a .,,,,.lt''iiiatinn hr, ,.r1-,n,1.1.d :rnd targeting'In 1992 rnunicipalitiesbecarne and de-institutionalization ol der peopl el i vi ng i rt r . r p" " t ; f t f . f o r p ro v i d i n gh t' a l tha n d " ' ti u l '" ttt to to in holt l,f ,h" tt'u"'y c.uncils this has beenextended lr',riir.r,lun.; been has bed's "ni long-term rn ,aa;'ion, theinumberof services. home-based targeted increasingly rcducedsignificantly,*nli. no"'tt t'asetlservicesare p c o p l e ' t t , highlydep e n tl c not l d e r
,4
C"ornPardtit'cHectlth I'olic1'
Health Box 2.3 Asylum seel(ersand the National Service in Britain cashon the NHS in rw'ways. [n an alrcadytightly irr-rpacr Asylumseekers puts.c.nsiderpatients .i nurnLer thc in limitedhealthserviceor-,y"i,-..r.or. applies to GPs strain,ri t*i'ting scrvices'This particularly ableadclitiorral -fhe struggl csto c ( ) pe N H S al so ,.,t. t i rr, poi nt of contactfc,r' i ' ,ati cnts' In p ar t ' seckcrs' asyl urn of w i th the scal canclnarurcoi hcal th probl ems cout.tfront conril.tg seekers as)'lum this rcflectsspecialnceclsarisingfronr bccntirrturecl havirrg or clisc:rses' i"f"ttit'u' t't trieswith a high previrl.tttt by t he probl crnsarc oftcn cxacerbatcd (l )u n ne,2002)' H ,,r" .,;.'',-httrl " " ' l u" 'th .seckcrs count ry thc i n arri ve thcv ol l ce p o o r l i vi ng conci i ttol lt's f a i s also posi ti on tnargi ttal vcrl ' arrcl (Oa s c i ani2(X , )2).fhc,' l uul " t' l .rrbl e rvi ccs' se hcal th rn a i o lbarri crto acccssi l tg
( ) f t c r l ' t h c V l ) r i r r s w i t h t h c r n tl i scr r sc s , v s t c lr rt t 1 'r
is rtggrrrvrrrccl .l"iiu".y,rf-hcalrh."r. r.rui..s.'fhc pr,6ler.
A tl crccl- r t loll ls servi ccs oi tcn l trrvc t.tot ctl l l l rrtcctl cl i r,Iersi ty' l -re a l tl-r S i n g l rp tl rc,rvl ri cl rS cC l l l sttl l .rar' ,cl l ccnl ergel r,sttcccssi r.rl i l ]' illt cgr ilt lll! ] herrl th svstcl n. l n cont r ir st , fn .' fVi "t" y: :rucl Incl i :rrtnti n< tri ti csi ntO tl -rc l css w cl l scrvcd b, v t l- r e b l rtc k s i n thc LJS Aco,rti nuc to be si grri fi cerrtl y [l -v rrccess< lr her r lt l- r h e rtl th crl rc svstel l t thrl u rvhi tes as l l l castl recl
5.5
Tablc2.4
Ethnic and religious composihon
I:.1| t trit t r ttttltr tstl t t ttt \rrs( ra l l l
I rilnc(
( 't'rtlllttll
( ..r Lr er sir r r 9l' li,; r \sir r r r I ""; i\lr oligr r tal r ttltl otllcr l' 1"'
l) r ctlotttitr .ttr tlr ' ( .t ltic' llr tl I r tir r Sl.li ie. \or tlr *i1h' lctr toltic. i\ fr icr tr t, I tltlot ltitlt' sL r ltltl l' ,r tstlLlelltir lor itit s. ( i111r ttr c)I.i",,1 Itr lliislr l - 1""1 ( othcr ( r . |' 1,, ( r lr r r illlr ' ilcek. I{ tr ssir lr l. Scr lr r r l' olislr . Itr r lir r r , ( ,r or tti.ttt r r ltl Sllr r llislr) '
I t . rl v
l) r tdotttitlr tlttlv ltr tlir r l r vttll clttstcr s ol ( ,cr lttlttt . lr r ettcll ' r r r tclSlolcr lc ltr r lir tr ls ir r tlr t' ( r r or tlt r tttl i\lber r ir lr r r r r tl ir tel' It.r lir r r r s ir l tltt' stttttlt.
lilllilll
Ncthtrlrtrtds
othcr I' ll' .lr tpr tttesc99' li,; ( ntr tittlv hor er r l, ( .lllllt se, lir r tzilir ttr ar r tl lr ilipr r lo) ' - "" r r r r ' tlr t r | I lr r t. lr s i ",; Wcsttr tl Iloll which 9' li, ilr ( ' ( ) t or igitr , tttr titllr "l tr r ks, \lor ttccr ttt, Atltillcr r tls r ttltl
l i r 'l l j i r r r r - s L t ) I II | | ( ) s It t() | I ( .r r thol i c ) ( r .- l 'i i ,1 r \ngl i c r r r r l 1) . j 'l 'i ,; otl r c r '( .hr i s tr .r r r 20.5 ;i '; l i r r l tl hi s t 1.9'r i ,; \l Lr s l i r n l '5'l i ': otl r c t ot Lr r r .r fl i l i .r tc d l l J .0'l l '' l ( onr .ttr ( ..r tl l ol i e SI fi l i 'l l '; l ) r ( ) 1( ,\l .y tt 1" ,,: l er tr s h 1 " 1,; \l Lr r l r r r i l ( ) " ,,: tr r l r l l i l i r ttetl
+ " ,,. l ) r ( ) t( \t.1tl 1 i '1 " ,,1 l {otl l l tl l -""; ( .r r thol i t .l - 1" ,,1 \l Lr s l r r l r 'i j"" l S. r l otl r c r
In tlor r cs ilt t t s ) . N crv /-i rl rttttl
5 r n g l r p tl rt
Srve tl t'tt
(Jn i te tl K i n e tl o trt
7' 9' ll' ; lr r r r opcr ttt Lt) .3' 11,,1u{ 1111i i\sir r r 5.7' ll,l l) r cific lslr tntlcr 4.4' 1,; nr ir ctl 7.li' ) i,; othcr 0..5' ) i,; r r r r spccilictl .l' ii' f"'
Ar r s l i c i ur l .+.9'l i ,; l {( ) l l l r l l l ( l :r thol i c I f .'1') i ,: l ) r c s Lr t" ti 'r tr tl t othc r | 0.9') i ,; N l c thotl i s t - 1..c ) ') 1,; ( r ..i 'L; r r r r s pt'c i l i c tl I 7..2'') i ';r tottc
( .hintse 7( ..8' .f1,;N' lelr r v l l' 9' 11' ; lr r clir tn 7.9' ) 1,; othcr l 4' ll' '
l j Lr r k l hi s t 41...5'l l ,;\1 tr s l i nt c.). li')'i,; l I i n tl tr | 4. 9'..ri, ; ( llr ri st rrrn .{'i 't,; ( .atl r ol i c 4.fl ') 1,; - l aor s t 3.5'l 'i ,; otl r c r 0.7'l 'i ,; r r or tc I .+.li 'll, .
Ittiligctlotls popttlr ttiott Su' t' cles r tntl l;ir lltislr r lr ttl Sr ttlli ntittor itics; for ciutl blr r tt { ) r llr stg,clr cr ltti( ) ll ittttlligt' r r tlt lr illtls. Yttgoslr tvs, l) .ltles' Nttilvegtr ttts ' ( ,r ccks,tlltl I ttr ks' ( r ' ) l'; lr r r elish li.l.( r ' li,; Scottish t Vt"lth 4.' l' ll,; Nor theln Ir ish 2.9' X,l bhck 2.' 11,;lndier r l' fi' ll' l l) ekistani l..l' 11,;r nir ecl l 2' li' ; other L6' ) 1' .
l Jn i tccl S te tcs
V hite lJ | .7' ) /,,;bleck l2.c) ' lf i A.i.r n' 1.1",' : N.lli\( AIll( l i( illl l' ,i,.
(2006)' S o r r r r c : l ) a t a fr o r n 7 lt' V/r tr lt! F a L :tl.lo o A
) 6,]i ,.
l .ttther .tl t l J 7'i 'l ,;otht r s i l l c l tr tl e l {or r r .r r t ( .r r thol i c , ( ) r thotLr r , Ii r pti s t, \'1 tl s l r r r r , l c u'i s h r ntl l \r tl tl h Is t.
( .hr i s tr .r r l ( Ar tgl i c r tl ' I{ or tl ar t ( l r r thol i e. I) r c s bl tet'j r r tl , N l ethotl i s t) 7 1.6') 1,;1\l tr s l i nr 2.7'l r i ,; I l i ndu l ') i ,; othc r 1.6'l i '; Lr ns pec i fi c tl or l r otl e 2l l 'i " ' l ) r otc s tr l ttt 52') 1,; l tonl en ( i r r thol i c 24'l '1,; N 4or nr or .r2'Ll \l Lr s l i r r r l 'l l '; other .l eu,i s h l '11,: I 0') i , r nonc I 0'1i ,.
r6
Crtntp ttrat i t,c H cttlt h Prt I i c1,
Tablc 2.-5 Health indicators bv race.IJSA \Vhitc
Illdck
7.0 .1.u6 .r.72
I .t..t 922 l.l.4e
7.t.0 [J0.2
611.6 7.t..t
L o w bi rrhr.vci ghr/ 1,000bi rths N c o nrrfaldcaths/I ,000 bi rths l rrfarrtcl earhs/ 1,0(X bi ) rths l -i fi ' ex1-rcctancv (at bi rth) Mal c l i crrra Ie \olr tt,:
I) ;r tr r fnr r n N r r ti or tr l ( .tnfc r
l or IIc .r l tl t ( .er c Str r ti s ti es ( - 2.( ) ( ) 6)
()u tc ()l ncs (scc' l ' rrbl c 2..5). si rni l erl l ,, thc Maori nri n< l ri n,i n Nc'v Z c a l rtr l cl has trrtcl i ti orrel l vhacl rr cli ffi cLrl r.rssi rni l ;rri rrni rrro rl r c hcelr h c l l rc s Y sfcl l r.A s nrrl rc rrsl ,l trrnsccl < crsi rrc c()nri l rgi nt< l s1-rcci filc,. rrropcell c o ttrl tr i cs,tl tcl ' w i l l corttl tl i cetc hcel rh cl cl i vervrrnclrvi l l [rri ng $,it h t lr cr r r tttl i q u c Iterv herrl th pr' obl crnsr,vi tl rl vhi ch rhc l rurtl rhc,tr.c.1:rt, . . r rrrnr s r sr tl t' r t | .
The comparativewealth of countries As c l i s ctrssccl cerl i o, tl tc ttrostobr" i ouscl cterrni nrrnt < l f hcrrl tl rcrr r cf uncli rrg a l rc l provi si ort i rcr()ssrtl l corrrrtri cs i s w cal th. l ti ch countr ics on l l v c rrl g c P tl t c()l l si (l crl tl tl t' tttorc rcs()urccs i nfo l tcl rl th carc sinr olv l tr...l u rr.tl rtr l r;t\(.nl ot' r..1i r..,' ,.ti on:tr.l l trntl :. l l nl ' or.tun,l tr.l \. r,., . , 1. , , ', , , ', . c ()tl l l trlcs ci l l l l l ()f c()r).tpctctvi th rvcrrl thi cr corrntri cs i rr hcl rlr h clr r c s P c rl tli rl g rrtl tl cattttot rtti orcl tl re l < i rrclof rnccl i ci rrcrrfi lucnt c( ) r nr r nes flr l
tl l ()\t
t.tsttl tr)1tl )i l t,tti \(.r'1(.:l \1t.t'ol
rrt..l l tl t
i sf l r,.(;l l l ,p(.t.L;l pi ti l .
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Socialand economic determinantsof health ln : r c lc lit i< lrt or th c o v c ra l l r,v c rrl th()i rl c ()u l t tr\,,fl tcrc i s evi cl enccthet the c lc g. r ec of ir lc c ltl rl i ty o r c l i s p a ri tl ,i n s o c i e l rrrrclccorrorrri cc< l ncl i ti o.s at thc l lat iollr ll lc v c l i s rr c l c tc rn ri n rl n t()f p o trrrr l rr ti on herrl th. (.< l rrptrresw i th gr c et c r ir lc t lt r a l i tyte ttc lto h a v c p o < l rc rl rc e l th oufc()nl cs ovcral l as w cl l rl s il lllor e t t t lc c lt t atll i s tri l l trti o n < l f h c a l tl r. N rrv rrrroi nvesti getccl tl re ass,ci etior l [ r c t wec lrP< l l i ti c e lc c ()l r()n rvty p c a n rl s oci o-ccorrrl rni c ceprl i ti ' rrs i ' vllr l( ) t ls c < lt t t t tri c se ttc l 1 ' < l trrtc fhl l tf, c o n rl -rltredt< l soci al cl ern< )crafi or c (lhr is t iar rc lc t llo c re ti cp < l l i ti c a l e c < ,,r,rn ri " r. l i b crrl ;l ol i ti cal cc6pepri cshacl h lgh. c r ir lc ' ot t lci rl c c l tra l i tvl tn c l rrn e n rl ' rl o v r ncnt,Iow er l vrrge apcl sal rrry Ic v els and r r hi g l rc r p ro l -r< .rrri o o n l p e < i p le l i vi rrg i n;r,ru.,rtv (1999). M or eov er , Nr t v rtrro a n c l S h i (2 (X )l ) fo rrn cl tl .rrrtcourl fri cs w i th l i bcral p olit ic al c c ot lo tl ' ti c sh a c l th e l rtrs c s t i n c o rl c r.rncl rvage cl i ffcrenti rl s, thc l c as t r ec lis t r ibu ti v ci ' p rrc t' f th c s ta te , r' l c l tl rc l ,w rl st ratc.f i rnpr< l vc_ rr r c ntin inf anr n ro rr:rl i tvb c rw c en | 9 6 0 a n c l l ()96.In thei r stLrcl of y i nfa.t nt or t alit y r r lr c s i n o H (l l ) c o u n tri c s , N i rv rrrro ancl rrssoci i rtesat tl rc Ir lt c r nr r t ional N e tw o rk o n So c i rrl In e c l u a l iti csancl l j errl th f.,uncl thi l t p . lit ic al v ar iab l c s p l i ry a n i n rp r.rtrrrrtr' l c in cl efi ' i rrg how p' bl i c ancl s. c ial p. lic ic s c l e te rrri n ct[re l e v e l s .f i n c c l u rrl i ti cs..l ' ' gencral , pol i ti cal partics lll()rc colrllrlitteclto re-clistribution:ripolicics, r,,.'h ,,, sr;ci,rlcler'.crat ic par t ic s , a re th e mo s t s rc c c s s f.l i ri recl uci rrg i neq.al i ti c,s a.d rn . r pr ov ingiuf ar rt rrro rra Ii ry '(2 0 0 .j ). W hile olr r c o L l n try d a ta Ia rg e l y s l l p p o rt t hi s thesi s, rhere are cxcep_ ti ons . F or er am p l c ,.J a p i rnra rk s n e a r o r a t t hc t.p f,r nr.st pcl purati or-r
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T'hc Contcxt of Hcdlth Corc
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c lis par it y r t t h c rtrrtrg i u s ,h < l w c v c r,i t i s rr < ttgcrl cral l y sccl l rl s l ' t t' t' taj 9r c x planr r t ion. A scconrl theorv, tl'rcstructurrl/l-s/,attributcs clesscliffcrerrccsirl health t ( ) s t r gc t ur lll f rrc t< l rss u c h ts th c p ro c l u c ti < l rtertclc()l l stl l l l pti orl< l f w eel th. b< l thrrt l. ilwc r S F . Spc r s o n s g c n c rrrl l yc x i s t i tt l e s sh eal thy ctl vi rottt.ttcttts, is that thcrc c< trtcl trcl ccl stucl v rc c c l rt 1 1 Ii < l r e rrrn rp l c J h< lnr cr r nc lwr l rk . ' wic lc s ; r r c r t cclv i c i e n c cth e t th c 1 -ro o ri n th c Ll S , LJK , arl cl pcrheps othcr l r ttrcl crrof ctl vi rotl tl l crl telri sks' c 1lr r nf r ic sas wc l l , frtc cl r c l i s p r< )p o rti ()n rrtc , w rl tcr, ( Huggi1s . 2( X )2 ).T h c f i .rc u n t{ )t' ce \p ()\u l c t() rti r p< tl l ttti orl po()r r t 6t bic lt r r < lis c ,s u | -s ta n rl e rc l h < l u s i n s rtn c l ovcrcrou' cl i rrg.Itl cotl trrl st, rrttclvchi cl es, highc r S F . Spc r s < l n sc n j o l ,h c rrl tl ri e rh o n re s .srtferrtppl i rtrtccs enc l lc s shr r z r trc l o ujs< l l ts . otte. secstl i sprrl i ri csi rl T lr c t hir c l t h c 1 ;ry ,..1c trl l u rd l tttt/ [tL ' l t,t L' i t,l tnr/ i rr bchrti ' i oLrr. of tl i fferertccs rc s u l t rrs th e s < l c i e l c l :rs s e s healt h iur olls ( ) it c 1 t hc c glt rrrc 9 f th c l rl rv e r c l rts s c sl c rr tl st() el l gi l gel l l cl l ti rl rrl tl l ti pl c high- r r s k [ c hr r v i o u r th rrt, i n tu rn , l c rrc l st() l )()()rhcel th. S rrl oki rrg,,rl cohtl l r r lc l c lr ug r t lt t ts c ,v i o l c ttc c , s c c l c trta rvl i fc styl cs, ol l csi i l ' , l .rtl tl rtl i et:ttl cl l t i rl l ou' cr S F.S y rl re c l i s p r< l l l o rti ottatclprcscl 6t hc r r r 6hc r r l th yb c h rtv i < )u rs that thi s l est thc< l rv i s thc gr ouping, s .M e n y o l ts c rv c rs h rrv c c o rrc l trc l ccl bV the c rrt i t rl rtrstl l e accotl l parri ccl ll( ) s t c x plr ut ato ry ,[tu t l n ()s tc ()l rc l u c l th s t r r r c t ur elis tt h e o ry b c c rru s cth c l rc h a v i < l ur()ccrl rsw i thi rl thi s l l rorrcl er s oc ir r lc ont c x t. As l to tc c l l )y M c c l l :l n i c , SF-Si s' pcl l .raps thc si tl sl c l l 1()sr ir . r . r p6r t r r inf nt l u e n c c o n h c rrl th()u tc ()l n c si,tr p:trt throtrgh i ts cl i rccti rrfl Lr, r< l trg hth c tttatl v i ncl i rectcffccts i f h:rs < l n c nc c , lt uf t lor c i ttrp o rtrrtl tl y th f r r c t < r r tshr r t c l i rc c tl ys h rr;rel rc rtl tho tl tc o rl l cs' (1994 l 4c)).Thesc i rl di rcct of tl tc scvcrl rlc< l trl 1-l < l tl etrts ilt c t or s r r r c nr o s t a p p rrrc l rtw h c n o n e c x r' u l r i rrcs S lr S :iuc or nea trc lc c l trc a ti o rt. I 1c 611cl. r a s[c c rr fo u n c l to b c a c ri ti c rtl vari el tl c i rt cl ctcrrrl i rl i rl ghcrl l th s t lr t qsr r t t , uv 9l ev c l s . At rt c ro s s -n a ti o n rrll c v cl , rcscrrrchcol l si stctl tl ysl r< l w s t l. r r r t hc c lis t r i b r-rti o lor f i n c < l n rch rl s rn o rc t< l cl o rvi th therhcrrl th tl f thc l -hc l l cst heal th 1' r opulr r t iont h e n c l o c s th c l c v e l o i rl l c c l i celspcncl i rtg. gep l l ctw ecrl thc thc rrri ni rtti T.c th rtt r c s r - r ltrslr c r lc h i c v c c il n th o s c s o c i c ti e s vrrl trcsof ecl ni ty. otl thc r ic h ar r c lt lr e p < to r,th l rt p l ttc c n l o rc e l n p hrl si s W ilk ins or r ( it 9 9 7 ) s u g g e s tstl rrtt h e a l th ,v ,cgel i teri rrrlsoci eti esare l l l orc s oc ir r llyc ohc s i v e ,th c y h rrv e rr s tro n g c r c o nrtnuni ty l i fc, ancl they suffcr thl rt rrpprori l f c wer 9f t hc c o rr< l s i v ee ffc c ts < l f i rrc c l u a l i r y.H c rrl s
6o
(',ontp ar at i t,e H ettlt h Po Ii c1,
h e a l th . L o w -i r-rcomefarri l i es are more Ii kcl y to assessthei r hcal th s t i. lt us rrs ' p o o r' . l .ow -i nconr(- pcrs()ns rtl c si erti fi cantl y nl ore l i kcl y to havc ;l rc v e n ta b l ehospi tal i zati onsthan hi gl -r-i ncomepersons,w i th orre st r - r cly w as four ti mes as l i kcl y to bc h ospifi n d i n g tl -ri rtthc l ow cst i r-rcon' groLrp tc ta l i z e c l i rs the hi ghcst-i nc< )rxcgroLrp (A ngcl l , 1993). The rl ost l ikel, v e rp l a n i rti o n < l fthesecl i spari ti esi s to l re founc' il n sotnecombi nrrti ono f t he th e o ri e s d iscussecli rbovc, bLrti ts i mpl i cati on for heal th pol i cy i s ' i qr r if ic i rn t.T h c i rnpact< l frrnycfforts to constrai n hcrl l tl rci rrccostsw i l l hi t nr ost s e v e re l ythosc groul -l sw ,l ri chrl rc n()t onl y nrost l rkel y to nceclthe car e lt ut a l s o l e i rs t l i l < cl y to hrrvc othcr ()pti orrs. l )cspi tc grcetcr l tcecl , l r r r gcr p ro p o rti () ns of rhe p< l or hrrve cl i fftctrl ty i rt g.ri rtrrrgrtLec\s to he llt h s c rv i c e sth rrt nri ght l l vert p()()rl rcrrl th. w i th i rtcortte,ecl ucrtt ir r rist N o t s u rpri si rrg,l v. gi vcn i ts cl osc rrssoci rrti on a l s o s i g n i fi crurtl yrcl i l tccl to hcrrl th strl tr.l s.l )crs< l nsl vi th l css ccl Ltc. t t ior r thcy hr' tvcl ' thi gher p r cveh rtv cn ro rc frecl ucnrsh< l rt-strry hospi trrl i zati < l rrs, l n()rc l i rrri tccli rr rrct ivit l l c n c c o f c h roni c c< l ncl i ti rl ns rrnclrrrc si g,ni fi centl y/ c l u ct< ls u ch c< l rrcl i ri < l rrs, anclthcl , hevc si grri fi carrrl vl ow cr sel f-asses sr r lor t o f th c i r h c:rl th.One stucl yi ouncl thrrt of el l i ncl i crrtors,ccl ucrrri onhaclt he s tro n s c s rr ' rnclrn< l stconsi stcntrcl eti onshi pw i th hcrtl thrtttclw rts the s ir t glc n ro s t c o n si stcnrprccl i ctorof goocl hcal th (W i nl < l cbyct tl ., l 9L)2). surcsof SF. S, s F l c a l th strrtus,thcrr, i s i nti rnetcl v rcl rtteclto vrrn()r.l rttcrl (N tl errrr< l t rrrtcl W i l ki tl sorl , l c ) c) c) ) . i ttcotnc ccl trcati on rrncl tr)i l rti c u l e rl i ' 'l'hesc thc soci rtl errd cult ur el c l i t i cr-cnces rl rc cri ti cal i n rrncl crsr,rtrcl i ng c ()n tc x t o f heel th rrrrclrecl rri rcconsi cl crrrbl ynr()rc rcscl l rchott hor' vthcsc frrc f< l rs()pcri rte.Thc i ntcrrrcti vc nrocl cl of hcel th crrrc rtfrri butcs t r ) ( ) ( ) r h c rrl th o L rtc()nrcs to a broacl rarrg,cof soci l l factors tl trrt rrrc botrnclu p ir r th c Sl rSc ()nstruct.,r\l thoughS IS rni ght l rrrvert cl i rccti rrrpact< l rrl tcrrlt h.ir i s n ro rc l i kcl v thar i t ()pcri l tcsi ncl i rcctl ythrorrgh ()fhcr fl l ct()rs.In rrck lit ion to i n c c l L r i trrbl crrcccssto pri nrary cerc, hcal th pr< l ntoti on ruri l cl iscr r sc p rc v c n ti ()l refi orts, orhcr cri ti cel i actors i ncl rrcl cuncnrpl oyntctrt,vi < llcncc, hoLtsi rtg. b rc a l < c l o w n< l f i arrri l vsupp()rtstrucfurcsarrcli rracl ecl tratc [)n c rl p lovn]cnt cl ur i nfl uencc hcal th by rccl uci ng i nconrc l eve l r r r r cl s ta u c l a rc l< l f l i vi ng. 1\' l orcovcr,thc i ntl ' rortrrtrccof l vorl < ttt ottc' s wcllb c i n g . < l ver rrrrcl rrbovc thc fi nanci l l l rrspccts, i s w cl l -cl ocurrrcr r t e( l (l l trrrn rc l grl trcl ct tl ., l t)98;' l i rrrrcr, 199.5).I.l rc tnrcmpl oycclhaverl o wcr strcss l vhi ch is s e l f-e s tc e nrrrncl cxpcri cnce si gni fi crrttt 1-l svchol ogi crtl l cvels l i n k e c lto hi ghcr l cvcl sof both strbj ccti vel t,errclobj eeti rel v assessecl o f p h y s i c e l rtncl nrcntal i l l hcal th. Il e i ghtcncrl unenrpl o\' nrent rrl tc s r lr e rrrtcs.A rcccl rt stttcl vcorrcl Lrcl ccl t lr r t t rrs s o c i rrrccl w i th hci ehtcncclcl crrtl .r ' i n c rc rrs e si n thc uncnrpl oynrcntri rtcs i n l :rrroperrn LJni < l ncotttttt' icsr lr u rc l a tc c l t() cl cteri ()retccl Ircal th rrs nrcrl surcclbl ' el cvatccl nrorrel i ty r r r r cs thc r clr r o v er th c fol l ow i ng l 0 to 1.51,cers'(l l rcuncr,2(X )I ). l ntercsti ngl ,v, (i crntanv Ii i rrl rrncl ancl S. u iciclc ti o n s h i p wrrsstrongcsti n tl re Ll l (, S w ccl cn, as a n c i c l c l i b er:rtescl f-hl trnrrl rc l r()re prcval ettt anl ong thc urtctrtpl ol 'ecl,
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6l
r r r c s r n< ll< i nlgrn c la l c < l h o la n c l c l n rg a b u s c, prtrti ctrl arl ,val tt()l tsthc ttncttry o u th . A t th c c o n rrn u n i ty l e v cl , rl crrthri l tcs havc bccn fottncltrr pl< lv r r [ r lc inc r c r r s ec lu ri n g ti n rc s o f c c < l rro n ri cc l c p rcssi ottartcl j ol tl cssrtcss,rtttclt< r c lec r c r t s c l u ri rrgti rttc s < l f c c < l tto ttri cs r() w tl l (l Jrrnvi ck, 1992). A l th1;ug,h thet ctrtpl tl vrtrcttti s crtrci l tl t hc f gll c ll, l rrrtri c srrreu p c l c :tr,th c rrs s trn tpti orr [tv a l troaclrrrrayoi stttcl i s s u pportecl h c rtl th p h y s i c a l nr c n ta l rrn c l b< lt h to hcrrl th l tcrtcfi tsfor the h rrs s igrri fi crrrtt < l f u rrc rn p l o y rn c n t ic s . llec lucti o rr 1' r opulr r f ioans w c l l e s th c i rrc l i v i c l tre l . 'f hc f anl l y h rrs fra d i ti o rre l l r,p l rrrc rl rrn i rttportrttttrol e i l l i l l tcsr:l ti tl tl hc alt h pr r ln to ti n g r()u ti n c si n to th e tl .ri lr l i r es of i ts rl tctl tl l crs.l t has al stl s er v c c lr l s r r rri rn p rtrta n t fe c i l i trrto ro f te l t-estcettt;ttl tlrl stl ei rl lsetti rrgthrrt pr < lv ic lc sc r i ti c a l c o n tri b rrti o n s t() p s v cl tol oei e.l lrtrtcl1' thtsi crrl cl cvcl ol ' l r r r c r r t .W hilc rc rrl i t) h rrso trr' n | rl l c n s h o r t of thi s i tl cel . tl te tl eel i nc fi l sr of t hc c x t c r r il c cile rn i l i rrn c ln rrl rerc c c rtfl ythc rrtrcl t' rtrtrtrrti l rhrrshrrcl,ttl vcrsc i i rtcl rh,rt tl trl rri rtgci s rtsstl ci rttctl c f f c c t s 91 [c e l th . S ttrc l i c sc < l n s i s tc n tl .v o v crrrl l hcel th strl ttl si tl ttl hcel thi er lv it h l6wc r l c v c l s 9 i n ro rte l i ty , b c ttc r ). srtrcl yi rottr thc N etherl errtl s.i 9r bc hev iot r r p e ttc n l s (S trrrtto l t,2 (X ).1 A ins t r ut c c ,c o rrc l trc l cth s rrt n ta rri c c lp c o ;l l c havc thc l ow cst tttor[ri tl i tt r' .ttu. whilc t hc r l i v o rc c rl s h o w th c h rg h c s t(.foungct al ., 19c)4).A nother stsdv ir ont t lt c Ll l ( fo u n c l th rtt c v c n w h c n th e cffccts oi sl ttoki tre,cl ri rl ki ng arl tl ( ) t hc r ulr hcrrl th l ,e c ti v i ti c sw c rc i rrc trl re r icl n, trrerri cclrttctthrrclrt c)pcr cettt rttctt (l l 13ON ew s,2(X )2). l tttr trtrrrri ccl I t lwc r r is l<9 i c l v i n g i l s c ()n rp rrre cto l i l < el v frrctor i s thc' s< l ci al a ttttcl crrt, rrre fo r th i s A lt hough th c rc rrs o tts expl rtrtrl ti orli s that .A rt< l thcr n c arby. s s pp( ) r t ' of h a v i n g a w i fc rl r h u s b rrtrc l l i fcstyl c i rrcl ucl i rrg l css hcrtl thv l ()n tc n tc rrrlto h rrvc,r |1; t h s ilelc n rc r.rrrn c w rtttcl s lc c p, c lic t rrn c l w o rk h e b i ts , a rrc lto b c nrorc pr()l te t() l < trtel i ness i l yrc l a ti < l rts h i p sh, o w ever, i tl w hrttcvet' f< l rtrlcl < lappear c lepr es s i< l nIr.trn . t ( ) c lt c or lr r tg cg o < l c lh c ,rl th p rrrc ti c c sa rrclprovi cl estr()l l l l soci rl l l i nks that r c c lr r c ct hc l i l < c l rh o o col f i l l h c e l th .' [' l tt ts, otl c w oLrl clexpcct that Ireal th or r t c olles w < l rrl cbl c b c tte r i n rh o s e c o t.ttrtri csl i kc.fepan arl cll trrl y w l l crc Stru c tu re src ttrrri ttr.tl tt()rcrcsi l i crl tfcrl tttrCof s< l ci ety. c los e f r t r t r i l ,v
The context of health care T - l- r is c hr pr c r l .ra sp l rrc e chl e a l th c rrc i n i ts brorrcl crcol ttext i rt e:rchof ottr coutrtries. \rVesuggest thr.rt onc cartllot tttlclcrstllrlclthe clynlrr-nicsof r.t rhe pol i ti cal ancl l egrl li nsti ttrhc alt h c ar c s y s te tl w i tl -ro trtr-rn c l c rs ta n cl i ng cLl l turi rl:rrtd hi stori cal envi tl " rc rrn c l c o u n try o f th e p ra c ti c e s t ions r r nc l arl clnl i r of thc ptl pul ati otl , i ts T h e s i ze i t e rrtc rg e c l . r olllent f ro n t l v h i c h l cvel of ccol tol l ti cequal )n rp o s i ti o r r, thc ancl l l i g i o u sc ( et hlic , r r r c i rrla r-rcr:c it , v ,all help s h a p eth c h e a l th c a rc s y s te ntof a country. F-achof 9ur cotttl tries has its own character, a certirin cornbiuatiorr of fe:rturcsthirt scts it apar t . A lt h g u g h fa r fro rn a n i 1 -c 1 e p t| anal vsi s 9f c:rch country, thi s
62 OunPdratiueHedlth I"cilicY ovcrvicw delnonstr2ltesthrrt eirch provides a clistinct settil4i tor the cnlerg e n c eo f i t h e al th care systcl l rovcr tl mc. c h a p te r I suggestcdthrtt there rl re strol l g forccs that rni ght be l ead ing to a col tvcrgcnccoi ptl l i ci es l l cross cottutri es. hl thi s brief l ty r-re c c s si ty tl l l vi ot r s o v c rv i e w o f thc c< l t' ttcxtrl f herrl thpol i cv i rl thcse coutrtri es,i t i s wit | Iri rrg thev coLrl l tri csi th rrt a l th < l u ghthey rtre rrl l rrffl gerl t,cl evel ()pecl l l e' trsci rr lf or 1vi l l that nl s syste th c n t a c l i v crgcntset ()f strrl cturali l nclvrrl uc tl -r esc W hi l c chaptcrs. c o l l p a rrtti v e purposcsi rt t| e f6l l ow i trg substr' ttl ti vc l ' tl l loll! l f,-,c t,r6c c rtai nl y crl l l tof crtrtl ai nal l thc cl i fi crcrtccs< l r si nl i l rrri ti cs thr lt sottl c < l f thc rrl l ol l l al i cs th c c < l u n tricr,i l ' ,.1' c,l rl hcl p tts tttl cl crstrl tl cl of thcsc hcl rl th crl rc systcl llslll enl rl ,vsi s i n-cl cpth ttl orc tl f the w i l l l tri s c < l r-rt th c fo l l o w i n g cl .rapters.
Chapter 3
Funding, Provisionand Governance
i lc alt lr c r r r c is < l ftc n th o rr{ :h t< l f a s rl s v s tc nr.,,\ ht' .rl tl rsvstenri s rr hrghl v c onr plc x c r r t it l ' l u rc lc o n s i s tso i rr rrrn g co f s u b s\stcnrs.r\r' ttorrgthcsc, tl re s t r lr - s y s f c nroi s f u ttd i ttg ,l tro t' i s i o tt l rn rl ,q o l cr-r,/r/('ru' .' cct' ntt' rtltor rrrcl cr s t enciln g hc r rIt h p < l il c r,'c o rnp rrreti v c l v . ' l' he s r r b- s vs tc n r o f fi trtd i rtg i s c < l n c c rncclrvi th rrri si ns ti rrerrci rrl r c s ( ) ur c c sr r nc le l l o c a ti n s n ro n i c s t< l th c p rovi cl et-s of hcrrl th crrrc. Il cel th c r lr c c r ur lr c f r r n i l c tl fr,,n r,r rrl l rg L ' ()t\()r.rrc csJ frorn t:trcs l rnrl soci el i rrstrr r r t t c c c ont r ibuti o n s to P 1 ' i v l l . i n s u l rrrr.r' prcnti urns l rttrl out-< l i -pockct pr l) , ' nr c ntby s , p e ti c n ts .F L rrrc l i n gh,o w c v o ; i s eb< l rrtl n()rc thrur thc techrri c . r lit ic s of r eis i rrg a , rrc la l l o c a ti rre fi n e rrc i e l rcs()rrrccs;funcl i ng i s rrl so rr l) ( ) int c r -t o p( ) r ,rrc lf,.tn c cl o rrrr< l lo i ftrn c l i n ers.t nr.rj ,rrrc\()urc.:i n hcrrl th polic v . ' l' lr e s r r b -s t' s tc n or f l ty rt1 ,i 5 i r,li t,c rr scs()n th(' cl cl i vcry of hcel th s c r v ic c s .llc elt l r s y s tc n rsp ro v i c l c rr ri u l g ,eo f scrvi ccs.encl peti crrtshavc v r r r y ing lc v c ls o f c h o i c c rv h e rrtrs i n gh c rrl th scrvi ccs,srrch,rs errrongi ncl i i' ir luel c loc t or s< l r c l i i fc rc rrtc rrrcs c fti n g ,s .l h c cl cl i vcrvof hertl thscrvi rcsi s in t hc henc lsoi rl i fi c rc rrrt1 -1 ' rcosf p ro v i c l c rsi ncl ucl i ngptrbl i c ancl pl i r' .rtu, pr < lf itor nr lr t - p ro fi t,h o s p i trrl s T . h c n ri x o f p rovi cl erstttrrl < es thc pl ovi si on oi hc elt lr c ir r e n r()rcrl r l c s sp rrb l i c l v i n fc g ,rrrtccl .' [' hc strb-svstcnrs of frrncl ing ar r c l lr r ov i s i < l n f< l rn r th c b e s i s < l f th c sLrbsvstcnr < t[ ?or,(rttrtttt' t,. ( i< lv c r r r r r r r ct lcs e c ri b c stl rc n ro c l c so f c o o rc l i n rrfi nghcal th svsfcnrsrrrrclthci r r nr r lt iplcilc t or s . (i o v c rn rrn c c i s rrn c l e rp i n n ccl bv tcnsi ons bct' uvccnpubl i c a nc l pr iv at c r t s l v c l l rrsl rc tw c c n th c c c n tre rtncll ocel i ti cs.A s govcrnnl cnts govcnrrl rrcccrrn rrl sobc tet t c lt < l plr - v r t n i n rp o rte n t ro l c i n h c rrl ths v srcrl rsr thought < lfes g o v c rn rn c n tc rrp a c i t)'o r e u th ori tr' . I n r t c on' r 1-l rrrl rticvoc n tc x t, h e rrl th s y s tcnrsrtrc < l ftcn grou;rccl uncl cr spec if ic t y polo u i c s < l f h c a l th s y s tc n l s , a s cl i scLrssccl i n Oh.rptcr l . ' fhc t- v p< llogic pr s e s c n t n ro c l c l s< l f fu rrc l i n g ,;l ro vi cl i ng atrclgovenri ng hei rl th c r r r c in t he f orrr.ro i c l i s ti rrc ti c l e a lty p e s (l l urrrr rtncl B l ank,2006). Thc i r nplic it r ' r s s un rp ti o ins th rrt c c rtl ri n rl o c l c l s of funcl i ngare cl i rcctl l ' associ rt t edr v it h c er t r .ri rr n ro c l c l so f ;rro v i s i o rr.F o r e r i rrnpl e, thc funcl i ngof hcal th c r r r ef r om t ax ati o n i s s a i d to n rrrk cfo r p r" rb l i cprrovi si onof hcal th crrrc.A s t he analy s is hc l o u ,s h o r,v s th , i s i s th c c i rs ci n the hcal th s)rstenrsl n sonre countries. In others, lrowever, inciiviclr-ral health s\''stenrscombirrc clifferent m odels of f r-rn c l i n g a n d p r< l v i s i o n ,a rrc le veu rel v on r.tl ri x of scveral
63
54
(knnptrratit,eHealth Policy
Tl ri s cl i rcctsthe attcttti ol t to thc c()tttttr Ytn o c l e l so f fr.rndi ngor prrovi si < tn. a t r cl s p e c i fi c p o l i t i cal contcxts i rt rvhi ch heal th systentsi rrc entbcci cl ccl l v h i c h rv e rei utrocl ucccli n Ohapter 2. F o r ex a rn pl c,i n l 3ri trti rranclS w ecl cn.w herc hcal th carc i s pl recl < l t' ni r t ar t t ly rttat t cc l (x)rnsl arge i rt the g< tve p u b l i c l y fu n cl cclancl provi cl eclgol , ' ernt.ttcnt < l f hcal th featurcs s()vcr o f l rc rtl ths y stctl ts.r\t thc srul c ti l ' l tc,the spcci fi c g()vcr arrclhcal rh n l rrrc ci rl s
Comparing funding of health systems I - unc ling < lf fe r s r t s o , , . l s t i l r 'r i r r s l 'r , t i t t t t o r l o o l
Tablc3.l
l'cr cdltitd exltenditure on healtb cdre in US dctllcrrs,200.1
LIS A I-rr.rcc ( i crrnrrn\, N crv /.crrl rrnd A rrstral i rt S rvcclne U t( l tal r' f rrparr N c" v Zeal encl S i ngrrporc ''
Ihe fi gLr r c for Si ttgr tpor e i s fr or tt 200'1.
,\o r r r r 'r '- s : l ) r r tr r fr ont ( ) F .( .1) ( 1.006) ; Si r tgr tpor t N l i r ti s tr v ol l l eal th ( 1.00( r ) ; t J r r i ted N r tti ons Steti s ti c s l ) i v i s r on ( 200.j ) .
ond Oouernance 6.t i:trnrling'PrrtL'isirtn Table 3.2
A us t r elia lrrrrttcc ( ic r t nlr t t v lt aly .fr prrrr Nc t her lr r rrtl s Ner,vZcrrlrrntl S ir er t lt or e Srvt'tlcrl LlK L] S A
as a Changesin health care expenditure Percentdgeof GDP t9 7 1
1979
1 9 8 1 / e,t9
1991
6 .1
(,.1 1
7'0
r lir r
tl/r l
7.r) t)..1
n /a
7.1 rr/ri
7.e
8.4
fl.e
r t/r r
ll/r r
ll/r l
5 .I
(r.l
6'6
6. | 7.6
.5 .(r rl/e lJ'9 6 .0 L ).e
6..)
().\
(r.0 n/:r 72 .5 .i 7 .6
. I
6 .4 rr/rr ll.(r .5 ..1 l l ..l
( ' ( r lllr ill) ' for Ar r str r tlir t' ' I h c ti !,rrr es n /.t rto l rr vr r ilr r blt -
:tr t' I totl t l 0().1. lr pr r t r ttttl Si r tg.r Por e
\r)1 /1 1 ('-\:l ).ttrl r oltl( ) l:( l) ( l( X) 6) r ltltlsiltg' tpor el\iir listr r olll c r r l tl r ( 200( ) r r r l d2006) '
cxP cl l di ttl re' orl hci rl th l th c i r p cr crl pi trr lr r t l( s t hc c ()L l l l trl e srrc c o rc l i l l ito ti r.cs rtsrl rr' rchper hcrrcl si x over c ir r c . ' I hc L J S Ai s i ' t fi ;; ;-,l ;;t' -.t" d' p t" ti ' Il ow cve r, thi s i s not tyl ri cl l l of , h i c h i ;;h :' l ;;.r;s p c n c l c r. es S ingr r p o rc w l 11i (l c ()tl l l tri csrl rc ()rl tl i ers.' fhc tl ppcr t hc c t r t ir c rl u tp ,cl )c c rru s cth c s c tw o A trstrrrl i rlrrtrcl N cthcrl rrrl cl s' l l rre rtc e' t,9 1 1 i l 1 l ;-thc r iur llc is r c p rc s c n tc c[ry ()l l capl tzr ;l cr 1 i S l i 2 , 74.5l l l l cl tIS $.j ,()413 S wec let t w , h i c h ,;,.,..1 b c tw c c rr rni cl rl l rc lN c w Ze,rl rrnclrrrc i n thc l ow er hc r r lt hc ilr c . l l ri tl l i rr, t,,,l u ,.l .rp rrrr 1.90' rrrtrgcrrtrclspencl :.rrlllverllge oi $.2' rr ' f hc pic ttrrc i * i " -ti l t' w h c tr l < " rk i l rl -lrt hc:l l th crrrc cxpetrcl i tttrcas pc r c ent ll! .c < l f(i D t,i rrl a l l l e .].2 .' I.h e rrrl tj tl ri tytl fctl r" trrtri esS pC ndbetw .ecl l (i l )P o rl hcal th crl rc.l fhe cl car crcepttot' t aboilt lJ r rn c l9 p e r c c n t o f th c i r is t heI J S A rv i th l .5 ..3 1 -l e rc e n t,fo l l ()W cc1b,v(i crrrl arl yw i thl .0.9pcrcent. Helr lt hs pe rl c i i rrg h a s i rl c rc l rs c c l s i rrc ctl rcl gT()s,l rl th< l ugl rlNesscl rarr-rati o th c rs. Ftl r exl rnrpl e,i rr tl re ethcrl l rrcl s i rr th a n c ()| .l l l tri e s s ()l l l e in c i- r llv 1974 and fro rrl 6 ' 0 to 8' 4 per cel l t bctw een hc alt l- rs pe rl c l i n gtn t' * ' " J period .f ciouirlcclover the sarr.re 2004, u,hile in tt-r. Uin'1-t.^i,t-t,p.naitrg t it t t e. r -r:.the s.urces of fu' di ng gi ve an B es ic le sth e .v c ra i l l e v c l .f fu n d i rrg, init ialinc l i c rrti tl rr< l ftl -," k i n d ,c l fh e l l l ths,V stcl l l w i thw l ri chw earedeal i ng. publ i cl v th e h e a l th systemsare precl orni nantl y th ' " i T able 3. - l s L rg g c s rs onl ' v w i th "ll th t LJS Aare thc cl car outl i ers f ur r dec l.A s b e fo re ,t' ;;;;;;" n i publ i c from respecti vel v'comi ng 26. 0 anc l 4 4 .7 p e r c c n t o i s p e rrc l i r-rg'
'(strr;ltLr,{t:d-or) ltratr-rluJrl lurlPeut Jo ls():) rLll Jo ulro la^o:) ',i1a,rr-]ru,r;rt1y {rtr,r s lglr lpc l ot ut - r ns Lr r alt : , t 6c l l o l t l t : ) o s t : 1 1. - lo c l - 1 1r 1t - t lsls ot t l J t ll s t il t t t t t t - l t t o 'r 's [ ) - l t r A \ t l ( ) ( ) l s p t l t r l 'l J t [ ] J N ' t llt r lt t 1 t ''t ' i l l l L l 'r 'r 't r t l 5 ijt ll) l( ) ( ) ' l .)rli r.u o,lJsr,t r r , ' i11 ' lt ll lt r J 'l t r L [ s ul lu.):).r,rcl 1. . 7g r r r O . t l s . - lir r t , r ; t - r ulr l. r ur c l x J J - l l r . ) t l l l t r J t l l t r l ( ) l J ( ) J L l l - l o '{'s . ) l l l l ( ) s rr sU J-rnlll)u lc lx l r r lilnc l' ll. , r . l, nO t 1 ' s J l, llt l t l <) : r ; t l t t l l t l t t t . l - l
(9 0 0f' 00( ) Z)
tllltr ' ) l I l( ) i' t1sr ttt1' 1r ' tocltr il- ttt5l ) r l tr ( 9( ) 0a) ( l ) l ( ) ttl ( ) l l tr l l r ( l
anD qryL1aquo atnilPuadxa p1o7 Jo aSpluauad o sp ann flflaaq uo atnltpuaQxa ryqn{ m saSuoq:) €'€ elqEl ,{tt1o11qqoaH a/14o,t0dtLto:)
99
Funtling, Prrntisirntand (lot'entttttcc
67
Sourcesof fwnding as d percentdge of health care expenditure,2001
Table3.4
I' ri L' atL: ftnrdi ng
I' ttltlic fu tr d ittg Or tycr tttttt' ttt"
.\r r i i l/ - sc' 1 /r lll' l'
( )rtt rl ' ltt tt'kt'l
I' ri L' ,rtt' ()thcr irrstrrttrtt'r'funtls
l) J|i l tctt l s'
Arrstrrtlie Frlrrtcc ( rCl-lllilllV
Itrrlt .frrpe rt Ncthcrlrrrrtls Ncrv Zcel:rrrcl Srvcclcrr t ll( LJSA
6 7 .5 l ..l 9 .l i 76 ..1 l7. s .1 .0 7 7 .1
8r.t u.1.4 .) L -:-
0 .0 7 i .0 6 ti .4 0 .1 6 -+ .0 t9 .l ().0 0 .0 0 .0 t2 . t
ll.6 -.6
|0 . +
7.4 I l.-1
s.8
2.9 1.7 z . t)
t7),
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n/l t
n/rt
r t/l t
n/l t
rr/l t
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16.7
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le.6 l7.l 7.li
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i. I 0. c)
6.o 0.1
.' I l rc l i g ,L rrt'sl6r i\lstr r r lir r . ( ,tr r lr r r ty r tntl.lr tpr tr t r r r t l r or l l 200.i . l ' |1 ," L g ,,r., lor ;\r r slr ' r tlir r r |ttl tlr c tJK r ttc l' toltl 1001. l l l i : ti s tl r ts l i r r ( i t'r tttr ttl v r l ttl l rtp rtt rtrc tro ttt f00 l. ]" tl ti r" i i g ,,r" r for Ar r str r r lir r r r c fr onr l00l. l hc figtrr c s t,r r ( 'tr tl t.ttl r '.r r l d l ,l l l r tl r i l r c l r ol tl
10 0.i. 1 1 /1= rro t.rvrrl ,r blc
\o l rrtc;
l )rtl rt fro r lr ( ) l:( .1) ( 20( ) 6) .
pr t t ic llt s I lr t y l trl v trto p rl y tt fi x c c l rl l l l ()tl l l tl l cfore thc i ttstrrl rtl ccc()l l l pl l tl V pi ryl l l cl l tsl l l rl y rl l so ()ccrl rl l s rl ).rrt-o f-p ()c l < ct l l e c l trc ti b l c sO s c t s inv ( ) lv ec (c T h i s i n c l u c l e sovcr-thc-c()tl l l tcrprcscri pti ,rrl s r c s r , lt . lf s elf n te c l i c rrti o rr. enc l r t r c c lic esl c rv i c c sl l o t c o v c rc c ll ty th c h errl thi tl sl trrttl cc. l. 99k ipg rrt th c p tr[tl i c s o tl rc e stl f ftrrl c l i rl g,i t i s stri l < i rrgthrl t c()ttl l tri cs c:rsc of s c c llr t ( ) r ely p rc c l o r-l i rrrrrrtle,vi th e r 9 1 s ( )ci rl lscctl ri t,v,rrs i rr thc ()r ol l fi ovcrl l l l l ent i tl l l dl- r ar r c c ,( ic r r tra l y , .frrp rrrta rl c l th e N e th c rl i tl cl s' i' r g, r r si1 t 6c c e s e ' c l iA u s trrrl i a ,l trrl y ,N c w Zcl rl arl cl ,l l ri trri rl l l l l d S w ecl cl l ' by , qr ' t , , . pr iv r r t cfg p c l i rrg l, l t()s tc o g l l tri e s rc l ,vorl ogt-oi -pocket payl l l ents (i crrl l rrny rrtl l l l c sf ronl 10.4 per ccl l t i tl ; lat ic ut s ,elt h 6 u g h tl tc p e rc e tl tl tg c -l ' h c e rc e p ti tttrsrrrcthe N etherl ands,Frrrnce t o 21 . 6 per cettt i rr A trs tra l i rr. rccof pri vate funcl n r lud t he LI S A ,rv h e rc p ri v a te i n s u rrtn c ei s the tr.rrri soLl cxpel l cl i tLrre,i t i s Irot pul )l i c o n ing. oO ns ic l e ri n g th e e rtrl i e f frg u re s cliverseirt the rlre sur:prisingthat t6e sourcesof health crrrc fLlncling '-.'-'ore g
6B
CompdratiueHealth Policy
th e d i ffe re nccsi n the sol rrcesof fundi ng are anal ysecli n ntore dcti ri l in t he fo l l o w i n e secti ons.
National health servicesand the commitment to public funding fu nclccl errrntpl cof e pLrbl i cl ,v N rrti o n rrlheal th scrvi ccsrrrcthe rrrchct,vprrl ecl i ronr trtxati < l rrrr nclis h e a l th s y s tcnr.H crtl th crrrci s precl < l nri nantlfr-rrrcl y a v rri l rrb l c t() cverv l t' si cl crrt i n thc cor.rrtry. l )ubl i c furrcl i rtgrcsu lt s ir t ancl S w ccl ett,togerhcr l vi th I t all' u n i v e rs rrlrrcccss.Il ri tai n, ).l er.u' Zcal ancl oi ptrl l l i c fLrncl i rlg. a s rt l rrtc col ncr,rl rc el rrssi calcrarttpl csof thi s t1,1-rc c()nrcsfrorn public In th c l' ,ri ti shN l IS rvcl l ovcr 90 pcr ccnt of fLrrrcl i ng gencr,rl rcst frotn c ot t t r iencl thc tl trati orr s o rrrc c s < , l vcr70 per ccrl r tronr b u ti o n s to N rrti < l nrrlInsurrrncc,u,hi ch i s a spcci i i c tar l cvi eclott i ttcot t r cs. (.o -p a y n rcnts l ry prrti crrtsrl cc()unti < l r rrbout orrl r' 2 pcr ccrrt oi fur r clir r g (l )c p rrrtn rcnt of IIcel th, 200(re). I)rortti rrr' rtt.tl ui l \ ,,f .o 1.1y111g1155 i n c l rrc l c : cl rugs, w hcrc prrvnl cl rts br" pati errts hrtvc ri sctt < l vcr t it t t c, e l th o u g l r thcy rcnrrri n l orv i rr corrprl ri sort to othcr courttri cs; c lcr r t el s c rv i c c s ,w hcrc pati cl rts l revc fo covcr thc rtrej ori tt' rl f the c()sfsLrpt ( ) il n rrrx i tn u t tt;rtrrclophthrtl rrri cscrvi ccs,w hi ch hevc bccrt w tcl cl v cl er cgt r l e tc c l . A rr otl rer s< l rrrccof trrrrcl i rrgi s pri vatc i nsurrrncc.' l ' he rnarl
Itun d in g, I' rou isirn an tl () ouernance
69
or r t - < r i- poc l < e p t a v n rc n ts r' rc c ()u l rtfo r a boLrt 16.4 per ccnt ancl pri vatc healt h ins u rrrn c e 6 .2 p e r c c n t o f to te l heal th ci l rc spcl rcl i rrgi n N ew Z c alr r nc l.l' h c rc r' a i n i l rg s rn a l l s h rtre .f l rcrrl th rcvcnue (rtbout 0.4 per c c nt ) is pr i rl a ri l v fr< l n r n o t-fo r-p ro ti t < l rsi l ni zati ()ns (N ew Zci rl apcl M ir r is t r v of H e rrl th 2 (X )l ). W rrh rh c c x c cpri ol )s,f pri nrary ci l rc, w herc a f c e- f < lrs er v i c e s y s tc n l o p c rl l te s , rrn d i n d j i ' i cl urrlco-l .rrrvrncnts for cl rugs, lt t ( ) s t health s e rv i c c s i rr N e w Z e rrl e n tl rrrc provi rl ctl frcc of chargc. l rr 2000, abou t 3 7 p c r c c l l t ()f th e p o p u l rrri ortr.urrs eovcrctl by pri vatc l rcrrl th it t s t t r at r c e< l fs < l n rek i rrc l ,n rrrc ho f th i s s u ppl cnrcntrrlA . l thorrgh i ts proport ior r of t < lt a lh c rrl therp c n c l i trrrcs rc n ' fro n r I.I pcr ccnr i l r Ic)l j ()t< l6.2 pcr c c llt ir t 2( X X),i t rc n rrti ttsn rrtrs i n a le n c lh rrsbcen steti c over tl rc l rrstcl cce{c. I ) r iv at c s o u rc c s o f l rrn tl i n g h rrv c rrl so pl rri ccl rrn i rrportrrnt rol c i rr A us t r r r lia,w h i c h h rrc lth c rl i s ti rrc ti o rro l bei rrgthe onl v c()unrr\' fo hrrvc ir r t r oc luc ecl u rri v c rs rrln :rti o n rtlh c rrl thi n s rrrrtrtcc ertclthcn to hrrvctl i snrrrn t lc c lit . l' , v lc )l Jl , tn o s t A u s tre l i rrn src l i c c lon l -rri rrttc i nsttt' r' tneu c, ' i crrrge. In lc ) lJ 4, h< llv c v c r, Me c l i c e rc , rl c ()n rp u l srl ry l rati ()ni rl hcel th rnsi rrrrncc , as i ntrocl ucecl .It i s pri l l rrri l v r t c lr t t inis t e rc c[rv l rh c (,< l rn rn o n w e rrl th w f unc lc c fl r ot t r g c n c rrtltrrr rc v c n u c , s trp p l crncntccl [r1'rr 1..5pcr ccnt i cl cnti f iec l inc r r r n ctl r l c v 1 ,,s trrtc rc v c l l u c l rrrc lc() prrynrcnts(H al l , l ' )91): L)61. I ) r iv et c ir t s rrrrrn c lcrc c o tu rtsfo r I I p c r c c nt of totel hcal th carc cx1' rcncl i t ur c whilc l 9 p c r c e n t c ()r' r)cfro s rl c < l - pavnl el l tsbv i ncl i vi cl urrl s. A boLrt ( ) lt c - t hir c lof th c p o p u l a ti o rt h a s p ri v a fc i rtsurrtncebtrt thi s rcprcsel ttsrl s ubs t r t nt ir r cl l e c rc rrs icn 1 ' rri v ;rtc i n s u rrl rrcefrrl rrr rhe ovcr l J0 per cel tt l l t lc ) 70 ar r c lt h c (r4 p c r c c n t j u s t p ri < l r fo Mccl i cerc rn l 9l l .l (P al rl cr rrrrcl S lr or t , 2000 : l .i ). Irr l i g h t o 1 ' th i s s te a cl ycl ccl i nc, A rrstral i a has trrkcrr nr c ils ur c st o i n c rc e s eth c p o p u l a ti ()nc ()v cragcof pri vrrtchcrrl tl -r i nsrrrrrnce, r c c luc cpr c s s u rco n p L rb l i ch o s p i trrlw rri ri n g l i sts anclscrvi ccs,arrclsu1-rp< l rt enc l ir r pr < lv c th c v re b rl i ty o f th e i n s u re r rcci n(l ustr)' .In 1999, Lrncl crthc P HI lnc c nt i v c Sc l rc n rc ,i l l l y ()n c p u rc h rrsi ngnri r rrtc i nsur.l rrtc rccei vecll t . 30 per c c nt s trb s i c l yp, e i c lc i th o - rrsrl rrl x rcbetc ()r rrsrl recl uccclpurchrrsc pr ic c of it r s u rrrn c c T . h e n , i rr.fu l v 2 (X X),thc [.i feti rnc IJcal th (]ovcr w es int r oc luc c clr v h i c h a p p l i e d a b rrs cp re rl i u r rr to thosc purchasi ngi nsurr' rnce up unt il t hc rrg co f .3 0(l 3 c rtc l s rrr.rrrn l ro rrncl rtti on,2(X ).l b).
Pu b licfun ding through socialinsu ra n c e S oc ial ins r r r-a n c ci s rrn o th e r fo rr.no f p u bl i c i uncl i ng. It i s a hvbri cl ancl c onr bines t w o v e ry d i ffc rc n t p ri n c i p l c s of rl rgrrni zi ng hcal th crtre: the ins ur r r nc e i s p a i c l fo r b y i n c l c p c n c l cnt i nsti tr,rti ons but i s pLrbl i cl y nr anc lat c c(lFre e t.n rrtr,2 0 0 0 :.5 4 f). In c o n trast to pri vrttc i nsurrrncc,soci i l l hc alt h ins u ra n c c i s b a s e c l o n th e p ri nci pl c of soci al sol i dari t,v. ( lont r ibut io n s a rc p a i c l a s :r p e rc e n ta g eo f thc sal arv rather than accorcl ing t o t he s p e c i fi cl -rc :rl thri s k s o f th e i n di vrdual ancl are often shrl redby c m ploy er s r.rn c lc n rp l o y e e s . T h i s re p r :cscnts a recl i stri br.rti veprol i cl ,
ry
Com7drdtiueHealtb I'olicY
l ow car nb e rw e e nh i g h and l Ow ri sk pati cnts as w el l i rsbetw eenhi gh and n) i r r c chi c rs . l )e p c n i a n ts .f cnl pl ,ryecs(i .e. n" -ea.ri trg sp' uses a-ncl l dre p< l ptrl rrtior l. coverage< l fthe a l s o c o v c re d ,thus i n effect ensuri ngr-rrri versaI H calt h T h e G c rrr i l n hei tl th systel l w as the pi oneer l l l l l ()tl s i ts ki rrd. y enr;l l 0ycrsattclctrl pl ove es prri clecl r-ral lb,v c a re i s fL rn c l edby c< l rrtri bi rti Ons Mcml l crshi p i s.c' otrl l l trl s or , v sal ary. l l ()t.l thl y Irs rt fi re d p e rcent,tgc9f the cci l i rl g,w hi ch i rr 2(X) '5 rt certr.ri t.t bcl ow wi th ai tnr-ralci trni ngs ,,,.r " u .ry ,r,.r. (i estrrrcl hci t.200.5).' rhc social fi i r w a s 4 2 ,3 0 0 euros (l l urrcl csnti ni steri unr w l rich futl cl s, rl ol r-prrl fi t recl by pri vl l tc, h e l rl th i n s u r rtuce i s acl nri ni ste (encl the cci l i rl g errrni ngabOvcthc publ i c l aw . F.tnpl Ovces o p c re tc r,rn cl er cl r()
73\.
s v s t c r l 1 i l l th c A c los c vr l r i i u t t
I:u n tli n g , l ' rrtt,i si rtrtartd O oucnuncc
71
l l l stl rl .tl l ccsystcl l l s' Of . fir plr r rnt us t c l tr()l l i n o rre o f th c s o c i a l h c :rl th cl l rc i escl 'l -h c nr air rs oc it r li n s r,rra l tcscy s te l rsf< l rs rl l rrri ccl r,vorkcrsi n c< l t-nprtt.l atl (K I-.N Ko l rtsttrrrtrce F Ical t6 fe c t . r ic s i' . f r r prrrr a re tl i c Itrn ' l r' c c s or the typc l l l rl l rrl sccl l l OK f t N) whic f t c i l l b e < l f e i tftc r th c s o ' n ' c r tl ttl cl l t pctl pl e tl otl -cl tl tpl rl yccl s( ) c ic t v - llt iut egcty c l p e. Sc l f-c rl l p l o v c rlw o rk c rs rttl cl I(t' ]N K o (K Ol (tl Ml N . , , u. . . . 1 bv tl rc ' N e ti o n a l Il c a l tl r Itts ttrr tttcc "r" sc:rtnetl s thc FI O I ( t . N) whilc s p c c i fi c w o rk b rrs e c li rl s trri l rl ccsi rrcl trtl c w < l rl < crs scfvi ccs In s ur r r nc cr r nc lt h e M rrtrrl rl A i c l A s s o e ra ti o tl sfor prrbl i c Ihc F.rrrpl oyccs' c t t.tyrl ovr-' cs. l o c rrl s ()\' c n l re rrt su c h r r s net i( ) nr rl ru rc l sY stcl l l trtl tl cr thc rrttl te i tt srt rl I Ic elt h I ns ir r r r il c c i s ,r w < l rk l tl rtc c -b rts e ,\gt' rter. i l l l tr\tLrl l i l l Ittsttrrl tret' S ,r.re ] l c rl l ti ()1< rttl l e e c lnt inis t r lt t ionltrrc ()p l frr' e. W i thi rl thc \\' e rrrrtl l rtl , rtt 5 . c ll , f t 6c . fa' r r rrc s cMi ' ' i rt.r .f I l t' rrl th . ' 1rrl .ge-serl l t' cotl tl t,ttti ct for sy s t c nl, s oc ic t y , n tttrre g ,chtle l rl th rn s ri l ' rrtr.cl s hcrrl th g ()\' erl tl tt(' tl t-tl l ,ttl ,tgetl c o v e rc .l l rr th e w hilc < lt hc r a. , r rr1 -r.,..' i .:r,rre insu r l t r r c c .
L J r r t l cr th c stlcic6
- r lt,tt.tltg e .l 5 \' \tclll.
cl l cl l stte tcf r l l l i .t\' l l l rl l l i l S c
bertefi tsrrtl clcorttri Itti ts owr . rhc lr lt lrit.ts ttrrttl c1e' ,r,,g r" ,t,' r'r,r' . i thi ts < l ' " 1' rt (S tl crel l ttstl rrttl cc ' \gel rcr' , ti 9 1s . wit hilt t h c g ()\,c l ' l p tc l tt rc g p l rrti < l rl s 2 (X ) 6) . pl erl s i rl .frl prrrl 'thtrs t6 a rr .5 ,0 0 0i l c l c p c n c l c rrti ttsttrrrtl cc T hc r c r . . c ' t or c trl l l l rel l rt' l rl rc!i sr r lt s llt ir r g t hc ltri v e tc s c c t()rr,,,.l ,,,l ,,1 l o v c rl l l 1l cl l t tl l rl t()rV systcl l l , i ttstl rrl t.tcc hcrtl tl r
Pr i vatei nsu ranceand the emphasiso n in d iv id u a l resPonsibilitY ( , our lt r ies t hat p re c l o n l i n a n tl vre l l ' o rr p ri v ' l te i tl srtrrl tl ccP r' l tc,rrsi cl crabl e herc to< l i ndi vi cl urrl .: , - r ' r f Lr or i, . r tin c l i ' i c l tta l ," s p ,,t' ,s i b i l i ty ' H o w ever' with resfrnsibility is r.rever.,r,.,-rpl.t.i.rcl private fr-r'ding coexists cl'r-rlllic derl v' and po< l r the rrs such g ro r' rp s par t ic .,l a rl v frl r d e s i g n a te c l fur - t . 1ing, is charand fr-rnding of system this of l'hc uSA is the archetyp,rlera,.,-r1-,le and elderly the for progra'r'res of rlctcrizcclb,vhigh ..r,opieritu. Outsrde
72
CctmparatiucHealtb Policl'
Box 3. I Medicare in the USA: pubtic fnsurance In a private system Medicareis a p.blic insurancefor the elderly,admi'isreredby the federal governmentanclconsistingof threeparts.Part A is compulsorvand covers hospitalcarefuncledthroughs'cial securitytaxespaid by all w.rking citizens.Part B is voluntaryrrndcoversothercostsincludingd()ctors'billsancl outpa.tienthospitaltrearmenr.It is fundedby morrtl.rlyprenriumspaiclby e n ro l l eesand subsri rnti alfederal subsi cl i es.undcr the tr:aciit ional prollramme,which covers86 per centof Medicarebcneficiaries, payments to hospitals,physiciarrs and providersirrc deterrninecl by-c.rrrplex 'ther prospectivepaymenrsysrents vvhichprovidethe programnrewith a higl,r levelof control over tlrc pricec'mp.rerrt of t.tal spending,brt not mr:ih l e v c ragcover the v< l l unre.f scrvi ccs.The re' rai ni ng benerfi ci aries ar e enrollec{in the Mcclicare+(ih.iccprollrarnr'c,underwhich privatehealth plans:rrepaida monthlycapit:rtionpaynrenrf'r eachenrolleethat is birsecl on the anlount Meclicarespendsper bcncficiirryin the gcographicareir servedby the pla'. urrclerthis systcnr,thc total paynrerf by Meclicarct
s o rn cc l isahl ccl(secl Jor.i .l )thc tl s l reel thsystcr)rrcrnai nsl rrrqcl vn r ar l
hm tl in g, Prr w i si rtrt tm d O o t' ar rtttrtcc
73
rrttc cl < l v c rs2.5 pcr cctl f < l f the p1;pup e r c c nt of t < lt al he a l th e x p c r.rc l i tu rc l a ti o n ( llit r on at t c l l (a h n ,2 0 0 .i ). O th c r p trb l i c cxpctl cl i ttrrcs sttch rrs c ()l Vctc r ans ' l- r os 1' r i trrl s l tp ri s e l 2 ;l e r c c l l t ()t to rrrl hcrl l th carc sperl cl i ng. thc s()vcrl l I Io l v c v c r .W < t ollr r rn c l l earn tl H i n rn rc l s tc i rr(2 (X ) 2)rccal crrl rrtcci fol pri vate 1 'tc 1t s I r r r c < li hc e l rh e rp c n c l i tu rc b l ' i rtc l trc l i t rgtar sLrl l si cl i es c< l ncl rrcl ccl rrtl cl bcrtcfi ts h e ,tl t l r p ri v e tc pu b l i c c n rp l (),v c c r r nc l i n srr r lr r r c c i s acttral l y spcrtcl i rl g h cal th o f to r.rl s h rrrc th rr t t hc s ov enune n t-fi n rrn c c c l l rl rportrtrl tl y. pct' crt1-ri trt. o r' \r.(r() 4 .5 9 .f 3pc r c ept , c c lu a lto $ 7 2 .1 .8b i l l i o rr c()\' ct' rl gc' c tro i l ts ttr;t trcc l 5 r t ti l l i o rt1 -rc ttp lhcrt' n i u r cs t ir t t r lt c (4. rcprescl l ts Wit h t t s c nt lr h e s i s< l rri n c l i v i rl trrrlrc s l ' ,o n s i lrrl i tr,S i rrgrrl )()rc rrtto t hc r v lr r ilt t lt < l i p rl v rrtc l l l s tlri l l l c c { s t' e l i o r l .l ). Ll rrl i l < cl :ttr< l l l cl rtl so c iel ir t s t r r lr t t c cs c h e tl l c s ,S i tl g ri p o rt l l .ts o p te cl l l ()t t() Irrl vc' ri sl
M ec lis r t v cis s u p p l c rn c n tc (l l )\,N ,l c c l i Sh i c l tl(rrrrcll ' .l cl crshi cl tlfor rhe i l l l c)90 to hcl p e l cl c r lv ) ,r r c r r f r r s t r()p h iien s u rrrn e ep r()s r' .u rrl teitttrocl ttcccl l l i l l s. hosl -ri trl l i zrtti < l rl tl r t' i r f< l r s trtv h o s p i ta l long , r v it h l )i l v 1 -rc olt lc i tl sttl ' rrtl .ei tt tttccl i crtl l trtl e S i n g ,a p o re n ri l l i o n Ap pr or inr r r t c ll' 2..7 1 .rc < l p l c ' i n (.1)l rtl rl l l )rel l rl thc rvi thi n p l .rn s S h i c l c l o r p ri v rtre th c f or nr of N{ c c l i s h i e l c l (.1)F. otrtsi cl e the pl arts h o s p i rrtl n ,i fh enot hc r 2( X),0 0 0 h o l c l i n g p ri v rrtc l Jc c r r r r sNlc c r liS hi e l d ' sp rc n ri trrrrsc, l c d rrc ti b l c se ttcl cl rri tttsl i rl l i ts l l rttl rl < l f b ccn ec ljt r s t er cslt ri fi c i e rttl l ' t6 k e c 1 -rp e c c rvi rh ri si rl g nretl i cal c()sts, c lr N ,lc c liS hic lc l r in rsc rc c c c l c c lp rc n ri u n rsc o l l c c rcclarttrtrrrl l y(l l crtcl srl rarl rl e i n 200.5cl csi grrecl [-h i sl c c lto rr rc fo rn r o i l Vl ccl i S l ril cl l -6 u r r c ler i9p, 200 .5 l )). t
-4
C otnpor,tti ucH r' tl th I' ol i cy
l )l u s i s p:rrt of thc ovcral l Medi S hi cl cl rcforrrrs ai med at cnc our r r gir r g g re a tercompeti ti on i n the medi ci rl i nsuranccmarket. A thi rcl sourcc of fLrndi ng i n S i ngapore i s Mecl i fLrncla, go vcr nm ent e n d o w nrent fr-rnd[rr-ri lOn t surpl useseach year,thrtt servesi rs a saf et y nct to p ro vi cl e fi nanci al rrssi stancc to i rrdi vi dui rl sw ho, cl espi tcthe sr . r bsidics a n d payrnerrtsfrorn thci r MS A s and the Mecl i S hi el dschcnrc,crur not plr y th e i r ntedi cal bi l l s (V asoo, 200I). A ppl i cati ons for Mccl i funcla ssist ance a re c onsi cl ereclbl ' Mccl i funcl (l onrrni ttees. l n 2002, rr[ror- r t178, 209 Me d rfuncl rrppl i cati ons w crc consi cl crccl , 177.949 of w h ich wcr c a p p ro vecl (S i ngaporc N { OFJ, 2006). I)cspri tcthe vi cw that rhis '. 1- M ' s y s tel l r i s thc ccntrcpi ccc ()f S i l rgrl p()r' c'hcrtl s th crrre fi nanci ng syst cnt , h o w cver, i t prcscrrtl v rl cc()tnrtsfor l ess thrrrr l 0 pcr ccnt of r r at i
Controf of funding and pressuresfor reform As F i g urc.3.I sug,g,csts, funcl i rrgi s ab< l utrr.ri si ng rcsourccsfronr rr r , r nr - lc, , f s ()u rces(such as tl xes, soci rtli rtsuranccc< l ntri buri ons,pri vrrtc insur r t ncc p rrc ttri utt.ts or orrt-< l f-1' rr)cl peyl (ct l rci l ts)rrrrcl:rl l ocati ngtheserrcs
Other P ri vate Fu nds
Out of-P ocket P ayments
Pr ivate I n su ra nce
Total H eal th C are Fundi ng
S oci al I nsu ra nce
Figurc.3.1
G enera l /E arma rk ed Taxes
Sourcesof health care funding
Fttntlin g, Prou i si rtrtttnd () o L'crnoncc
75
c < lr lt r t r it m c nt o u l l i v e rs a l i t,v< l f rl c c c s sl l c t thc rnaj ori ty < l f thci r ftrncl i rl g f r < lnr t r r x es . ll ri ta i n e n c l Sw c c l c rrrrrc c l rrssi crlcrampl cs of thi s rr' pc ttf pult lic ly f ur r c l e c lh c e l th s y s tc l tr n ' h i l c A trstrrrl i r al rcl N cw Z.eel :rrl c{ w i th tl vcr c < t r llt ir r ct lt x fu n c l i rrgw i th s tro rrg c, l c ttte ttt s< l t l l ri vrrtc ftrrrcl i rrg otrt-oi -1-r< l cl < ct rtrtcl i ttsttrrttl cc p ri v rrtc fr< l n r c < l rl i n g of fL rn c l s 20 pc r c c lt t ptrvlrlcn ts. S < lc ialils ur l l l c c s v s tc l rs rrrc h v b ri c l s :tt rottcv i s rrri sccli rottr i ttcl cpcrl ,tttclrl rc basccl< l rl the c lgr t ils lr r r nc e i u n c l s , b trr a l c p rrb l i c l r rtl rttrtl ri t(' cl (i c rrrrrrrv rs thc cl rtssi c,tlcrrtrl l P l c of thi s pr inc iplc of s o c i e l s o l i c l e ri n ' . t rhc ttl rtj or \ ec()tl l l for t y pc < li it r lr t lirl ge trc ls o c i a l i tts ttrri l l c c tttl tt' i l rrtti otl rl ui tl t rl re he,rl th s\' \r(' l l l \ l rl . e o l n l .r.rri sott it v 9f hc alt h c rl rc c x p c !r(l i trrre Irr eocri sts n' i th strol l g rrtttcc i tts tt s o c rrrl rtn c l Nc t hc r le6 c l s t hc .frrp e n , i ttsttral l ec.l tl clotl t-of pocl < ct fro rn h rtrc l i n g , c lc r r r c r r t sof ltri v rrtc 1 ' r' i v rt tc rr l tt' tt' P l i r rttt i tl sttrat.tcc s v stL' l l l \ h e pilv lllc llr s r c s p c c ri v c l v 'I-i rl rl l l r. ' rl th l rrrg,cl irel r tttl pri i ;l tc i trst rrrttl l s p < l n s i b i l i tf r l11r lilet c splrrc ci rrc l i v i c l u erc i l cc()tl l l t c< l rtrptrl srtrl ' srtvi ttgs , h i g h l ,vi n c l i v i c l rra l i zecl ilr r c ls . I n S ir r g a p o rc a ptrbl i e i l l strr' erl cl is l< c r ,r,, v hc r c a sth c L J SArc l i c s o n rr n ti rtu r c of pri vrttc r lt c c r t t t hc pr i c c o f l c rtv i n g< l v c r l 7 p c r c c rt t of rhc 1' l oprrl rrti
76
fomllratiue
HeahhPolicY
1) ' H o w e v c r, pr' rbl i cctl ntrol of fr-rndi ngcomes at a pri ce (K l ei n' 200 bc w i l l care heal th of payer thc of governnl ent as In c v i ta b l y ,th e i ,-tterests efficost irrld fr-rrlcls, reflecteclin its apprrro.h ti, raising ar.rdallgcrrting A nc' I,tcr c i e rrc i ,a n d c ontai nmerl r are l i kel y pri ori ti cs (Fattore. l 9L)9). phi l os
I' un tling, Prrtuision and O o t,ern an cc
77
c Omp l e x i tl ,< tfs o c i a l i n s u rtnce svstcl l tsl trrcli n the cnse< l f < lr gr r niz at i< lr ra l ( ic r r lr r lv is c < l rr1 -r< l u rrcllry e cfc l c l c ra l i s rl .L ] ntrl the nti d 1990s,therc w crc 6v c r 1. 000 c li ffe rc n t i n s u ra rrc cftrn c l s ,c i rch rri si rtl l i ts ttw tt funcl s arl cl s c t t ing it s own c o n tri l )u ti ()l t ra tc s . t Ie e l th ci trc rcs()tl rccsw cre i rl l ocatecl fronr thc bottortr uD l'urclcloctors u'ere frec trl clccitlcotl fhc trcatlllent of pr t t ic pt s .M 6r c< l v c r,th c fc c l c ra ls ()v c n l re l rt u,rtsl i rtti tcclt< l sctti rrg (rrncl alt er ing) t he f rrrn rc w o rk i n w h i c h th t' i n s ttrrrttce ttrtttl s arl cl provi cl ers ()pcrlrtccl. H< lwc v c r . cv c n s ()c i a l i n s u rl rn c e s c h t' tres rtl l ttu for sotttc cotttrtl l < l f (j tteottre-t' el rl tccl . ) corl trl f u1c lilg. I t r t h e N c th c rl e n tl s , i o r c r,rrttl .tl t'the \et l )\' ccl l trel tehettl cs rl rc [ t ut i11r rt llt CSf()r th e tr,r,9s 6 c i ri l i rts trr-l tt ee tttrvcvs r otl j o r t' tt' i t g( ) v c r lllllc llt ,a l l c l u l l ti l th e rrl l t c h tttl g e t r rl l oi )(r rl l t' l l t' ,rl th c r lr r c lt anc l f u tu rc c rp c n c l i trrres p rrb l i s h c t lhr tl re l )e prtrtrl terl t of hr t c lt hc s t i' t t u so f s p c n tl i rtgc ei l i rl g s (l .o tl c 1,//.. l t)91):.i -' 1 ). Irl tcrcsti rtg,l r' . r t r iv r r t e hc alt l r i n s u rrtn c c l rrrse l s o l tc c rt s t rl l j cct to crtcl tsi V c regtl l rrti otl for hi gh-ri sk ettl pl ol s gc h lt s p9< llin ge rtc l,t s ta ttc l a rci ltts ttre tl c cprtcl < rl g,c i rrtcgrrttetlthc l .rl rr' .tte arrcl trc rl cl tIi s c tl ttti rtu c c l c c s . ' l' hc r c c c l tt rc i tl rrtrs schctrl c..l i l | .l l l i \ i nsttrrttrcc s o c i rt l ils ur r t t r c c it t t tt rr s i rrg l c . trtti v c rs e l s< l ci el i l rsttrrttl cc of rr r ' r lr ot hc rc x an rp l c o i s u c c c s s fu l p rr[rl i c c otttrol llv stri ctl y regLrl rl tccl s v s t c prwI c r c i rrs u rrrn c cfi rn c l srrn c lp r< l v i c l crsrtrc el l < l tr thc g( ) v c nlt lc lr t . In tp o rta rrtl v , rrl l h c e l th c rrre prtyl l l cl l ts rrrc trtrl cl e [ es is of a lr r ri ()n e l fc c s c h c c l u l cw i th i n rp l i ci t l i rni ts ort the i ttcrcrtscttt < lv c r r r llc r pc n c l i trrl c . In .frrp rrn , a l l b i l l i n g ertcl prtvttrcl rt i s ccrl trrrl i zccl l o f th c N a ti < l rrel H cal th l ttsttrrtl ' tcc,w hi ch t t hr < lr r gh t lr c p rr-v tttc n ftrrtc e r c v ic ws all lt i l l s s trl trl i ttc c l n c l h a s th c p orvcr to recl ttccP i tyl l l cl l ts t() nr ir r in' r iz cf r r r u c l . S . v s t c r t r atirrn c c lefi c c ti v c p u b l i c c o n tro l of ftrncl i rtgi s w cekcst i rl hc:rl tl -r s y s t c lnst hr r t rc l y o n p ri v a tc i n s u rrrn c c .' l ' h ctl S A i s rt crtsei rl poi rl t. Il i si ng hc alt h c x pc nc l i ttrrcl ra s b c c n i r l n rl i o r p r< l bl erl rrrrclrhc LJS Acorrti rl trusttr cotl tl tri es. A s be t hc nr os t c x p e l ts i v c h c a l th s v s tc n l < l f a l l i rrcl trstri el i z.ccl l sv c r 1 .5pcr ccl rt of i ts (i l )P orr hcrrl tl .r s ec u c r t r lic q t h c L J S An o w s l .rc trc o rl ati < l ns.It i s Il ot onl v c r lr e, r llnr os t c l o u b l e th e l rv c ri rs co f i n c l trstri rrl i zccl prrbl i cc()l l tr()l< l ferpetl t ttakes th rtt fu n c l i n g p ri v rl te o f t hc ; lr ec lor nirl ru tc c ftttl cl s rl ncl i tl sttratrcc of frrrg n rc n trrti tl n c lit Lr r ec liif ic u l t, b L rt rrl s o th e i n the Il S A . strtl cttl rc fccl cral i st , s c th e r rv i tl r th e pr ov ic ler or gr rn i z rrti o n sto - I ' he LJ Shc alt| s .v s fe l ni s e n l tn rrrl g e ml rti ()lof pri vate i trsttr1,.500 over t crrrc orgrtltizrttiolts;ovcr 73(),000 cloctors, rlrce c()plprllies rrnclrnrrnrrgccl r t r os t of r v hot n rtre s p c c i a l i s tsi rl p ri v rrtc p rrl cti cc;over.5,800 actl te care f i( ) s pit als( r v ith .5 .1mi l l i o n e n rp l o ,v c c sa) n c l 1.5,000l otrg-tcrtr crtrc f:rci l i t ies . M < t r eov c r,th c p u b l i c s e c to r h c a l th s ystcm i rrcl l tdes.1,l 4 I cotl ntl es t hat oper at e co mmu n i ty l ro s p i ta l sa rtc lc l i r l i cs;thc.50 statesw hi ch rctai n l l c s o f p ro te c ti ng thc heal th of thei r respect hc pr int ar y c o l ts ti tL l ti o l -l aro t iv c r es ider r tsa n c l th e tra i n i n g a n c l l i c e n s i ng t> f medi cal perstl rrnel ;anci f inally t he f c d e ra l g o v e rn m c n t w h i c h fu nds Mecl i carc ancl the i oi nt
78
ComParatiuc Hcalth PolicY'
veterans'r r r r d Mecl i cardprogri tnl l l l e i rs w el l as speci al i zecl fe c l e r:a l -state re s e a rc hh ospi tal s. l rrth c l gtJ0,,thcgtl vcrtl l nel l tl .tttcl l l ptecl t< l ,contr()l Mecl i care/ groLrps (D I{ c is) , a spcrrdi ng bv i ni ti ati ng cl i agnosi s-rcl rrtecl v ..i i * i a prtvlllcllt' hrrsrt schcclr'rlcci system unclerwhiclt erlchctrtegor\,'.oi trcrrtnrent g()vcrlllllcllt i a.rcl er t. c' rrstrai tt pri vl tte scctor c()ststhc 1 ,1 ' rt6 c rn r< l rc, crrrc syst elns' thc crel rti .' .f I-l MOs l l tcl .t[cr l l l l l l l i l l aecl c rrc ()u rrt gecl col l tl ri tl :tt i( ) t of l rl i rl cl ucl ccl hl rvc ()th e r rtt t(rl tl ptst., c,uttrol cost grow th trti l i zet iolr rl cg< l ti rtti tl rts, pri ce s e l c c ti v c;rr.l vi cl cr c()l ttrrtcti l rs,cl i scotttl t prl vttl ctl tl l l cth()tl s.t\ftcr thc l cVcllinf lc o u tro l p racttccsJancl ri sl < -shrrri ttg i rl i ti rl ti on oi l )l { (i s r lt lcl O ff ()f h eal th carc crpcncl i trrresi < l l l ol vi rl g thc costs hrtve ri scrl rrr piclly, n ra n e g e clcrrrc i rr thc i atc l c)l J0sto rtti cl 1990s, crr sef or ' i s cs1' rcci rl l l l ' thc ,,g " i ,,' i ,,l.cxccccl i l g gel crrtl i nfl rl ti orl rrtcs.' fhi s gr< l r' vthi s tr< l rvrl P Pr or lch Mc c l i c rrr c/Mccl i crriw clhcrc, cl cspi tcl )l {(i s, rcel i n g c l o trbl ci i gtrrcserl rlttrrll y' S i rl g l l p< l rcl S el l c,X ccpti .,r' t.,thc' rtrl c.l rl 2()()(),rheW tI()r:tl l l
Health services and patient choice servi ccs,rei l r' ct ir r gt hu H c a l th servrccsrrrc i i rst rrncl i oret1l tl stl l l ccl i c.l l rrrtclthc:rl l oc:r t it t t l t r f scrvi ccs of p r()l tl i ncl tcc()f Ll ()ct()rsi n thc cl cl i verv hcrl l th scrvicescet . t rl .rccl i crrl A s frrbl c.3..5strggests, h c e l th c i l rc rcs()U fces. l .ctl l i ty .f c' l r c clelivtl -re ac.,r.l i ,rg t. thc ,p" .i fi .i ry rrrrcl b e c l i s ti r-rgui shcd j -,. l 7). l )ri nrrrryci rre i s t,vpi cal l l ,l essspecieliz. ccl e re c l(s ecrrl soohaptc, l ,
() I:u t ttling' Pr rruisir trtttntJ t tucr nttn cc Tlpes and settings of health seraiccs
Tabf c 3.-5
AmbulatorY scttillgs Primtrl ( )trc
79
( iPs Scrvic es pr ov idec l ll1' work ir r s ir l t hc ir owr r p ract ic c s or ir l hc r r lt h
Hospital scttings b,v(i l )s S c rvi ccsP rrl vi ci ccl ir r l o t t t l - t c r l l l c t t r c nt t r s i t t g h o t t l c s .
ccrltrcs. A cu lt' ( )dt't'
Scrv ic c s pr ov it lc c l bv i r l< lq ir l s1-r c c ielis t s ' ur ' or thcir or'vtt llri.lctlces or cctttrcs. l'rerrltl'r
Tablc 3.6
Sc r vi e c s p r o v i c l c t l b - v r lr t'r 'i , t l t s t s( ) 1 1\ \ . l l '( l \ ( ) r i l l ( ) t l t p l r t i e l l t ''l c l t 'tr t l t t c t l t s ir r h o s p i t r r l s .
percent'rge of ExPenditwreon medical seraices ctsd health care expenditurc, 2002
I n ltrtttt'rrt ('Llr(
( re fl l -l i t1 1 |
.17.6 31.7 .I .1.5
.lrrpr rr ncls Nctl'rcrlr LJSA
3L).2 .i 7 .6 2 7 .6
strelirr A r.r Irrrttcc
\ o r r r r'r': l )rt.t fro n l ()l :( il)
() u tl t,rttutl ('Lll'(
i l.l 2t.4 20.7 .12.4 2 l.lJ 4.1..5
H o t n L 'l o c r t l t b aLl r C S( 'l 'l tl C C S
o 0.4 .5..1 0..5 i.5 2.2
( 2' 006) '
ttl cl i fi erc' rttl < l cal i ti es th rrr rs c c ot r c llt r yc e rc . T h i s c l i s ti n c ti < l tlc o rrc s potl cl s clrre scrviccslrrc clclivcredirl rrrr-rllr-rlrrof c:-trcclclivcry.T'ypically,prin'rrrr,v or hc'alth ct-rrtrt.s) tory settings ir,t.l., a, (loctors' prrlcticcs "-:"1: lll:::"t h o s p i tal sctti tl l l sor l n,outpi tl cl l t ."." r . . ui. " , r r r cc l c l i v c rc ciln (i n p a ti e n t) cl eplr r t t - nent s < l fl r< l s p i ti rl s .l rl c < l rl tra s t,c l rr tl ni ccl l rcscrV l ceS naV etra(]l ()f _ rl l l c l rtr e cl cl i vcrccli n i 1 rrl ngc ti rn ally bec n less ,r.r" J i ." l l u ' ri e ttc c l :'rllcltlursing hotnes' ,.'t,ingr, ir
u0
(.ompttratit,c H calth I' oli cy'
crrre cxpen clit ur e is less, .f aprrnrtnd A ustri rl i a thc di ffcrence i rl herrl th by a btl ut 7 pcr cerrtl gc poi nts. I{ou' cvcr, i rl l coutttri cs arc chrr r : t ct er izccl will llc This servi ccs ' crtre hcal th horl l c of rtcgl i gcnce rr l ntost ti ni vcrs,tl (r. in Ohaptcr in t'ttorcclet:ril rrclclrcssccl of hcalth crtre i,'rrt'icsbetwcctl ctltttrl)rtticnt rtcccssto cliffcrcrrt t,v1'lcs rri cs. rcfl ecti l g cl i fi crentl evel s oi prrti cntch< l i cc.(.hoi cc ci l ll t llcr lll clil'f cr cloct
( F tu t tl i n g, It r rn' i s i rt t t tt n cl ) t t Ltt' n rtt rt t-c
Box 3.2
ut
Liberalizationof Medisave use
f L r n di t t p a t i c n t A lthou gh thc Mcdisav e s c hem e was or r ginallV t les igr r c dt o cr.trlpilv cotrclitiot'ts chronic c"re, a, c,f 2006 patierrtssuffering fronr specific S i n g i r p t l r e 's f o r t lc pr r r t 'r c nr li. r T' his iL"ir ,ru ,p.,ie nt b ills us ing M SA. rtckllor'vlcclgct-rlent gor"crtrtttctrt's tlrc rcflccts hc:rlth carc financing system c l i s c r r s c sc'a n b c t ltat ()tltp rlticn tcosts, es pec iallvf O r p, it r c ' r t sNit lr c hr o n r c rlrc l)rltrerlts vcry higir ancl p.sc ir financial pr'btcrn to rrrilrr\'l.rrttictrts. . r r ll)w rll .f t , t t r t r t l , r , . 1 r . t r r y . . ' , , , : e \ 1S, \ r., u sclu p to S$. 10( )of t hc i' ' i r c c ( ) r 'r r il (t ) r ' e . t c 6 "ll,;*; f"r'-rity :i t . r of S$. ] t ) t ) . r r r \ ir ' t r r r r r r t ' n rc'r[rc's'M SAs itrli,. "l h v p c r t ctltli.llrctes. a' pr.vcc1 ir'tpilticnt tr c r r t ur ellt . hc i. Lr r c . t t t lit i. t ls . r rre l . c c . t t r s t 't h e r c s c lec te t l ,ir' rr, l-'igh cl-r'lcstcr.l lev c is r r r c l s t r ( ) lic . * ' t ' r c c r t t tr r l s t r r h c V . l l t t l t llct l t ' t r c r t t t o *ell-. r tab lish ed , cvicl c nc c - lt as c tI lr ot oc 0ls ln rrclclitiorlto thc lrtttrttrrlrl ithtlrln'rtl lte auclitecifor tlclltttteltt oLltc()lllL's. trlr is s c hc t ncis s tr b j e c tt t t r t t l e t l t r c t i l r l e t r r r c lc NlS, \ s oi u se thc lirllit o f S$ 30 0, bill r v it h bills bc lor v S$. 1 0t o l r c l . r r r r tilt r t r s l t ' of S $30 ()n cach ()Lrr pr r r r c nr 0f 1.5per cerlt otl clch otltprltlr'lrt l)ill ill l-urthcililorc, rr cllsh cO-trtrr1,tncnt g( ) v c r nnr c r r is t c . t t cc r r t c t l t h a t t h c Thc i, x t . cxcess .i th c clcclu cti 6lc '. l i c v to bcconrtr pfclllrlttlrelV MSAs allowing by prolrlcr-n futurc ,r crcatc rvill the logic of savirrg for' see clcplctccl.l)rltlcrtts,()n thc othcr hencl, clo not llcrlcc, thc \vhcn thcir cLlrrclt lecds ltrc llot ir(lcqtliltcly lnct. fr.rturc 'ccds srrvingfor w h 'v pt r l l l i c t hc t < l t o. c x plr t in pr c s s t lr c g,ru. .nn tan , was u tlc lc r f h i r n trlecfing h c alt h c lr c nc c t ls was r t t ( ) r c it t r p . r t l t n t irut ur. 1i,,',p .tierrr) Ltlrr(
l l l ()l l tD.l ti t
l l t l l ('(' tl\'
, s o r r r r - e : l l crtcl stn rrtttl l r
Icprl rtl l l el l t l l l rr lre a l th cc lt t f c ( ) r g( ) iltetl i rc c tl ,vt< l .r s 1 -rc c i rrl iosLt l tpi l ti cl l t tctl clttl l l c l orl gcr ti ntcs rv rti ti rrg , l e ttc I h
82
( .t t rrtltttr ttt it' c H c tt lt h It o I i cy'
ch oice is expet r st ve pri vrl tefuncl i ng.A possi l rl eerpl anati on i s that trrrrti erl t of cost collt llllli rl ti rnes cs1-rcci l l l l v ,r,r.ltl -,...i ,rr. l i k" l u to be restri cted, ot ] c t t i t he t r t : lit l tht' Ll 5A | l .l thl rt l l tel tt. Thi s cr.rni tl so trccountfor thc f,rct r olc f or ( iPs, getc-l < cepir lg, of Fl Mos w as to i ntrocl ttcca cl rarrrctcri sti cs t f r lclit ior r r ll t hc ir l thLrsl i rni ti ng,rhe w i cl e choi ccs oi spcci al i srsi rl hcrcrl t t o r 'viclclccl v, rl j r,a,n. r\s notccl crrrl i er,n()t sLl rpri si rtg,l ,this i nsurrrr.rcc tnl f H N l ()s l l v LISprrti ctttsartclcl
Welfare mixes in the provision of health care r cf lcct ir lgt hc s l ow for cl i fi crcnt l evcl sof prrti crrtchoicc, H cal th s,vstcl tlrrl clt 'cisit lt ls spcciiic l l rts ()r' si tl ti z.utl rve rrs s ..' u ," .f r-;' ' ' l rl .,i ch hcrrth su' r' i ee t
B o x 3 . 3 We lf a re mix : mix e d me a n in g s a n d p o l i c i e s in lvvhichhcalth-scrviccs As.,tt-ouceptwclfarernix lcfcrs to thc clivcrscways thc clivisi.'
F u n d i n g , Itrt tt' i si rtttttrttl (' oucrntnca
83
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prtl vi trccsottcn act vc t unit ar y p< llit i c rrls v s tc l tl ,rv h c rc rrrtl rri c i i ra l i ti es:l ncl o f tra ti o ttrl l p o l i cv i l rogrrrml l res'S i nri l arl y' rr s it r plc t t t et lt r t t i o tr " * .-ti t'g ()v c rl l l l rc l rtc ()l l trol rvi th strorl g cl etl l ctrtsof fe par r c O ur lt it r e sc e rrtrl rl cl c c c r lt r eliz lr t i< l rl .H c a l th' igh()V l l l ll sl c c i s h i ghl vdccentrel i zecl l rcr< l ss47 ,,r' e r"rlrtc .t rrl tl rl i ci ' rrl i ti cs.e' cl prtl vi cl cs i r regi. r r r l pr . ef c ctu rc s ,,n .1 p ri rrci P l ctrl l cl erl ,vi ngrl :rti otr:rl t]lix t ur c O f c leliv e ry l c v c l s rc fl c c ti n g rr b rrs i c l L )L )7 :1 0 7 )' l )c s p i tc th i s' thc cerrtral l l ovcrrl nl cnt folic ic s ( N, r k al ra i e ' o f h c.rl thcrl rc thr()tl {:hthe ri gi cl nlr lt nt l. illlss t r ( ) l tsc o l ttr()l < l v c rl rl l rl s l l (' c ts rrt t c cl c r t t r ally c t l n tro l l c c lfc c s trttc trtrc ' i n ht' ,tl tl l g()vcrl l rl l l ccl s l, c ( ) ' t r r ls t t ( ) (tc l -u rr.r\,,th c ro l e o f tc rl e r,rl i snr rl rrtl the t$o eottl rtri esi l l ustrrrte rtr ilbiv r r lc ntin A rrs tre l i rrrrn c lth e L l S,\. l trc' c c t t sttl r-srstctl tsof l rc' rrl tlcl h< lw n. t O c lc<slt g o v ern e rrc cc i l l l V l tt' r'l l c tu tl l rrtr eerrtr' t]rzetl hrghl r ttl ore is l t r A r r s t r r t lir cr ( ) n tr()l< l v c f h c e l tl r ft[rc l i rl g ft' tl crel l rr ctl rerctl v c rv [)()()t' rl t' e i r r t hc US A whc rc ,r,' ,tu ,t.,.r' l d c rl v .rn c l t< r ccl tl l ol hrts A trstrrrl i rt p r ( ) s r r llt lt llc s . ( )v c r i h t' p " " tw rl c l c ^ c 1 d cs' hrrs tl ri s rrrrcl l ti r c/ rrl ..20().5) c c . t r r r liz c c f f c c ti v c .,,,..' ,r,,i(r).c k c tt,2 (x )4 ; r i trrrcl i rrgdcfi l ' ccl frtl tl r 1.rIirrte tl i p ro p o rti tl l l r c c lt r c c csl ult s t ru tti e l l ,vth c tetl cl ettcr' ' cerl trel i ' si rl u i l ' s tr()l l g b c c l t s ot lr c c s . N' lt lr c o V c r,th c rc h l ts r v it hir r c lr c l. r < l ftl rc Atrs tre l i l rrrS te tc s l trl tl .Ierri t< l ri csi l rl cccl l tV cl lto rs of fi rrrrrl cecol rti l l r' rcs bc (l) wv c r , 2( X ) 4). (.o rl trrrri l v . th c tJ S s ,v s tc r l l highlv f r egt lr c r l tc tl .l " o th c ' tl trrrtr-i c s ' h < l l v e vcr' httvestr()l l strl rtIi ti ()tl tl roi rl tl t()l l < l ttrvi t.t thc prtl vi si tl rl t c lc c c r r t r lliz r t t r < tnrrn c l i n c l i v i c l trrtls trl te hc lt lt lr c lr r es c r v i c c s .rtl c l < l frtl l l trs tl rtl c l l l tl wcri trl pri vl rtcS cct()rS . i rr b o th the U S A arrcl.,\ustrrrl i rrb,v A lt hor r gh t 1. , " ..,,t.,.1 f.ru .,.,.r,.,.l .n a s ttt r' < l l csi tl ftrrrtl i rl i i ,goveIttrrttet: rr ec c s s it vhr r v c s u l ts trrn trael rrc lg ro rv i trg statc' ttl yri rrcl i stri r-l i g r-l l y (.l c c c rrtr,rl i zccl tl , l l trtcclrrtl l < l tts r t r ov is i< lnr c r r rrri r.rs l r iv rl tc s c c t()rs ' l< lc elr r r r cP
policy The authorlty of governments in health [ . ook ir r gr t t hc ro l e s o fc c rrtrc rtrrc l l o c rl l i t' v , i nhcel thgt' u:^t' ]:l t]ttprovi th:r arl cltl -rei tnp< l ro f th c c o n l p l c x i ty 'o f hcrrl thsvstcl l l s e p< lwc r f ulinc l i c rrti rtrr t ir lr c c < lf pt llit i c l rl ..u ...* ,,f< l rs h l tp i rl g ' h c l rl thsystel l l s.Ll l ti rnatcl ,v,hcal tl r s)'s/cr77s at diffcrcrlt lcvcls: hertlth s-vstclllsl.ls g,ru..n",l.. rrlrval,shrr;r1-rcrrs l .rcrrl thcrrrc of provi si on thc r c c luir e c lir c c ti o n t.,r,l r' i r.r" c e n rrc w h i l c cl i ffcrtl f i tl .l portrrtl ce rcl rl ti vc th e inc v it r t bl, vir r v o l v c sl < l c rrl i ti c s[{. o w e v c r, subclifitlrerlt lllll()l1g rls rrs \vell clrt lcvcls l,:rrics rrn.ronghcirltl-rsvstcnrs-I'l-re rt'ithirr a.cl rllll()lls variati<)11 systenlsrvithir tt-.,.r",..,i.hcrrlth rur,.,-.,t. as well rrs s;recificpolitical proViclcd is crrrc l.rcrtltl'r svsteulsreilccts l.rorv c ( ) nt c X t S . F t l re rl l tl ri -rl e ' l re l rl th g ()v e l n a ll cei shi ghl ,vcel l tral i zcdi nB ri t:ri rr, L J SA .I' hi srefl cctsthc frrctthi rt the wher er lsir r s m .re .i .,..,,tr" l i r.l c l i n th e .' f th e p ubl i c funcl i ng al r.dprovi si orr I lr it is h c c nt r 2 rlg ,ru .:-n -,.:n ,i s k e y to i uncl i ng rr' c1pr.vi si t)rl rl atLrral l v healt h c r r r e,w h e re ;; i ;;,-,. [J SA rn i re c l
90 C)tmp drtrtit,c H ed lt b Pol ic1, bctr,vccrr thc tw o co unt r ics also c l c ccrrtral i zcs g()vcnri l nce.Thc cl i fferences t r l. t p < l i rrtto the i nrportancc of pol i ti cal col rtcxts. A s the ctttttp: r r is
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Figure-3.2 I'ublic control of funding and prouision of health care
Fu nrling, I' rt tuisi r ttt ttn tl () o uentLtncc 91 ancl peri < l cl i c lr gc ing pO p r" rl rtti Otrsa,c l v l trc c s i rt rrl ccl i c:rltcchrl ol ogv thenl sel vesi l t rl l i l rl i fest < l ftcrl p rc s s tl rcs ll o rv rr ttrrrrs ,a n c l tl .rc s e " i. r n, r n' t i. t9 c ()p trg l e 1 c l c ()l trri p c () sts. Il ow cvcr, tl .rc i rl sti tuti ()rl rl l 1- r , . . r r ur . , g< l vertl ttl cl l tst() ecl cl rcss c ( ) lt t ex t s< l f h c rtl th s y s tc l l l se rl tl th e c rrp rl ci tvtl f C ottntri es' F< l r t hCs e pr c s s g re sc ()tttl l l tl c t() v l l rV c o rl s i cl crrrl l l t' l l ctw eetl i n []ri trri rll rrl cl hi gh i s , i l cl l .rroV i si ort . r " , , . , ; , 1. , ;l trb l i c c ()n tro l < ri fu rr.l i n g e S wc c lc n,wl rc rc rtsi t i s l o rv i rl th c L ISA ' oi htl ,rl th S igniit c e n tl y ,th c p i c tu rc i s rtrrtrcc o tl l pl cr therr thc t-v1l ol < l g,,v r' tsstl l l l es , ur r . 1, . 1'i,,,tr,r.i .c c .l i r (i 6 e p tc r I l v ..l tl s.g,gc\t. [-hc tl ' 11< l l < l gv rl tl cl cl s rvi th ccrtei rr i rrtt' cl rl ssoe c l i rc ctl r rrrc t ir r r tc c r t r r i rttttrl c l c l so f ftrrl c l i rl g grl cs l rrrrtcl of ftl rrtl i rl g c()l l tr' ()l p tr [rl i c to th c c x tc l tt th ,rt h i g h of pr < t v is i < trr i s trtt' : V crsrt.' fhi s r i .e rl ttcl in lt e, l. l r v i th h i g h p U l tl i c c o n tro l Of p ror.' i si orl S rvccl cl l . l i Ii t' ri rr. ,tt sttel l ior t hc hc a l th s y s tc n ts i rt s o tttc u o tl t ttt' i cs ()f ttrrti tl ttrrl rr i tl t.rl It\ ( ic r r llet r Vl n c l th c L IS A, rv h rc h :l rc c l o scst to tl tt' JtL' lll\llliltlct' sVstelll' hcelth scrv iCc . s 6c ilr l ir t s t t t - llllc c s v s t c ll l i l l l ( l 1 ) l 'l \ r '( ) t l l l t l i r '\ ' q ( ) \ t t 'l l ' t-r'\|(.Cti\(, 1\ ' .lr r t lr t ' lr t ' , r lf ll \ \ \ I L' lt l\ r t l tl l t t 't 't t t 't i t t i r l q p r
Chapter 4
Setting Priorities and Af focating Resources
(l Irrptcr.] rl epronstrrl rerl that herrl thsystcl ttscl i spl ayvrrri rtti otlin t he subt r hcalt l'r s y s tcl rs < l i i trrrrl i ng, provi sron encl govcrtrrrnccthrrt i tttl -rrtc
The goals of health Policy Ev c ry prol i cyi s i orrncl cclon goal s errd o[rj ccti vcsw hi ch shotrl clb c clar it iccl c rrrl y i rr thc pol i cy-rrreki rrgproccss.' fw o l cvcl s of goal s erc clisccr r r iblc. T h c fi rst arc Iroecl stercclg()rtl sthrrt ofrcn fttrrcti < l ttsynrl tol i cr t llvr t t lclr r r c l c o ftc n nrorc i n thc reel rn of p< l l i ti calrhctori c than rcel i t,v.' ll tc sccor l, -er , t lc. r 'lt pol i cy. []o t h ul l l ti c g,oel sthrrr i rrtrncrt perti crrl rrr s 1 -rcci fipr()grrul c gor lls thc succcssor frri l urc of ,r pol i cy. A l thotrgh s
92
csttur ces Sctt in g Pr i or ities ttntl Allo cdth tg R
93
Oual i tY
Equ ity/Access
\ Cost Cont at nm ent (Ef f icenc Y) i
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Oompating'goalsof hcalth ctre
t , |.lltt'l..,l.ttIlttitltlt lr t lt t . lr t ' lr I t |r t l|. ir r t |iv it lt r . r |1. ' ll i t . t t t s i s l . r r i l l t l t r r . A lth
pri ori ti cs' Irr e rrtl tl t" rl i i y s h rrp cclhcel th carc crur t ly ,t he goel s ,,t " .1 ." coul cl bc cxpl rl i rl eclby how l rt r gc par t , t he d i s p rrri ty ru l t()l 1 sc o tttl tri e s corl rpcti nggorrl s.ri freel r,u ,,,r s rrb s i rl i ary n r t r c h c ur phr r s i se rrc h ,l ,i ,i ,r,-} rtttcl < l fthc hcrl l th crrrcpr< l vi cl crs rs , rl U to l t()l 1 ty c lonr0f c hoic c f < l rc Orrs u n te or s< l l i dari t,v" l hcacttrel i n s ur c r s ,r r r r crl r s s o rtc cl lt()ti ()l l s< l fc < l l ttl tl o ttl i tl ocl di sti n.cti on'isn nrrti onrrl thc b v rrix of t hc s c po l i c y ,i ,,.t1 ;.1 -l "bte c n s h rrp c c l i rl ohrrptcl ) ' l rl cl i scttssccl c ult ur es , polit ics rrn c li n s ti tu ti o rrrl s trttc tttrc s th c t lS A ' f ( ) r il] s tl l n c c ' w i th tl re s tf()l l !]l v c rg h tptl t()l l i l l di vi cl rral frcctl tl atrcl tl c()llllllttt.titY,tttlivct-sitl:.rcccss lty lt
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c o verrl gethcrrl th pol i cy i rl rrl l l) c s pit c u" . ," ,,,,' .t' " g " ttfi " g t-l tl i v e r' s a l p e ri o c lp l aced.pri or-i tvorr cnsuri ng rrl l c lev elopednr r t ro rrs' ; ;l t:-} ,;tt;a r o f rnccl i crrli ntcrventi < l rl s'N ew c it iz enshir c lr r c c e s sto rl u e x p i l l l c i i n ga rra y t() cxistlll!' strllctLlres' bccls wcre rrclclecl l.rr1-rlt"l, were br-rilttr"cl t'.ttt'-t1' n l ade i n rnecl i calcdr' rcati onand s ignif ic r r nt lyer p a n c l e c il n v c s tme l l tsw c rc rrncl personncl was increr.rsed biorncdical ..r."..1-,,-ih; t;*td; of medicrrl b y the el ncrgcncc,of nl anv new t lr e boundar ie s o t " l t' ti tl n t' e * tc ' rc l cl ltlc w i rrsti tuti onrrl mechani snl s w crc . ' u rth ..n ' ,,rrc ! nr ec lic als pec i ,rl ti e s F
94
Compardtit,t, Hctrlth l''olit'y
i rti ti a tecito cnsLrrerrccessto these rcsourccs,tl ' rr,rs i ssui ns i n thc cr r r of te c h rrol ogi ci rlrnecl i ci neas tl re new rrucl cus< l f heal th carc. Thi s p ( ) st war b o o n r of mccl i ci ne, i n turn, w rrs nret by hci ghteneclcxpectrrtionsancl c l c m i rttclfronr s thc publ i c for grcatcr rrcccssto rl n cvcr-crprrrrcl ilrrgr r senr r l o f o ftcl r costl y r.nccl i caI i nrrovati ons.
Equity and access:continuing problems T w < l tr " 1.l cs tl f rtcct' ssn' crc rtcl cl rcssecl bv hcrrl rl rp< l l i ci csoi thi s cr r i: iinr r nc i rtl a cccssrurd phvsi crtlor teograpl ri cal access.Fi nrrnci rrlrrccess wr r s r ) r cr l tv rc sfrucrtrri ng l rcri l th cerc ttrncl i ng ancl provi si < l n s() rl s to pr oviclc tttti v e rsalrl cccssto rtt l cast rt rtti ni nrell evcl of Ircrrl thcrrrc for al l cit izcns b rts c c lon rrccrl .' l l ri s cntrti i cclci thcl crerrti ns sr,' sfcnrs < l i cl i rcct public fi rta rtci rrgertclpror" i si orrof serr,' i ccs()r g()\' cnrl rcrrtl rlrcgtrl eti onrrnclcoor c l i rtrtti orrof pri vetc si cl i ncsstrrrrrl su,i th gurrrr' rrrtcccl c()vcri rsci o r t hosc p a ti c n t s w h< l i cl l through thc gaps i n rl tr' pri vetc s\,stcl n.S orrrc,sr r chr r s (i c rttra trv encl thc N ethcrl encl s,cl rosc to strcnsthcn hcal tl r systcr nst hat sct up ;rrc -c h tcclW orl d W ar l l l vhi l c < l fhcrs,srrcl r,rsthc Ll l i .anrl S r,vcclcn, l tc w s ystcnrsto l ncct thcsc goel s. l :rccpt f< l rthc tJsr\. \vhi ch ch()sclt ( ) f f ( ) c s ta b l i sh a nati ()l tel svsrcl )t,el l corrnfri cs crrurri nccll rcrc w crc ler gcll, s trc c c ssfttli n rrchi cvi ng urti vcrsrrll cvcl s < l i rrccess,cl cspi tcrnaj o r clivcr g c trc ci rr thc ntcl ursuscclto i tchi cvr:thrtt gorrl . M l ttrv cottntri cs w i th Lrtri vcrsrtl c()vcrrrgcfecc a probl crrr oi cclLr it vof i l c c e s srcl ated f< lthc prescrtccoi rt ri crcclsystcrrrr,vhcrcpcrs()nsw tf h st r f f t c i c n t rcs< l rr rccs obtrti n scrvi ccs r,vl ri ch arc ci thcr unevei l ablc or c o tts trr ri l tccl i rr thc ptrbl i c s)' stcnr.Ironi crtl l l ' ,thcrc i s srcatcr publ i c r t wit r ctl c s so f thcsc cl i scrcprrtrci cs i n thc coutttri cs w i th n:l ti ()nelhcal th sur l iecs w h i c l t lrevc tnrrcl cthc srl ongcstcl ai nrs for fi rranci rrlcqui tt' . Frl r i n st r r ncc, w l ri l c urri vcrsal i n,i s rrt thc ccl rtrc of tl rc l l ri ti sh N H S , oi tcn i f r s r r p r
St't t i rtg l' r i rr i t i t's tt n tl A I h t ctrt i rtg Il csrt tt r ccs
9.5
huge techin su fficicnt nu t l[ c r < lf pet ier lt s it t t . t t r t t . t yr tl r l t l r t r c r t s t
( S t ul{ c lt ' r , r / .,2 0 0 .5 ). thc A lt hot r gh n to s t c o u n tri c s h rtv c c rc rt tecl rrl cctrti vcs t() c()rIcct < l thcr r' cl i ttcl ttcctttctl ts ri ,-i .rrrr,f- i .rrrrei .rl rrrc c,rl r g. , , g, r " 1. , hi.:"i rrrSrrl 1 i tl ttl orc cl ctei li rl (thi s rs tl i scttssecl p ro b l c rrr rh c rc s o l v c c l ' 6 r 1 9 t 1- , , , 1ic i.h,, r v c l r,t, o tl e t,f rl r.' l l i ghcst tl rttl rl rt' rsof Chlpt c r . 5) . F< l r i l ts ti l l tc c r( i C rn rrrrrV i l t ttrl l rrtt:rrcrl s.l tl l rt'eotl eetl tl ' i l tc(l to tc rri l . l, , at , r r ,( s c c ' Irtl tl c .5 .I)l rrrtth c v r llY t' ,.' 1.l .l er' tl tttl .tttp< l rve u.tt w l l ,-' re ,rrtr lc ) c . )f.hc 1 ir c c d O rnt() s c t u l t 1 t| e c tre e pcr cl octors of .l tl tl i rrorl rrl l l n n c c c l s .,tn c l th e 1 1 1 11111rt' tpler t ning lt r rs c c < tl re rttei rtrti tl tof thi s l .rol i cvrvrrs s pc c ialt velc l rc s i o rrrv rrsl rn ri te tl .,' \l th o rrg.h si tl e effcett \\' ;l s tl l i l t t < t lir t r it t lr c a b s o l trtctl ttttl l rc ro i tl o c to rs . tl tl c oi i ts (l i trretl .l (x)I). r r r r el r c gions l tc c rtn tcl l l ()fc rl tffi l c ri v et() tl cr' vcl oct()rs ctl tri rf i s thc frrctthrrt the r \ n ir npor te l t [rrrri c r 1 9 c s te Il i s Ii rl g 1 l h1' si crrl i s si grri i i crrrl tllll'l ()rcc\l ]t' rr\i \t rrs l r lc liv c r l,. , i hc e l tl rc rrrcs c rv i c c sto t' ttrrl rrrc hi gh c()st()f cal l i trrlctl tti l .l ttl erl t th c < l i [c c r.rl ts c ( ) lt r t pc r , c lt s cb rts i s .i rr p e rt A s rt rcsttl t,tttetrvs1-rcci rtl i zccl c i rrc. rrrc c l i c a l , r . c . l. i. lt o s up p l y ,r," r..,f th c rtrt i rr tl rl l rl tl rcgi < l tl rtlcctl trcsr' vi thrl s c r v ic c sc r t t t l ' rcp r< l v i tl c ccl ffrc i c rl tl yo rl l y i n A trstrl rl i rl ' i s cs1' rcci al ecutc l ,v c r it ic r r lnt r r sso f l to p trl rtti o tl T . h i s p ro b l c rr r p< l ptrl rrti otts of thc l c IJ S Al v h c rc rr s i g n i fi centrtti rtori tv Nc w Z c r r lr t n de rrc th g,c< l g,rephi crrl . c tl rv h c tl p e ti ctl tsi r< l ttli stl l etccl liv c ir t r er no tct' u rrtlrtrc r' rsl :v es thci r loc et i< lt r hr s rv cc c l tr,rli i rl rl rl c i e il l c c c s sto tl l c srttl l cl cvcl oi l l l ccl i ci rl c i rt r' vastcclti tl l c t ur ban lt r c t lrrc n , trrrv c l c o s fs , rc l O c rrti Oncosts rrtrclctl sts i n thc hi ghl v orl l V rl cccss. i n c i fc c ti vc pr oc luc c s r rb s trrn ti e li n c c l rri ti c s pr< l bl ctl t' rrot l t i s th i s c ' ot r c c t t t r lr tepc
Ouality care:what is it? ' f hc goal O f h i g h q rrrrl i tyIrc rrl thc a rc , i r h rtl l nrerl
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ie rprel i tv i s oftcrr ccl rratcclw i tl r thc l atcst cl i l rgrtt tu s c c lL. J rrfo rttrnatcl v, 'sf tc c l .rn o l o g i cs,w i rh cttr:tti vc tttccl i ci ttc,el l cl w i th spcci al i stscrvi ccs.Th is thrrt cl tral i tvcatr l l c cl cfi rr ccl c n rp h rrs i sc a n be cl cccpti vci n thet i t rrssunres spcci al i stsartcl i ttrcrtsi vcrl l ecl ical rnccl i cel b y tl re n u n rber < l i nrachi rrcs, K cssl cr, 1999). (l tral i ty as (sec ancl Mc(.l el l an i n tc rv e rrti o nspcrforrrrccl to hee lt h i s el s< lof cl Lrbi ousvel ue w hcrt c< l tttl trrrccl c l c fi n c cbl y tcchnol < 1g1, rl ttl l l bcr
Cost containment; strategiesof constraint In th c 1 9 7 0 s escal ati ngcosts, i rr l argc prtrt ftrcl l ctl by thc otrrctr-et lclccl o ill l ty a gl tl l trtlrcccssi < l t.t:rrlt w crc rrggrrrvetccl g ,o a l so f rrc c ess rrnrlcl rrrrl i tv, rtt lcl c ri s i s .()n e rc sul t w rrsrrn urrnri stakal l l cshi ft i n crnphrtsi sfrotrt,' tcccss c l u a l i ty t() c ( )st contrl i l l nrel tti n orcl cr t() col l strrti l t trttbri cl l cclIl crrl thce r c technol ogi crtlcxpi l l l si ()tl :rt lcl b< l uncl l css s p c rrc l i n g A . g ci ng 1' roprrl rtti ons, h c i g h tc n e c l publ rc cxpectati otrs sol i cl i fi ecl thi s g,oal i n the 1990s. M o rc c l v e r, i ts prouti peucc \vi l s errcottrrgccl by thc i cl eol < l gi calsh if t
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t ou, ar c l sn c o -l i l rerrrl i s n r,w h i c h c s c hcrveclthc w e l farc strl tc and pl acecl thc c< l ns1-rtctter r r phrrs iosn c fi i c i c rrc yo f th e ttrrrrk c t.N o cotrtrtryescl -tpccl l l l l rxi rl l i zi l l g effi ci ency and p ro cl trcti vi n' . i rn p ro v i n g < lus s hi i ts t< tw a rc l s hcrrl th cl l rc. More()ver, t() i ttt< t p ro c c c lurcs inc or po re ti n !l l rru ta g c l l e l rt \rVc s tcrn w i th thc rt< ttrrbl excepe c< l tttrtri cs, c lat c ,r c f< l rn rc ff< l rtsi n n ' ro s r r i< lnof t h e tl SA , h :rv el rc c n c i fc c ti l ' e t() thc c\tcl tt thrrt thcy hrrvestol -rpecl < lrat lc a s t s l < l r,v cth c le ra tc o f i n c rc ,rseol hcrrl tl rcrtrespcncl i rtgas a proport ion of ( i l )l ' (s c c ' l a b l c .1 .2 ). ,ttttl svstcrttcffi ci cncy hrts I r < ln i c rrl l vth , c c rrp h a s i s()n c ()\t eorrrrti nntcrrt rotl s1.ri g111;11s' l l l scrl l vt w hcrl f < lr c c ccv l :rl u rrti o n< l fc l L r,rl i n(rrnc fi o rt thrrt \\' ..1\ l rc sct i rr pri ori rtt' s cl i stri l l trti rrg thrtt g o a l ) b r rc rl rri ring rr s trtrc c l c lualit yw l ' rs \ot strrpri si trgl r'thi , s tttotter. for o f v e l trc I c r r lt h c rl rc rc s ()rl rc c si l r tc n n s c:rre i ttcl ttstrr. rtrccl i cel hcrtl th thc on s hif t r n g ()rl l sh e s frrc c col 1 -r1 ' l < l s i til rortr ' g,rou tt rtecttsttttttecl ttr pr < lf c ss i o rrerrrrc l s hl c e l th c rrrcc o n s tnrcrs l vho hrtvc er pc t t s i v cc rl rc r' ttl < l rnc' l i rc c tc o s t' (l l rrrr< l p,l c)92: l .5t)). ( l( ) s t c ()l ttrri l i l l tc l tts trrrtc g i c sc l rfi cr si gni fi certtl yrtcrossheel th sV stcl l l s. ( ) bjc c t i v e sc rtn b c f< ls l o w th c re tc o f i ttcrcasci tt costs,t() st()pc< l st:frttl tr r is ing irt rc rtl tc n n s , ()r l n ()rc rl rre l ,vto rrcturrl l yrecl ttccthe ctl ststl f hcal th c r r r c ir r re ,rl tc rn rs . T h c h c e l th c rrrc scct()rst< l rvhi ch rr prtrti cLl l i trc()st tl rt w hcther tl re hc:tl th c olr r r lin l l c l tt s trrttc g yi s trrrg e rc cvl e ry cl cl ' rcttcl i ng l tucl gctl trtsi s,throtrgh tl rr rr cl i rcct s er v ic c srtrc i i n e rrc c cbl ,vth c !l ()v e n mrcrtt p tr ovi cl crssttchas physi ci rtnspl l i clol l rl pr r lt licc o l ttrl l c tsrv i th i n c l c p rc n c l c n , llv f c c - ior s c rv i c c l te s i so r h < l s p i ta l sp a i cl pcr i tcrl r of scrvi ccpr< l vi cl cclor t hc pr iv rrtc rn e rk c tp l a c c .A s s e c n i n Oha;l tcr.3, c< l trrttri csw i tl r rtl tti ortrtl , w cl l rts sevcrrtlw i thhc elt h s c rl ,i c e ss. rrc he s th c L J I(a n c l Ncrv Zcrtl rrrrclrrs < lut , s u c h rts S i l tg e p o r-ee n c l .frtp a r r,cxcrci sc cl i rcct l l trcl gctaryctl trtrol , thc N ctherl artcl srel y rnore 1v hilcc o u n tri c s s rrc hrts (i c rrn e rrv ,Ij r rrncc,rtrcl Irr c()l ttri tst,thc LIS A ,anclt< r rr1' rproech. < 11f hc s c c o n c l c, o n trrl c tL l rrlb rrs e c l l css cfi ccti vc rl l i rtLtre < l f rl r t les s e r c x tc l l t Ag s tra l i e , c l c p c rl clrl p()l l The crtpl tci tyfor I r ppr < l ,rc l tc si n, c l L rd i rrgth o s c [ta s c c il n rhc rrl rtrketpl rrcc. s uc c c s s fu lc 6 s t c < l n trri n l n c n tp o l i c i es, thcrcforc, fl ttctttrrtcscortsi derabl y t lont orl r.'c ()r.n ttrlto tl tt' ttt' rt. S wc cl c rri s rr g o o rl c x i l n rp l c o f rr c ourttry rvi th a nati orralhcal th servl ce t hr r t I r rs c ffe c ti v cc o n tro l s a n c l w h c re tl -rcgencrrtlrtrl e of ' ptrbl i c fundi rrg r lll< c s f< l r l tu l tl i c c ()l ttr()l ' a p ;l l i c s . H < tw evcq i t' t cotrtrast to B ri tai n arl cl si,nceheal th carc Nc w Z crrl rrrrcth l , c c o n tro l o v c r fu n c l i ngi s cl eccrttral i zecl regi < l rral thc ti er of g()verl rrai secl by v l e dfr< tmta x e s is pr ec l < l n ti n ;rrrtlftrrtc s l e n n g l trclt' t d..2005\.' Macrol evel ' rnerrstl rcs nr ent ,t h c c ()g l ttyc < l trttc i l((i 9i c os t c o l l ta i l l l c n t v a ry , b e c rru s ecoul rt,vcouttci l scl eci deon the rrrtc ()t thi s, r c gionr rlta ra ti < l rt,th c mrtj o ri tv o f w h i ch gocs to heal th care. B esi cl es global buclgctsplay rln ir.r'tportantrole rrnclcoLllttv councils lrily allocate S i rrri l arl y,col l l l ty f unc ls to d i s tri c ts r-rs i n gn c c d s -b a seclgl obal br.rcl gets. hospi t:rl susi rl g gl ob:rl ancl ccntrcs h e a l th rn rry fu rrd c l i s tri c ts c ounc il s o r pa,vrl -rcnt. Tl -re ol l y truc 9f fi trms 6 th c r br - r dgc tsi 1 c o rrj u n c ti o n .,v i th
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or throtl gh i rl cl i rcct rt c l i rc c t,rc g u l a to r n,ccl i ct(ntrrcr< )-l l l rl l l l tgcl l l cl l t) (ttri cr' -l l rrrl l rt!l cl l l cl l t)' e.cl rri rtccl rrt i i u ." ry ra .,..,.rs cfi orts crttl bc' i rl i ti ett' cl ti .,.,l l ,' ,i ,rr' rrti crl ts svstcl ll, ,1..l . ,,r'l vi , cl crs l ru rth c rr..r., a " p .,' A i r' i f'' r< l l i l ti ()l l al ,strl tcof l tl crrl- or .i rh.l . bv pul l l rc' agcnci cs i ,r.,p 1 " ,r.r.,-l,..1 ( l 9t)0: 107). F' trropcetl " n .l b ,v tl rc p ri rrrttcs ccror. A cc,rr.l i ' tg t() l l e i rrhrl rcl t gl obel l ni l cr() l l ti l l tl l gel ncnt stratc!l i es sttcl t.rrs c OU trtri c stc n c lt< lerrrl thrrsi zc l l ' rti e i urr' i ts l vi th tl S A . the 5 .c l g e tst. c .rrr.l ,t.l .l i ltl. " " l rtt s' stctrs, w hrl c l l l i l l l ag,cl trcl l t l l l rl cf() o i c c n tra l i z c c l c o rrtrOl . l rrrg,el V rci cctsrcgtrl atorv Il .rvcvct' f' r hcrl l tl rcrrrc' ,;p ;;; i rs rc e c lr, fi .c-rtrre i i ' .' ,i ' ' ci eli rtccrrfi vcs t() l l l l Lr()-tl l ' l l l Jgc s()l l l c ttl ,rr.' s w ' i th c v c n ' i ' n l :u ro 1 -rct hi s i s chrul gi rrg rrs p c c tso f rl l c c l i calcrtre. pri rttl tri l ,v ()l l stri rtc!l l cs l )c ru rr.c l -s i c l c c()st contrri rrrncnt rcl i cs rl * i rt!l P rl trtrtt e()l l scl otl sIe i rte l l v rl c s i g n c c t< l l rec l ucc c()l tsU l Icf rl crl l l l trcl thi s i s-l rcctl rrrl l l i shccll l 1' | .)strel l ,v tl e s s tl f th c c tl s ts .l i ;,r..,vi .l i ,rgcl rre. rtscrs< l f hctl l th cerc' ci thcr rc c l u i ri trgs o ttl c fortl ' l ,,f .," t shrrri rl gb1' thc oi scrvi cc(e' g' $i ' 5t)per hosl ' ri th ro rrg h u s c r c h rrrgcsas rr i l rrt rrtfc pcr trtri t sottre prescri l -rti otr), ta l n i g i .,t,l i 2 0 p cr cl ocror vi si t, l i 20 P cr l ]' 1)1' l l t-:111] l ccl l t ()t l l l ' rrtl cl l t c()sts,.]0 .f th c lc .s t (c .g . 20 pc. eul rt ,i .ttt[rrttttttt rl rc tl orl l l rtl l v ()trt-oi -pockct.c()sts ' cr c ()s ts ),()r s ()l tl cconrl ti treti Ontl f thcsc. s()el ()f cl i scottrrl gttl !ltl scf a p p l i c c l a t th c ti rtre of rrsc rvi th thc cxl l l i ci t tl rl phv-si ci atl sto rctl ttce l ,l ty crtc' nsi on, rtcti tl g i rr.l i rcctl y c l c n trrrrcrrrrc l sS rrrc i l l thc crl st. s c rv i c c s < l ' th c k,t,rw l c.l g.: thet i hc prrti crrt.ttrst (c' i l ' thc i i rst cxccsscs or A ' .t6 c r e p p r.a c h i s t,r r:.' .1.i recl ccl trcti bl es thcrcl l v el l cgccl l l ' l l l tl st prl -v, 1 11 0 0 p c r c o n c l itrrl n) w hi ch the cottsttl rl cr tl . rrrg i rtgc l crl trrtl c li s c < l tt rl cr()sscoLl l l ' l ' h c k rrr.' i .f cl c' rl rrcl -si cl cstrrttcgi csvrrri cssi g,rl i fi ci l rl tl -v l tll rtl l rl rc thc l l l ()stc()l 1l l 1l < fi tri c s . l n (i c rn re r rl :,f< l r i nstl rncc,co pl ' t\/l l l cl l ts tracl i ti tl rl .parti ctrl arl t'i rl rcl e1,.)t.t13 et u,r.l .,-lrrncl 0 i o rrt o f-1 -l < tc l <1-," ,, hrrve' ,., ctl ttsi tl the' l .re' ci rtcrcrrsctl ver. ti < ' r f' c l ru g s .S i ' ' .. t6. l ' ,.r1' 1990s,htl w e herl th orl crpctl cl i tLrrc totrtl oi c rrrb l va n c li rr 2 () 0) reprcsentctl l 2 per c' t' rtt copfess.l -cs. cost i rrererrs' rs .,.,.. i l ]| .,rr" a ' tl l {i cs5cr.g.2()04:7.1). w i .rh i tl prrttcrl t for chrrrgcs e rrtl tl ctl .i l l el trcl i rrg, i rr o ther rrrcrrs' l trrVbcert i .,,.,y ,,," ,rr, tri l l l sp()l ' trl tl ()l l' rchal )l l i tati l c ci l rc f.l ci l i ti es' ,rtttbttl rrttcc c l a v si n h O S l -ri t l l s, rl l l oi ratc rl t thc co-pavrtl e rrn c cl l c n ta ltrc l rt l l tcnt.l n 20().l ,.f.rprl rlttl crerrsccl l ' .' tpl .,' -ccs' Fl cal thl tl sttri l ttcci rtl rl l 20 ttr r.surcd l ' ,ytl ' .i c rrrcf.r p r.rti c l r ts t6e N rrti .rl rrl H cal th l trstrrrrtrcc .i g p c r c e ' r ro p r.l ri t i l t l i ri c w i th thet .f F ottrl cl l ti on' 200' i a )' ( Bc rtc l s r.n a n rl l tl c ()n trl ts t,r rrtl rcN etl l erl l rrl cl s< l r' rt-< l i -tr.l tl cketpl l yl l l (]l l tsl -revctra cli_ l-rilve role atlcl ollly co-prl,vllle'lltsftlr glasscs tionttlly pla-vcci ",r'r,*gir.r"l
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The politics of co-payments
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it . pr r c t or 1a c c e " ' ' ; ttrrr.l s t lc ic t y . W lri l c tt-,..1 -,,.,1 .,1 .' .rs tl i i rrc tl tti tr,tl ..,' ri sel l rlr'rtl thctieto c.el P il vcl \' orrtrl l c i t" rlth.sc t' r tt ' i tt p rt' v i c l i rr* ' " ti " i i i tt 1' ' y ' " fttv r c c lt t c c c l it y pr ov ic lilr g t* tt." p ti t" rs to th c tt' -p " u n ' t' ." ' (" ' g' N ttt1-crrl rrrttl ' spol i cv
;1-:ll:illli;:f]l'I:llijlliil'li:fi:l .,""'in""a ('r)s), thi,.,'t"it]'" <,n higlr r''" lll,lll:ll;,il:*i:,:'il:;;|,:':iljil:"i'Jii;..";;'i""'' (1992: l ' 3c))' ''lr'lr.rri'cr t:t1 tt;;i -l l tt" ti i fi ti t' ' .tt' r , r s er swill ) t" " t' r-tt' .t S Lr pply-s i c l c c tl s tc < l rl t.ri rl l l l c l l tl l l cn"ltt''t lstl rcsl rregcl rcrlthe rl l ylir'p.siti.rl l l ()rcctfccttr,c crlttlil thtf .'r1'rccirrlly ,.,-,,i,',r'u,1.'.r, rhrrrrclcr'rrrrcl-sicle is c lir c c t , c c l l tfl l l c tl l l tr< l l s ()l l P l ry l l l c l l ts ttltll rrtl vi cl crs.l c()ltrcl ]1l 1l C l l tltherc l l l ]()11 ctltlrrcl cs.that fti r i rrs trrrrt"' .' Jtl l .,t' l ) tt" tt' ' tti ts ' catl l' . r tr< 1 1 -l " tt' scvcn thl rt w l rs l rcl -ri cvccl rc th rl t ' l rl y c ()s t-c () l l tl ri tl l l rcl l t of s trg g c s ti o rr ll' s t r ollg rrs thc i ntr< rcl ucti on sypply " ' tt.' a i tttt ' i ti t t l' r r ot r gl- r " t' i t" t' l " t' ' ftt cll -. ()al-'.,tli'trt thc LJSA'rrlostc()tllltrlcs tnll-rosttlg oi itrsttrets rrrrd/or by hrrntls thc su1-rplysiclc by tln'thc' cepacitics.f "'t"*ift""irrg ()11pilylllt'llt"t' ntlt'"itit" "nA clircct,celltrrll c'rrtrtils cltrrirrgthe 1980s' Irrrrtrcc +'Zf ' For itrstr'tt'tcc' thcir hcrrlth 'u"t"t"i;tt'i"i-,ft
and the Netherlanclsintroclucedsystenrsof global buclgetingto rcpl:lcetl.rc daily rates paicl to hostr'ritals, thus joining thc LJI( rrnclNew Zcttlancllvhich a l re a d y hacl rl recl -rrrni sl ns for crrppi ug hospi tal cxpencl i tures(l Ju r st ir ncl P o u l l i c q 1993: .5). S i rri l arl y, i n 200-5 S i ng:rporei mpl erl enrecl a global b r,rd g ctpol i cy for publ i c scctor hospi tal s rrncl herrl th crrrc i nstir ur ious (B e rtc l s marrn Founcl rti ol r,200.5a).l )ubl i cheal thsectorI.rospi falarr s dhcalt h c a re i n sti tuti ons,i ncl uci i ngpol ycl i ni csw l ri ch provi cl epri rl arl , l rerr lr hcr r r , : , rtrc given a firecl buclgctrcglrrclless of thc nunrbcr of prrticntsthcy trcirt. Ac l c li ti ottali nstrunrcnts of rcgul l rt()l ' yc()sr cOntrri | i l rre rrt ru' c fce t ut cl p fi c e c o rttrol s,control < l vcrcrrpl rci tyof thc svstcl r i rnclcontrol over wallcs rrttcsl rrl ari cs.l abl c 4..1i l l usrrrrtcsthc' uvi cl crrrrrryoi 1' l ossi bl csh< l rtf o longtc rn r s u 1-rpl y-si cl c J' hc rnost cl i rcctsuppl l ' si cl est r r t t cgy control s rrvrri l rt[rl c. i s t< l ti g h tcn c()ntr()l s< l vcrrci nrburscnrcl rtor crrforccpaynrcl )tsclr cclr r lcs. T h i s i s easi cstto l cconrpl i sh i n an i ntcsratcclsystenrl l ,hcre thc sovcr r r l n e n t h as thc crtprrci tlto , sct g,l < l balbrrrl gcts.S r,vccl or rrnclfhc Il l ( ar c cless i c a lc x r rtnl -rl cs of i ntcgrrrtcclhcal th s)' stcl nsrvhcrc sovcnrnrcl rtsct sglobal b u c l g c ts,i n thc f< l rntcrcrl scrl t thc rcgi < l nrll cvcl . In l i ri tai n, thc total cxpclt d i tu rc o f tl -rcN IIS i s sct l l y thc' l ' r-errstrrv ancl i s prrrt ()f fhc governr r cnt 's th rc c -y cerl ygcncrel spcncl i nurcvi cw . ()ncc thc overrrl l spcncl i rrgh as bcen s c t, th c I )cprrrtnrcntof IIcal th cl ctcrnri ncsthc fLrncl rrl s l ocrrtccl to l )r inr ar v (l a rc ' fru sts. l n c()ntrrrsr,hospi ral sarc ftrncl cclthrousl r c()l rtri rcts.( , ( ) st v < l l tttttcc()l rtrl tctsare prccl < l rtti rtartt rrncl i ncrcasi ngl y i ncl ucl c nr t r i( ) lr r ll (i roLrps(l }rreeotr,2(X )4:1 77) .As trrri ffsfor spcci fi cI Icel th (i :rrc I{ csorrr-cc
Trrbfc 4.3
'l'he range of supply-sidccontrols
Short-tcrn-rcontrols []Lrcl g,ct cci l i ngsfor hospi tal s (l orrtrol sorr steff ntrnrbcrsi n hosl .ri trrlor s cl i ni cs ()l rtrol s on l cvcl sof rcnrrrncrrrti < l rr ( .,r tttrol s
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ScttirtgPrkfitics tuul Allttcating Rcsrttrrctts l0-5 r,r' i thotrtccl l tral i zccl c ( ) nt r ( ) lov c r ntc c l i c rrls p c n c l i n gc rrn b c rrc c orttpl i shccl col g , le[ al [ uc lgc t in g . A l tl ro u g h c l i rc c tp ri c c e n clrl trartti tv l trol s rl rrrybc l css o r c l i rc c tc i l p s, thcv can bc appl i cabl eto al l . lt f " . t iu. t lian g i o tte l [rtrc l g c ts s, thi ts arc p()tcl l s es lr c llt s 6f hcrrl th c rrrc ,i n c l rrc l i n gp h rtrn trtccr.rti crrlertci t i; t llr r t l. r ' t 't . t t tP rt l tt' tl ti v t" [ . r r c l< ingt hc c -c n trrrl i z c crcl g ,u l ,rto rVe 0 rttrol oV er hcrl l th crtrc fotrrl d i rt \ \ '\ r ( 'l l l l l l ir lpl. r r t r . lt r ' t l . l l) t r ) \ p L \ t i r t 'p . t i t t t t 't t l . onr t ' o l . t h t '\ l c 't l i c i l r c p r ( ) s r i lllllllc. th crlicl l9u 0sr1t hc < lr r c r r r c r r it c oul. l e ( ) l r s t rrllll c()\t\ t ( ) (.hept c r . 3 $e|t ' r n t t '0 t l t t . c t l ( 1t . 7f i ) , I ) l{ ( is As no fccl in t l i , t g , r l o s t i c e r r r el i t t l r t t 1 . . 'r '
ptltt.r.r.6 rrrrtrit, r , t lt t . t l\ . \
t.ri,lt,rr..t'.lrorvt ' r t . r ; t lr lr t r lr is : lI Pr ' ( ) . t ell . ll( ) t l( '( . t l l l l ( ) [ \ '( ) t ] \ l t . l i t l . 'r 'l r i t t l l t t ' 't 't 'r o l r i l t g c l o o r ' I.ng run cvcrr f < lr N, lc r lic er c r r nr l t hlf it h: r s r t 's t r l t c c l i r l r r tIr-9 ug h r,r,h ic h pr t t ic nt s ar c s ir nplv r c er lnr it f c t l f t l r , r t l c r t ' l ) l {( ' n h t 'r l t l l t ' rrrcvi
106
OomparatiucHetrlth Pctlicl'
9 f H e a l th i f arry acl dccif:tci l i tf i s to bc rei nrburscclthrotrgh soci al hca lt h i rrs u ra n c e(M:rarsc, | 997). T h ro u g h 1;ut thc l ' 190s, S w ccl el r si l w r.tsl tbstrrnti rrldccl i nc i rr t he l u .l m b e ro f h ospi taI bccl sthrrt w rl s more cl rrtsti cthrrrt i rr othcr ctl tttrrr ics (l rr-rro p e a O u bservat11ry 9n H cal th (l erc S ystcl rl s,200l :49\. A t thc srr t r lc ' l ' ht' l 9c) . 5 ti n rc , th c 1 'rosi ti 6n9f rrtrtl tul rrtor),ci l rc w r.l sstrcl l gthcrrecl . pri rl l rrrycrl rc rl s l l scprrrrl tcl ci ' cl tl f c, r r c l )ri rn l tr,v(.a r e A ct rtcl < rt< l w l ccl gccl a n c l d e fi n e cl i t as thc b:rsi sof hcal th care.' fhi s i s si gni fi crrrl t,bccrt t t sc eotrntrrcspri nl i try C l trci n S w ccl crlhl ts fracli c ()l tp a re c lt( ) ()fher [:ur91.r.111 ti o n rrl l y b c e rtl csscl cvcl opccl . As i n o thcr coutttri cs, at l crtstat a rhcf()ri crrll cvcl , therc hrts bect l r t l l ttl rl tol -vcer c . l n o v c l l c l tt a w rrv frortr hosl -ri trrl si n thc Ll l (. Irtsrcrrclrrtrl cost-cffcctl vccr lr c ancl both tai l orecl < l f pr< l nri sc s c tti trg ss c c n tt() h< l l clthc i rt thc c()l l t cxt rcl cverrt parti crrl rrrl y rtrc (S rrl trn a rr d L tl ..2()06\.[]oth 1' roi nts r't t lcl ttttt.ttct rctttei tts oi tcrt < l f th c IJ ri ti sh N H S l vhcrc t)rtti cnt cl crnrrrrr-l eri st ir lg i rt rttel < i rrg w Ic rc s q c c cssi vcg,()vcnrl rcntshrrvc bccrt i rrtcrcsrccl i tl the vi si otl < l i e' pri l l l er.v crtr-c- lccl' fu n c l sg < tfu r tl rcr. J' hrs ts c1' l i torl l i z.ccl pl rtl crs, rtot ()tl l v i rl thc pr' , r vih c e l th s c rv i cew hcrc (i l )s havc bcconrcl < c-v s i o n , l ' rttf rt l so i rr thc < l rgrtrri zrtti orlof hcel rh scrvi ces. l rol l ow i rrg thc p trrc h rrs c r-pr< l vi cl crspl i ti nthccarl v1990s,(i l )sw crcgi vcrl thco1' rti ot loi [c c g n ri n g ,' f l ncl hol cl o' s' rrnclrccci vi nl ]fttttcl sto prtrchescrl rrl l l sc of cl ir llln o s ti c a rtc l cl ccti vc l trocccl ttrcs.-l ' he hc.rl th rcfortl l s ttttcl cr thc Ncr 'r ' l .a l r< rtrr!i ()vcnl l ncnf rn l L)L)7brri l t rl n thcsc cl cvcl t)ptl l cl l tsrl rl cl(i l ) pr ec(l rrrc' l ' r' trsfs'A. s pert of thcsc trttsts,(il) s ' l )ri rrtrtr,v ti c e sl tc c rtrl c so-crrl l ccl of rrl l hcal th crtrescrvi ccsi l l thcir rtrc rc s l -l < l rrsi bli rlc r thc c< l nrrl i ssi orri ng, rrrc rrsw l ri l c r cnrai ni ns rcsponsi bl cfor thc provi si ott of arttl l ttl atoryhea lt h c ttrc s erv l c cs. A fi rra l suppl V -si cl cstrrl tcl l y t() c()st c()r1t1ti l l l 1)cli sl t thc cl -c.l ti ()t l( ) i c ()n rp c ti ti v cnrrrrl < ctconcl i ti onstrncl crrvhi ch thc ttt()rccffi ci crl t prtl vi cler s ()t t c th l i v c e n c lthc rcl rtti vcl \/n)()rcc()stl y()rrcserc cl ri vcrt()ttt()f cri stctl cc. fLl l l cti( ) lls provi si ol l rncl i trncl i ng s l c h :r1 ' l p ro l rchcntrri l s scprrrrrti ngthe l rl t hc provi cl crs. tl p c()l l l pcti ti < l tlrrtrl otl g Itttc lfh tts , i t i s essutttccl<, l pcrti rtg, L J I( i n tc rn rtl rl rrrl < ct. i rrtrocl ucccli n thc carl v l c)90s. ftl r i rl stance.s clf g < l v c rn i n sl tul tl i c l rospi t,rl s,ttl sethcr w i th pri v.rtc-scctorIl ospi trrl s,wcr c c n v i s e g c c lrrs c()nrpcti ng f,,r' e()ntr.l i t\ w i tl r thc hcal th rrutl l ori ri cs t hr lt sttrrol tl ttlit lg fg p c l c csl c c tl rr{ rrryherrl th.l Jccausc< l i thc hcetcclctl trtr< tvcrsv i s i tttptl rtl l tl t to l ool
The government and the marketplace ()l l tl trcncl < l vcrt he i ber:tl i sl t), s F u c l l e c lb v idcol ogi cal shi fts to' uvrtrclrreo-l is thc inclusion of lllllrkct or rlcr()ssWcstcrn clcr.r.rocrrrcics last few clecaclcs
Scttine Prktritics and Allrtcoting llcsttttrccs
107
cl u r r s i- nr ar l< cr nc t c h a l ri s m si n p u b l i c h c a l tl r s,vstel rsi tl tl rcl cr ttl provi cl c i rr c elt t iv c st o inr p ro v c c ffi c i c rl c y(R :rn l c l e , l 9 9tt). A ccorcl i rrgto nc< l -l i bers cc to r tl ro n o ;l o l i c s p ro v i c l e fc u' i trcctl ti vcsfor systcl n effi rrlis r r r public , ci enc y enc l in f r t c t e rc l i l < c l yto c o n trri np e rv e r sci trcetl ti vcsw hi ch i n cffcct p , , , , iih c f iic ic nc y (s c e Il c y w o o c l , 2 0 0 2 ). l )c spi tc thi s peratl i grn shi ft, i .. ' . , r " . u" qc v ic lc n c cs u !l !l c s tsth rrt rt to trl l v i rc c ttterkcr i rl hcrl l th i tl sttrrrtl cc cr r r rpr oc luc c r t c i tl .rc rc c l tri tyrr< l rc ffi c i c rrc \' .F.vcrri rr thc LIS A , cl crtrl y thc , c g o Vc rttttl cl l tcxcrts ctl rl si tl crl l l l l crcgtr rtr( ) s tr Dt t r k c t - < l ri e n tcscvl s tc l l 1th l rr t r lr y ilf lt r c r r c c o y c r th e w o rl < i rrg so i th c l l l i l rl i ct thotrgh, tl cspi te thi s c i fo rt i rl c()l l trol l i l l !lc()sts. cfior t . it r c nt r r ittstl ' rel c rrs ts ttc c c s s fttl ( ic nc r : r lly ,g( ) v c n l n c l tts c l rn t,rl < co n c o f trv o tl trl i tl l ' ()Ll tc\i rr l egtrl rrti rl g h c alt h c lt r c s v s tc l tts , rrl tl ro trg h e s S rrl tttl rln (2002) stl l l gests tht tw tr rtppr ( ) ac hc sof ic rt c x i s t s i c l cl l l ' s i c l c .' T h e fi rst rrpproechi nv< l l vcsrcgtrl rl ol l thc l l ()11ti < 11i6 t hc lt r lr e t c ()l tv u n ti ()n rtls e rts co f s e tti rl g c< l trstrl ti l rts of ecti vi tY i s tyP c n r r blic s c c t ( ) r . ' l ' h i s c l c ta i l c c lc o rr.u rrrrrtc l -r rttcl -c< l ntr< l l i rrsri tLrforccs rtttcl g c pc r elly c lc s ig ,rrcto c l s rrp p l a rrta n c l o v c rri c l c tttrtrl < ct ptl ti 6r r s .T his c r r r rl rc c ffc c tc c lb y s p e c i i ,v i n sc ()vcrrtscof i tl sttrettcc l i ci cs, .r dp rc rl i u n l s , c ()n tr ()l l i rtgrhc (l tl rl l l ti t)' errtlcl trl tl rc gr r lat ilg pr c nrl )c rs h i lrrn i tr l of pr ic c s , t ttl rttc l rtti tl lsi c t fc c s trtl c ttl rc s rrrrclschccl ul cs,fi ri ng w :rge c ont ro l l i rtg l tl a rtrti rtgc e p rtc i ty . I;or crrrl l tpl c, rtl thotrgh thc .,- r t . r , ",'.1 tl ver .5,000 i rl tl cpcrrcl crl t .fa pr y r c s chc alt h s y s tc n t i s l e rg c l v n o n -p ttb li c, by arc hi g,hl l ' rcgtrl ' ttccl p rtl v i tl crs i ,' r , ' . , , ' , . " lt llt r t srtn c lth c l a rg c l ,vp ri v rl tc bi l l i rrg cerl trel i zccl strtl ctrl rcr th c rrn i v c rs rrli c c th c g< ' pr lv t yct trtrct tr tt tr,c l tth r< l rrs h bi l l i rl g' of crtrrt s te ttd e fc lc ()-p rrv l l l c l l tse, rrc lp r ohi bi ti ol l ertcl ' f lt c s c c 6lc l rtp p r< l :rc l t, g ,c ttc re l l vtc rtl tc c l pro tl l :rrl < ct()r pr()-c()l l l l )(' ti tiv e. plr r c c sur o rc c rn p h rrs i so n tl rc p ro tn o ti < l rtof scl i -rcgtrl rl ti orll l y thc lr t ' : r l t l r
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rsr()u l l h thc tl pcrrl ti orrof tracl i ti orrrrl r' rn ccl o r.rs r.rn rcth i ps y r c r s , p11; v i c i e rs g o v c rtrl l l c l l t' srtl l c i s t< l l l rovi cl c I l l rrl etl cc T h c rrt er l< c t plr c cpri rtc i p l c s . i t e s rv o ttl ,-li rt othcr,trcrl s < l f thc cc< l tri u n( ) ns t hc v t r r i < l ttss trrk c h o l c l e rs , c h c rtl th crl re sY stcl l li s, i rl ci fect, rr 91t \ ' . Lit t c leri1 p tl rc tl l :rrl < c ttt' to c l c lth ()p c rl rtce cc< trcl i rlto g thc pri nci pl estl l l a r gc I us iles s t h rrt, i f l c ft rrl o n ct() , i l l b e s t s c rv c th e c () l l stl l tl crptrbl i c. For reasot' l s s r r ppl- vr r nc lc lcrrra n c lrv evctl i n the , .liic Lr s s ed|c l91 v , 1 o s v s tc l r e rn [ro c l i c sth c p trre tl r< l cl clrttrcl t rl s r1r(]sLl l()i c()l l strrl i l l ts s c l' ere i l tc c h < l s p i ta l s , e s p e c i rrl l v IJ S A , ; lr < t v idc rs , t' bscrve rs l l rgttc rl l l l l t: l l t' S otl l c g ()v e l l l ti o l l l l l s te tc a l l (l lr l c e l , Ic gulat ion l' r r " rhr t r t hc r r ajor Il S p ro b l e n r i s o v c rre g u l rrti ottatrcl c< l t.l tctl tlthet i i the e c rc l c ft to ()p c r l l tCorl i ts orvtt, heal th crl re e( ) llpc t it iv e r t r a rl < c tp l rrcw .l i lcrnmrrsr'l,ottlcl clissi;ratc ( (ial i farlo, 19 92\. l- he r c as on w l t,v i r p u re l l rrrk c t rrp p rtx rchcrl l l l rot w ork i s that l -real th ts e o f th c s e l f-s c l c c ti n gm e cl rani srnsthat w ork to chcck c r r r cc < t t ' t t r ' t itlt()n hcal th care n t er k c t ex c es s c s .Irt g rc l e r fo r a rl e ffi c i c n t , mrrrl < ct-l l r' tscc1 a src e s s enti al .Fi rst, al l cl cci si tl rl smust :\ ' S t ef itt 9 lv < t r k ,s e v e ra lc o r.rc l i ti < l rl Ire tlrat of the cottstllner. Seconcl,cotlstllrers nrttst knor'v tl.revaluc and
108
ComParatiueHealth P t,l i cy
Thi rcl ' collsLllr er s c o s ts of thc goods tl -reyare contempl ati ng purchasi ng' the y cho
109 S c tti n gP ri rv i ti c s d n d A l l ocati ng R cscturces
Box 4.2
What is moral hazard?
yout ft':"d:,1,t-i You haveiust finisheda rnealwith a groupof five of oI l c) l t a prl celTr:) of desserts c a r t e w i th h y r es t t ur ant an , d th c w a i te r ro l l s ncltchink you do and full are you t'ecause order to each.You irrehesitant Then in a flrrshof brilcan set {5's worth of fi."tutt from thc dcssert' six wavs' meaningthe bill the vnl-'are splitting il#,'t;;.;;;;;;,'t,, to get a will yrrtt Surely {1' oniy be cost of the dessertto you wilt i: thlt U nt()rttrnatel y' t' r..l cr' etrd e h e a(-1, g ' t y o u $ o p l c ,r,u rc l ; ; ; " J ' ; ; ; t il' .,f t.
hcrrl th crl rc ttrerketpl rrce' in < lr c lc rt o s hr rp cth e c l i v c rs cc l c n rrl l rc losf t hc tl tt' tttrt t' kt' t.,tl t' tl t' tti t i rl ttl l ti ci t' rttttt w lr il, . t lr ir , . l, r t .sl l ()1i l (' i l i l tr' :rr,,l t' l i rr urrrj or ohj ccti vc rrf ntoves A c lc el wit h t hc p c c u l i e i i ti c s o f h e rtl th c i rrc . i s to ctrrl l thi s tl orrrl towr r r c lsnr r t nr tg c ccl rtrc i rr th c tJ SA e n c l c l scw l .rere rl l tl l Ll sc t thc pl rrtr' scxpel l sc' haz r r r cb1, l lir t r i ti n gs, c rv i c c sth rt th c i trs u rc cci the ( ) t hc r r r r c c hr rrri s rlcrs l c s i g n c ct< l l rc i tr tl r tl r< l rr rlhrl zrrrclrrc c()-P rl vl l rcl l ts, in f< l trtl cl rrs r' tcc()tl l l ts t ] lc c lic al- r r c c e s s rtytc s t, rtn c l trl c c l i c rl l s rrvi rrgs Sir r ga; r < lr. e ' ac lc lit i< l n betw ectr to tl rc i ' ts v l l l l l l e try o f k rl tl wl ccl ge rrrl clP ()w cr ln 6crrl th crl rc i rral ti l rtv rhc pr r t ie' t s r t ' 6 l .rc rtl th ." ." p r,,f.i s i ' ' rrl s , 'f tl crrrl se ancl .the rccci ve thcv , s th c v rrl u co i th c s c rv i c e c ( ) lls ult lc f st < l i trc l g ,c sprerrcl i ng ri sk cfi i ci crrcy, f it ilur c < lf lr r r k e tp l rrc c l tc c h r' rl i s rl rst() p r< l tl trcc A l th< l trgh h i ghl r' P r< l bl crtrrrti c' t hr O r r gl- ins r r r rrrn c ei s c ' s rc ,rti a lb u t e l s o P ri vrrtc th rrrl c l c l l ttrcl crlof prr,vtl l ctrt. r-i s k th e s ;rrc rtc l c rrl l pr iv r r t c ins ur lrn c c the prcnl i ttnl s Of' rrri sc l crl st rrt o r c x c l ttc l e , t< l rrrc c r.rti v c ir . r s ur c r shr r v errrr ' fv p i c a l l ,v ' . p ti .u l tr" hcal th i trsttrrl tl cc rs trost high- r is k inc l i v i c lL ra l s . w hi l c nrost herrl th crl rc i s c c < lt r t lnt ic r t lt tl p c o p l c * l tt, " " h e a l th , v c < l b trri nrrff.rcl rrl l l cpri vatc i nsttrance' c . r s . ' r c c l 6y s i c k p ,.],rp l "r.r.ra 5 l t. pri rl ci pl es thtrs i s l l ot possi bl c I t r c ilr - t . trcc c lis tri b u ti 0 n l t,ts c c l< l tl t]1 rtrl < e t ancl , uv it houtilr t c r v e u tr()l .r th rrt n e g rl te sth < l s cvcrv pri nci pl cs < l f suppl y i s necdec] t' ncchrtrl i sl rl c lent ir nc l.lir sOrn ee " t.,.,t, tt-].tt," s tl c i a l i tr sttrrl t.tcc t-o r c s olv et his p r< l b l c n l . sector.how cver.A s notecl f h. _r . ar c w a ,v so f c o n tro l l i n g th e n o n -p ubl i c i s domi rl rrtcclby the pri vrrtc ear lieq llt hot r g h .fa p a n ' s h e a l tl l c a rc s v s tel l l for pati e.rrts,al l -scctorsi l re ir . r s ur ar c cs cc to r rru d p r< l v i c l c rsc ()m p e t e W hi l c fec schccl r' rl e' r c gr - rl a te cth l tt" ' g h a c e n trrl l i z e clnati onal ;;rt l rrrgc i n crrre, heal th avai l abl c t< l r _r r . r iv c r scirove l ra g e g L l e ra n tc e s:l c c e s s
1 10
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e rsbeen successfuli u rcstrai t' ti ttgt ot al p a rt th c uui form fce schecl r-rlhr' h e a l th c rrr ccxpcncl i turcsancll .rasrr cri ti cal rol e i n sctti ng al l ocati ort1- t r i, r r i ti c s . It s c rvcsas rrn al l ocrrti onrnechani srtrl ry provi cl i rrgrr fi l ranci rrli n ccnti v c s tru c turc for thc pri l vi si rl n of scl ecteclscrvi ccs(i .c. pri rtrarv care) [ r . v s e tti n g th c fcc rrl l orvcclhi ghcr tl -rrrnthe actul l costs. l tr c()l ttrl l st,l t cr lll l ty' sctti rrgrhc allor vutrrvcl c< l trrc cl ccnrccl c l i s c o u ra gernecl i calrrppl i crrti < l ns (r9 l ) thc schccl(l c)L)2: For Ikcgrrrni c6sts. fc c s l 1l w cr rtcturrl rrb l e thal thc ertcl thtrs shrt pit llS, servi ccs certrti tt ru l ci s rr' p < l rvcrfultool ' i or pronroti nu th c c l i s tri bLrti onoi hcrrl thci i rc rcs()Ll rccs. In rd c l i ti on to.Irrprrn. ()ther c()ul ]tri cs:tcti vcl ,vi tttcrvcttc i n pr ivr lt c h c a l th c ,rrc nr,rrkets n i th rl ctrri l crl rcgul ati orts of rhc cottttttr.ttt cl- r t t t cl c o l ttr()l tYpc. In tl re \etherl rrncl s, for i ttstrttl rc. P ri V r' ttui ttstl rcr s r t r c n trtn c l rrtccl to l .l l ovi tl e brtsi ei nsLrrrurcci tt sct l trcttti tttttsf< l r certrl i n high l tt c< l tl tr it . t ,it l ri s k i n c l i l ' i cl trel is.,' l roi u' c not cl rgrl rl ci or ptrbl i c i ttsttrrtttce. sttppl cttrcttt.l rvr()l c, t hcr c onl r' ,r pri vrtrc i nstrrrrncc tJ K, w hcrc th c 1' ,l ,rvs i rr the LI SA l vhi l c trr,trl < ct. rrrttce pri ," ' rrtt' i rtsrr i s l i ttl c rcgul ati < l rroi thc rtrttlof t er t corrtttsi rtg rc g trl a ti rl ni s w i rl csprcrrclbut l rtrgcl i rurcoorcl i ttrrtcrl . rrrc rp r()cl rrcti vc. c ()r.r A l th o rrgh rrreny trecl i ti otrel l y' prrbl i cl rcrrl th svsrcl l l sl trtvc ttrtcl cr g
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rrrth c r tl rrrn 1rr< l vi rl ers: tl ret i s, thc i nsrrrrrnccfunds ((i rcfi t' t tr1.,2002; rr[rotrthv al l orvi rrgcrtlplov I hi s rvesl ' troLrght 1997). l .i c v erc l i n krrnclN l rrr.l c, breeki rtg l vi rh thc tracl i t ion of ftrncl , thrrs c c s a frc e chgi cc 6i i nsurrrncc ()c c u p a ti on-beserlhcal tl r i nsurrrnce.l n (i crrrrrttt\' ,tl te i rtstrrartccf Lr t lcls c o n rp c tcf or erl pl or,' ccs()n the b,rsi s< l f thc contri buti ort rate. Ttl rtt it ig. r t c tl te g n e c t nalcl i stri !sti on of heal th ri sl < s,rt ri sk rtcl j trstrrrcll l lt cchrrl l i s lllhr ls
llc c r tc s trrl tl i s h e cs lo tl rrrti n th e o r.vrl t l cestcl i ffercrrccs i n col rtri buti orrri l tcs r ef lec t r h c c ffi c i e rrc yw rth w l ri c h i n srrrrrncctrrncl snrl rnl rgcthei r fi pi rrrccs. I r or ti c a l l y 'Atrs , trrtl i rrl rrtsta l < e nl rc rrsurcsto [rol stcrpri vatc i rrsurl rpcerrr light of th e s tc a c l yc l c c l i rrei rr rh e p ro p orti orr of thc popul rrti onl vi th i 6surr lt lc c f < l r p ri v a tc h o s p i ra l trc r' ttn rc l rtsi ncc thc l c)80s.l n orcl cr t< l i percesc t hc 1- lo p u l a ri < lcrr< l v c rrrs c< l f p ri v a tc hcel th i nsurrrncc(l rH I), rccl uccprcss t lr c ( ) l l p trb l i c h o s l ' ri trtlrv rti ti n e l ists rrncl scrvi ccs, encl srrl -r1' l
Affocation and rationing: the need to set priorities A s t r r r c s s u rcesn rc rg eto c rp rrn c l b a s i c carc coverrl gcto i ncl ucl eaccessto ir r t c ns iv cc ttra ti v e rc g i rn e s ,th c g o a l of r-rni versrrl covcrage i s threi rtel ed. T he f uuc l a n .re n tapl ro b l e n ' rfrrc i n g a l l cor-rntri cs,then, i s how to i l ccorxr r odat e t h e s ei rn p o rta n t, b u r o fte n c onfl i cti ng gorrl s.w cal e ( 199t3)l i kens t his c iile n rm ato w h a t l o g i c i i rrrsc a l l a rr i nconsi stcnttri acl :a col l ecti on 9f pr ol- losi ti o r.rsa, n v n v o o f w h i c l r a r c compatrbl e rvrth each othcr but
112
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w h i ch, w he n vi cr,vedtogethcr i rs a threesornc, frl rn' t a co r r t r aclict ion. ' Perhapsw c c:l l t havc < l ttl vrt contprchctrsi veserrvi cet> f Il i gh clur llit r ',llt r t n ot onc avai l abl cto al l . Or rrconrprchcnsi veservi ccfreel y' rrvailablct o all, ()r a hi gh cpral i tvservi cc i rcel l ' availablc t o all, b Lrt not of hi gh 11r-ral i t.v. r r chr t r acl b l l t l t()t contprehcnsi vc. ' .rrch< l fthcsethrcc possi bi l rti cscl cfir r es Itcrrl thcrtrc costs r t lt clor gr t lt itcri sti c l -rosi ti oni rr tl rc nrocl cnrcl cbrrtei rbottt 9()l { s r rti ()rr.l W crrl t,.| ). -rr se hrrveoptcclt() ensurctrrti vclsalc( ) vcr : lsc W hi l e l n()sr\\)i l cstclcor,rntri l tu t l i rl i t thc rense of hcal th carc scrvi ccs,thc Ll S r\ hrts r r svst ct lrt hat vccrrrc, l tut cl rc l r()t g uilr r llt t ceclt t t o ffers l ri gh-tcchnol ogr'corrrprchcnsi . rrl l . Thosc 11' hol r,rvel i rst-rate i nsurrtnccc()vcri l l j chavc rcr t clvit cccsst ( ) orrrof chtl i ce, lt t r t r t t t hc c h i gh cl ual i tv nrccl i ci ncui th eorrsi cl errtblfrcccl (.r' i ti cs ()t < l t rteti ol l ,rl hcr r lf h svst cllls s\' stcl l t. l rcrrl th i l thc c ( )st ecl Lri ri of tl trrrl iil'.choicc er r cl ottl v rtt tl rc eost rl r guc tl trl t l rcc rrvei l ebi l i n' corttcs ( sugscsts thrrt r' r , hilct hc t hir cl re pi cltcchnol ogi celcl i tfrrsi orr.W crrl c 1998) ()pti ()n- secri ti ci rrgs()nrcconrl )l ' cl rcnsi vcttess i tr orcl cr to ec hicvc r lt lcast rr c()rc rerrgcof hi gh cl trel i rl ,servi ccseverl ebl cto rrl l rves r t l. lossilt ilit v rvhcn cl rLrssrvcrc fcrv l ut(l rrci rtnrcrttssi nrpl c, thrtt i s tto It lt t g, crso. lt is s i ntpl v n()t p()ssi l )l ct() n)ccf thc ncccl sof el l ci ti zcrtsl vi tl tottt c
11 3 Scttinc I'ricritias and Allrtcoting llesctttrces o f tra d e ()ffsth e t c a n l l c fi l orc or l esstrl tnsparcnt' requir esc ons ic ie ra ti ()n l , i r o r u n frti r,b u t al w i rys controvcrsi al ' cent r aliz c dor c le c c n tr:rl i z c cfa through ol tr rrl l o!l ra t w c ' a rc ttn l l l .rl c ,rrl dtrn\vi l l i ng F inr r lly ,as s Lltttl tl tl cl ttettl l i rri tccl rrl l pcrs< l rrs cl .lt ionp< t lic iest o l l tc c t th c h c a l th c rrrctl e e c l s< l f 1 1 tth c i rrc l i v i cl tl all evcl rrre url avoi dabl e res our c c s rr r r t io n rr.tgc l e c i s i Orrs cl ri vcrrby the (l - r r nr r nar r c lB lan k , 2 0 0 7 ).T h e trb i i l tl i to trsl l rl trl rcof scrl rci ty tl ctl rl rtl cl of s i rrcl i thc thrrt (.h a p tc r i t c c rtrt i rl I rrl rrk c s l trc nc lsc lis c us s cci rr recl tri ri rrgthc tl .rtrs rcs()tl rccs' w i l l c rc c ec l th c rrrrri l rtb l e l < lu 1 -rs vic lualsl. r ncgr (.tl l l ccti r i rl rpossi l l l cfor i s i t cl i ' ' ). rrt f iO t r ingof t hc sc rc s ()U fc c s(s c cl i o r ' 1 ..1 rrl ccl i bcrl ci i ci rrl tv ,rs rl ' ' leel l clcl i l ri crrl l v (l ( ) c t ( ) r st o < lf f c rr tl l tc c h rl < l l < l g i c e l fc crrtr (2002)thcrc ) ,\s rro t crlbr l rl eel < ci r e r o r r ll pat ic rts (\rV c i n s tc i rr,2 (xl ). c rrrc rr rti orl i tl g,ttl .l tl o frri r hc:rl th h e a l th l tc r r < thc elt h r e i < trrtrrv i tl to u t t'e tl lr t t t r v t t lt ,r t r t l rt' :rl rl rLi l t' t'l ' i l Ii t' tti tt' tt tr' ' tIl ' i cl ctl tr,-' rttrtl cl lt():ttt t I { et ioning,r s g c n c rrrl l t,c l e fi rrcec sl th c tl c rri rl' ll< l t r r) he .rrrr eotrl tl hrs P t ,' i i t. rv < .,u l db c n c ti t i rrl rrr trf ia6lc pilt ic r t ' v h rl \\/l l :ttt' r' ct' tl rLrg' pr< l cctl trr-t' tl r trelt t lnc llt , lt ut n r< l s tOftc rri t i s t-rnc rl l c tts i v c $' l l crc si tttrrti ort thc i rl e l w a y s rc strl ts slt c c if ic f < lr r t rit trrk c s , rrrti < l rri rrg ( c l c rri c c() l l ) c()st gr< l tttl tl s' i i vt' l l thrtt i s trc rttrrrc n t nci i c i a l p( ) t c lt t ir lll! be i l rrpl crl l crl ri t' of l l ow to rr r t iO r r ir r is g r r c c c s s a rytl, tc c l u c s ti < l nb c c < l tl l cstl ttc l vi th< l rl t.c()l l l pl ' ()l l l i \i l l l l I I , , uv c l. wc ils s rrc i c g i ti rre c ,ve rttl i rtr' rrrti rrl i tv ol l the provi si tttl ()t i < l ctrsecl l l c r,, s t r c c es s l. ? t r r t hc rn t< 1 r.'i iJra r,r,,ra a r,,ra .e ppr < 11- r r iet c ' h c .rl tl rc .rrc ,rv h tl c l c i i rrc s i terrcl htl rvi si tcl cfi l rccl ?A rl tl w het
Box 4.3 Rationingis essentialin tax-fundedhealth systems by thc. Lll('s Nationill It has bccorle c()rnrnonplacc for tlccisions nrrldc ( N l ( 'E ) to bc.grccted with ( llinit "l F' r c c llc nc c In stitr"ttcio r Ilealt h "n. i l n s t i t u t c 's r c j e c t i r l n f best the nrake ttl rationing of iclealwith ,h. n...rri,u-'for sonre forrn big qLritc' one Not nrisunclerstanding? of lirnitcd funcls. A si,n1.,lecase b arrie rtore so lv ingr hi, t t "' ' ' n"' u' . t ic at ionpr obl c r n i s t h e G o v e r n m c n t 's choicc' By urging patrclrts unbending cornrlitrrlent to the mantra of patient (iovernmenr cffectively ignorcs the .r... rr.- hcirlth services, ;,;;;;r: the facttha tatax - llas ec ls y s t er nlneans s om c k i n c l t l f r i r t i o r r i n g i s e s s e n t i a l lTht I.an ctt,2006) .
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(.ritcrirt rrscd Nlcclicel lrcrlctit t() 1]rltiellt l \ l t 't l i t 'r l t 'i t l i t t t 1 l 'l t l (l l l Social class or lttctttrtlcrtp:rcifi Abilin fo prlv A l t i l i t r - t ( ) P i l v -f o r i t t s t t r r r t l c c ( i rotrp ttrctrlbcrsll i1.r F.ntployntcrtt l : n t i t l c t r r e rt \lcrttrs tcst rtttcltrcrltlllcllt l-itigrrtiorr to sllitt r-tcccss r o t i . t | , t l 'g . t t t i z : t ti t 't t t o I \ r r p p o t 't S l
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S t' tti rtgI' ri rti ti cs antl A l l ocdti ng l l csrturccs 1 l ' 5
Box 4.4
Medical triage
l hen nrany patientssirnulTria ge , m eaning. c hoic e' or ' s elc c t iO ll " i s t t s e c w pcrs.nncl cannot attend to o,r.lr,,rty rreecl'nredical:rttention ancl 'rcdical requires immcdiate contlition r,r,hosc all. The rrlc is to first trcat pcrsons state. others, seritltts lrorc il t() prggrcss will thcy without which rr-.' "fhis "tt",lti cot]dition is ntlt as rcri,rLls'rrtlclr'r'htt,trc strrlllc, arc dcferrccl' whose A second cleplrftlllcllts. srlrt of triagc is oftcn neccssarvin busv clllcl'!i(rllc,v s c r i o r 'l s l ,ivn j u r c c l n r a y sort of t r iagc is ir t t lic at c dir l c lis as t c r su h er e t h e l l r ( ) s t ltbsorb so tnttch u'otrlcl crrrc if their oi clcrrth risk bc lcft unticatccl cvctr trt l l c c o t l r p r o t t l i s c c l .A s \ \ o t t l d of t 'c s c r t c t hc . , r ' olk f hlr t ir t t c nt i( ) lt ti'tc l' c l 6c trcatcd if *'i l l t . r ir t i. nir r g, t r ir r gr r r c r ' s f hr r t s . t n t ''i l t i c r t t s '. t "p pli" a of r c s ot r r c c s , r , ,t l- , "' , ,r v or r lt l b c f t l t i l e e r l t l u o t l l t l t l i l 'e r t l c s o [ l r c c s tl.'|cu s c frtlttt t lt , r s . n. lt i( ' l1l\u ht ' r r t t t t lt l lr t ' t t tl i t t t t o tr "
c l r s t l i l 'r t r t e t l r t e c g r t l i r l g n tcchrttt is t t t s , r t r c c lic r r lr c s ( ) t lr Cc s llav c l r l l r " l v s l l c c r r c l c g r e c s g l - s t r [ r j u et i r i t i ' t() scts 6 t c r it c r ie t hr t t ir lhc r er lt ll' c 1ll r t e i r l v r l r y i l l g , g r ( ) t l llclccl irl rr llrtrttcttlrtr ln rrln t11s tr r ll ils t ar t c c s , r r lt i( ) llillll c r i t c r i r t r l r c t t i r e s , t 't t 'c e s vrtlyc c ( ) nt c x t t hr t t f c s t llt s ir l r lr l ill c c l t t i t r r l l l e . l i s t l 'i h t t t i t 't l be sccl < lr rs ( ) c iel r ls wc ll r ls s t r ic t ly r r lct l i c r t l c o l r s i c l e r : r t i o t r s ' ( ) l l - . l t i o l l i r l g i s 1 'r t 'L ', . '1 1 i1t l t 'v . 'r r .\ltlr,, r r qlr . r t . ( ) r r r lr ir r : r t i( ) rrrr l t lt t . s t 't r I r '\ ()ll prrrtictllrlr c r l l p h e s i s p l i l c c s v s t c l l l s c r lr c c()u rltrv r . iiii"r . ' . r , hc elt h hrlvc rltt crrsicr tilllc tlslllg to rrns. ( . oLr nt r ies r v it h r lr t t ior lr t l hc al t h s \ " s t e l l l s t h c i r c o t l t r o l
116
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involves exch-rdingcerti.tit-ltreatnlents ancl procedures frrlm thc list of of nledical re i rn l tursi rbl cscrvi ces.A n ol rvi or-rsl evcragei s the :rssessnl ent bel ow . Irr thc N etherl rrnds,for cxanrpl c, the cgver te c h n ol ogy cl i scussecl a g e o f soci al hcal th i nsurancc has cornc Ll nder scrl l ti n,vrtrrclhonlt t ct lcl erttalprtckr t gehas , hi l e rhe strrrrcl rrrcl p a th i c cl rugshrrvc becn excl uci cclw i rl w hi cl r covcr r ge w rry' thc expl i ci t H ow evcr, . b e e n c or-rsi cl erablrcc1r,rcccl y i t trrrl < cst.t nyexclt lbccrrtrsc rl orc cl i ffi cul t i s d c fi ned al s6 mrtkcsrrrti orri ng potenti rl l l ,vvcry cost ly ir l s i < tno f servi ccs hi ghl y vi si bl e ancl thcrcforc p o l i ti cal tcnrs. S u l tpl y-si tl crrrri oni ng i s trrrcl i ti onrrl l ,vpracti sccl l ty nati orl rll hcalt h s e rv i c c s:rnc1cl cpcncl sup()n sctfi rrg stri ct l i rrti ts < l rt rtl ecl i calfacilit ies, c c l u i p n tcnt ancl pcrsor.rucl .l trtti oni ng i rr both thc N cthcrl rrncls r r t lcl (i c rn rr l ry hrrsf< l cusccl tl re ttttnrber o f hosl'r isr.rchl rs rccl trci rrg on l r)crl surcs ri l tcs, rrrl clrcst r ict ir t g cotttri l tLl ti ol t rrttcl brrcl gcts ta l b c cl s,sctti ng scctorrrl s.vstcl l l thc s avei l a [ lillt y t lf Irt thcsc of ckrctors. th c i l c rcrrsc i rr thc rruntl tcr tt< l fccli rl O hapt cr rvi th, as rc s ()u rccsi rrcvi te$y effectscl i ni crrldcci si tl ns. (i P s pl tti crtts fr
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Resources 117 Scttirtg l'rictitics dnd Allctcttting s < l m efo rms cl rtl l l e ci rrri cclout onl y A r t ot her r ls p e c to f ra ti o n i n g i s th rl t -r earl y betw ecn fe i l to cl i sti rrgui slcl b y gov en- r r r . , .,, ^ .r,,r,.,' * h i l e " o th e rsAs o trc tl l ()vcs to the rl rore expl i ci t public ar . r dpr iv a te s c c to r c h o i c c s ' ' fa b l c 4 ' 4 ' i r tl l < l resystel netl cgoverntl f for t ns of r at it lu rttga t th c b o tto n r found i s n o s u rp risctl .rrrtthcsc t)' pcsarc l n c ut r olc is r c q ri rc d rrn c lth u s i t .s
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rclatccl(ltlcstl()l lr eglr r c lilr gt lr c g< lv er t lt r lc t lt r t llc i l l r l l t l ( ) l l l l l g c c l l t r c S ( ) l l lly rr t lt es c t lc c is i, t l s t l l a c i c 6 r 's , r 'c r t . t t t . t c t l t ' w6crc tl.rcy rrrc c ar r r ec l , r ui, "r " i r r t l i 'i c l trrrl 5.rtrtls' .r 6i t t git . "t el clcp 2rrtlllcnt ,,, n' t in' "", - i^' , hc r r l t h highlr c c r l t r l r l i z c c l t l r c l c c c t l t r l r l i z e c l , lr
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a -sl r n rcrrnst' ,f s" " t.l l l tf-(' rrr!lcverv t iat l. , nin1l r r l s o h e s b c c n p ro p o s c c l c rcl trcl i rrgfr.trt c,veri l ge trei l tc it iz . c r r l. . , , iii .l e v e l ,f h e a l i h .l ,rrc .,' ' .1 " trrr c]c-offhcrc i s l l ct\vcen tttri ret' l lt c llt s out s ic lct h l , p a c k " g " .' Ih c c rp l i c i t l ' rrrs i con thc < tnchrrtl clrrrl clttrtccl ttal s al lr c c c s st o t h < l s c t,.r-u i i " ..l c .,-r.,..1 otr-thc.othcr' l l r t' i t" ttt" i t" tty fc e si bl c sctvi ccs ilc c c s st o t hc tu tt ' " n g tl l c v c l < ti h c e l th c rrrc f.cttscs < l trpri tl rl try cr' rrcrrtl cl Ira .l c . r r lr y c ( ) ' r t r i. r , " rr s ol srl l l trri l rspl rrnts,fcrti l i ty high _ t..h ,.,,,i ,r1 ), r.ru i ..s s trc h c r c lr . r c lc s F l o w c v c r' w hcl rrbesi c ti ::,]:l ]t:l :{::t:l t r c r lt r r lc r r t rsr t rc l c o s trtc tisctrrg e rv ' t . , i, i|. lu. l. t r r lli l rl i tc c l l tc c c s Sttl i rl tc rl s i v c l rtl cl crpcrl si V cctl fl tl V (' ]rc!]l 11l rrs C | S ]l t c ,ru .r, tg.. l l cal tl t systcr]]sstrch r . r nc lc r . r ninct h s e g ,Orrlo f u n i v ers e l i rl provi cl i rl gtl l l l vcrs ttcccssftrl l rc l l l o rc llr it r r in, Nc w Zc rrl rrn clltn c l.l rrp rl lrl l ' w c r p cr crrpi trlc()ststhal l . tl ]:' -i d" ; s r r l c . v c r r lgc a ,,.1i " ' tta i " i a i t.,i " g of a s t hey l i rrri t thc evai l ebi l i ty oper t t lS s y stc rrl , b u t o n l y s o l o rl g high- t c c hr lolo g ,v n rc c l i c i r.tt' O" ttth c y trv toprovi cl cl cvcl soft' t' rccl i ci rl crrrc rrc l v rrn trtgc' ,' , in. t it " . t o t hc tl S A, th c y l o s c th i s ( ) t lc lr ppr t l a c h t()rl ti ()l l i rl g',tl rc ()rl tl cS i trrl crt,i l c cslttl ' tl c fi rrcl rscttl fftttl cl ttl gprl N c$' Zerl l rrrl clset trp thc l 9c)2' l rl l l c l to < lr lis t of c or c ," ' u ' t" f l r c()tnprc. 111] i tl rc th e tl l l j c c ti vc tl f i rl rl rl erl l ent-i ( , t lr e S c r v ic . , t,.,,-,-,,-' I..|w i ttc -[6c (,.r.r' ' i ttec rrrti .' h e .rl t6 sc.n' i ccs. l. r er . r s iv. .c, r " ," ru ,.i .; ;;;;r;* r, t. ftl r rts s c s stl l gi r scrvi cc: benefi t; vrrl rtc l tl r pr t lnt t r lgr lt c c fo l trr p ri rl c i p l e s pri < l rl r-rcl vl rl ttes tl rc ctl tl l tl rtttl i tv' s lll( ) llc , Vf;lr ir r l e s sl;l tl c lc < l t.ts i s tc rl c r' rv i th it ic s ( Nc \ v Z ea l l tn c l (,tl rc S c rv i c c s (,tl trrrl t i ttce.l gg2).A ftcrextctrstve o u l r ri tl l l l c of speci fi c trcl ' ttl l l cl l t p' blic c r lr r s u l trrti .n a l c l rc s c rrrc h s' cci fi c l i st .f ftrncl i rrg . .l n -l i rtccc,' c l trc l cclthrtt a r egir r c s .6. wc v c r, a t-.|i .,rn categori es w r.tstttl tctl rl l ' rl e trel rtnl cnt pr i0r it ic s \ v ith c x c l r,s i 0 rl < l f s p c c i fi c treatExcltrsi.ll ftrtlclecl' tllre:rc1,v 'f ,irrcl.1-rtccli.stcrrcl," ..lttrittr.'scrviccs cl uesrl ri sccl al so but erpl osi vc' r t t c llt c t lt ell( rri .r * " ' " t" t" -tl y p o l i ti c a l l y str-rcci fi c l l t' t-l ot.tg rl c c o tl l l t for vl rri ati ot-l t ions of f r t i rn e s s a n c l c l i c l n o t categ()rY' ;latients r,vithin a l )urrni rrf;'(l ommrttee report a p p ro a c h n u " i t' fft" tl i n th e l 99l A not hc r p n o r i ti es i n the soci al heal th i nsurr r c lv is ingt he D u tc h g o v e rn l rl e l l t.o rr Zeal i rnd' the (' ommi ttec ' 51 )' S i rri l a r to N ew r r nc c ( I - Llm.1 9 9 7 ;
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ComParatittc Hcdlth PctlicY
th tcchnole a corrprehcr]si vei rpprroachthat w oul cl i nch.rcl heal p r< 1 1 -rosecl provi si ot.to f cr lr c, ,,g y ' ,trr.rrtt,cl tt,the usc of gtri cl el i nesfor thc rrcl ecl tti rtc rvai ti r lglist s' th " icl enti fi cati 6n1;fcri teri a for pri ori ti zi rl g pati cnts on "' fh n .1 c a i rn w as to provi cl epol i ti ci rrnsw i th tool s to cl cci cl cotl a brrsi cher t lt l- l it r c i rre p a ckrtge.S trchcrpl i ci t pri ori t.Vsctti l l g Il ' rtscotrsi derccl tl ccet t r lr v ft lr ell' carc cssctl ti rtl t6 i l cecss rl rc l c r t6 c< l r.tti l uc S tt.l t' rrtl tcui l l l l r epor t ' si trccthc pLrl l l i crrti orl< l f the (.< l trtrl l i ttec's l l tte rc s t i l ti l l y,h< t." vcycr. 9f hcrl lt h t cchcost-cfi ccti vcrl css 6tt r.tsscssi tlrhc !l i l i ti rrri v cs l trrvef.;cLrsccl l l ennu'ccn < l tl choi ccs thl rl l n o l o g i c s (rtrtclcl cvel ol l i rl ggtri cl el i rl cs)rrrthcr A gei i l , thi s rci l ccrs profcssi orl elarl c l pt r blic s erv i c c s (l Iarrr. l L)c)71' t:.i 4). fc s ts ti l nccto thc rcl n()veloi ccrtei rrscrvi ccs,stl ch l rscol l trl rccpti vtjt ,t l'ot l. t p u b l i c furrtl i rrg. ' l ' h c S w ccl i shl )erl i errrcrrtrrrr l )ri ori ti es(.orrtttti ssi < l rlr'.vhi chrepor t cclill i rt i ts cross-pi l rtvl l l el l l [)crshi pl l trt els
ScttirtgI'rirritics and Alktc'rtins llastturcts
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The Oregon Health Plan (OHPf
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t() l c l i v i c l L ralr's vcrcsrl rvc-vc(lrl l l d i l sl < ecl s t ir t c s( ) i hc rtl th . ()ttc tl to L rs a rl ci n :l scrrl c frotl r hcel th. of ()f strl tcs th c sc r ls s ig, ltr t lil. i l n c ri c rrls c o rc t() c :tc h of thcsc crrch rttttl (p e ri cct hcel th)' , , f , . . ' r , , ( r r s g o o tl :l s (l c i r(l) to 1 0 0 s t at c s oi hc rtl th w rl s rl s s i g l l c cal rl o v c re l l .l l tl l l l cri cl l l r' vci ght' ' l Icsc QW I] tl l trs tIe pri tl rs c ( ) r c sr v er c u s c c lt() c .l l c .l rttc th c c tl s t-cfi ccti ycl l css,,trl cl (N " l cl l cl el sgrr t' t tl l ' . 199' i )' rt rl tl l l e l l t p.ri rs it y , r r t ll< ir r g .< l f th c c < trtc l i ti < ltrc T he r c s ult o f th i s p r()c c s s w i rs i l sefi (rs tl i ' l crrgtrc trrl l l cs' of orcl cr-of pri ol i tV ' c onc lit ior r - trc rl tl l tc n t 1 -,,ri nr,t,tl .c c l i rr cl csccrttl i rl g ()rc g < l rr procccl urcst() l )e thc l ' l arr, th e < l f LJ nc lert hc i u rp l c rtrc trtrrti < l n l l y thc rl tl r< l l ttl tl l trcl g,ctccl totrrl th c o rr iunc lc c lir r rr g i v c n v c e r c l c p c n rl l c' cl ' l t. trcrtl ttcl l t s1-rcci fi c t-v i rg s t r r t c lc g, is l e i u .., rh ,,r .* 1 -,l i .i tl n ' hc alt h c r tr c ftrttc l i rl g . l l ccr' tt' tsc l{ r t t ionin g l tv c rc l tts i < l tth rrsb e c rl c ri tici zcclrl s pri ce rrrti ()l l i l l g pri vrrte i n the scrvi ctl s tt t h< ls cpr r t ic p tsrv i th th c rrl l i l i ty t() p rl ,vc rrt l< l btr.tithc Other lr ar k r : t ( ) r cl s c w h c re w h i l e tl r< l s cl v h tl cl o tl tl t l l l tl st cl () w i th()Ll t' ()tre c()ncl i ti 6tli s rvhct' t i rl c ()tl s i stcrl ci cs' pr < llt lc r t t sir rc l trc l e' c o -l 1 1 o rl )i c l i ty l c o th c r ro t rrn c l' c l i a g r.sti c creep' w he rc d' cttl rs nl ani ptl inc lu. lc c lr r r rcth l i st (sce Mr-rl l cn' lat c diagnO s c sro c l ts l l rc th c ,v fa l l w i th i rr the i trrl cl ccl crl n l ei l cltg p6l i ti rl l so schel l l cs 199U) .( l, , rc rc .u i c c o r o th c r p ri g ri ti z i rl g g i te n i ntcrventi ()nsfor speci fi c l i i esrtvi rl g, c al pr es s ur c sto rl d c lc i ra t.tl a ti c , supptl rtccl are been i' c liv ic lr - r a l sw h e n s c rv i c e s th a t h rrv e tr:rcl i ti ol l rl l l -v clirrinrttecl from tl-relist.
120
Compartttit,c Hedbh PolicY
theseattenl pts to pri ori ti ze h ealt h car e Al t hough not rl s transparent11s of .faparl has a cl car pri ori ti z'ir r gf t r r r cfee structr,rrc s e rv i ccs,tl re r.rni versal M or e ti o n through i ts cor.rtrolover the cl i ffusi otl of ncw techrl < l l < lgics. f or a al l owcd chl l rgc the becatl se cl i scouragecl rrre i t.tt.t1l vrtti otrs c x p e n si vc ner r r est of tl r e ctrst i t to thc by conrprrri trg l tc w trcatntcnt i s c()rl tputecl ()f r et e l o w rhc cxpl ai rl nl i gl rt orl c c x i s ting trci ttl rrel tt.1' hcrefore,' uvhi l c r r r lcl of clc: r cl the vel rcrrtti < l tt ,,rg ,,r ' rt.,,,,.pl trntati on i rr.frrpan by cul ttrrel cxpellsr vc 1997), H agi hrrr' t, c l i s l i kcof i rrvrtsi vetcchrttl l ogi cs(Mi l l er rrrl cl govcrttl ' l l cl l t' s r
SattirtgI'rictrities dnd Alktcating Rescturccs 121 ( iiv en c < l n fl i c ti n gv a l u e s , th c p ro ccss of setti ng pri ori ti es for he:rl th p " ' tt' s of tl cbrrtc " ' w hi ch cmnn< l tbe c r r r c m u s t i n e v i trrl l l y l ' " " etl cl w here thc search f< l r some r es < l l v e cbl y rl n a p p c a l tt" c i t" c t to provi cl ecl cci si on-rnaki ngrul es f or t r u l rr o r s e t o f ;,ri n .i p l " ' c l e s i g nccl willal w a y s p r< l v c e l r.rs i v c .H c tl c c ' thccrtrci l l i ntp< l rtl rncc< l fgetti rrgthc tl -rc ri ght proccss w i l l ins t it u ti O r.ra sl c tti n g o f th e c l c b rl te ri ght... - erl clthi s i s the best w c cart hope e l .l s \,vcrs pr < ld u c es < l c i a l l ya c .c 1 -rta l ' ,1 f or . (l (l c i n a rrc l\rV i l l i a rn s2, 0 0 0 : 2 ' 5) thc tteeclt< lc< l trtl l trncl , t rtti tl tlpr()ccsscs r rtttrl i l ll c g i ti u r.rc r'rrrti I n < > rc l cto tcchrri cal ()r thc abottt crl rc' c < lr r iicl c n coc f e p trb l i c * l ' " ' tl t])tl < t t l < tt< l w ' arc rrtl cl vrl l ues s< l ci l rl l tu t l v l rn t rl s s u rrl l tc eth a t tl eci si orrsrefl cct l. r s Dc cts trrkcn irt wrlys thllt rlrc trllllsparcllt'
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122
Contlttrtttit,a Ht'alth Pttlir'1'
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l obrrcco l) i c t / a c t i v i t r p i t t t c r r l s Al c o h o l MicrobirrI rlg,errts 'l o r i c r t g t 'n t s Nl o t o r v c h i c l e s l;i rclt rtu s Sc r u e l l J e l r r t " 'i o t l r I ll i c i t u s c o f d r t r g , s To t a l
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Scttiny Prioritics dnd Alktcoting Rastntrccs 123 O hr t p tc r 7 , tl .rei rl p rtc t o f o b c s i ty o n heal th cere spel tdi l rgi s sr,rbstrrrl ti al r ur d g ro w i n g ra p i c l l y (T h o rp c c t a \.,2004a). T lr c s c c l rrt.lrti s e s e l -i ()tli\rl p l i c .rti t,ttt fot' refi ol l i l l u. Fi rst, they S tl gl l cst t [ r t t rrrrvc fi 1 1 rtst6 rc c l u c ch c a l th c r rrcc()stsl l l tl st l )c cl i rcctcc]rrt hi gh trscrs s inr p l y b c c rru s cth e y c o l l c c ti v c l y c o rrsttrttestl ch e hi gh pr()porti ol l tl f the iulr ls . ' T h c rc rtrc s c ri ()u s l i n ri trr ti tl rrst() tl l t' e f i t' cti t' t rtcs\ ()f rl l l y c()st c ( ) pt r l l 1 r1 re 6strrrtre g rc sth :rt i o c rrs orr tl tc 9() percctl t tl f thc poptl l ati ()l l rhcrrrc . t hr r t co l l c c ti v c l v rrc c ()u n tsi < l r o n l r'()l rc thi r(l of rhc t< l telLJ.S hcrrl s pc r rc l i n g(l' l c rl
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124
Compdrtttiue Hcalth Policy
Box 4.6
How much is too much?
Gregory'X' is a 'frequentflyer', a labelthat many emergencyrooms give to their regularvisitors.Developmentally disabledand unwellin largcpart becausehe refusesto take his blclodpressuremedicine,between1995 and 2001 hc called'9 I 1' and was taken to the emergencyroom by ambulance o v e r 1 2 0 0ti mes.H i s cmcrgency ri desarrdhospi t al roonrvi si ts,ambul :rncc s ta y s h a ve cost the taxpayersover $900,000, w i th no encl i n si ght . Accordingto thc staff, Mr. X enjoyshis notoriety and tlre treatmcnthe receiveswhich he takesfor, srantcd- 'last yearthey f()ld me my bill was a q u a rte r-nri l l i on ci ol l ars. I sai clso w hat?I' m si ck.Take careof nre.'Is the r e a moral obligrrtiorrto treat suclrpatientsindefinitelyclr shouldsocietysct l i mi ts ?If so rvhoshoLrl d i rnpl ement thesel i rni ts?
I
,So r r r ce I..xtrrrctecl : fronr Irostcr(200 | ).
goocl sr.trtcl Itr rrrta g c oi scrrrccrcs()urccsi n w hi ch rrrecl i cal scrvi .usr r r c ra ti o n c c l ,th c cl cb:rtc< l vcr l i fcstyl c ch< l i cci ncrcasi rrgl l ' w i l l i ocrrs ()n t hc e x tc rtt to whi ch l i festyl c ()ui l hr to i nfl trcncc rati < l rti rt{cl -l cci si < l ns.M or c th ru t a n y o thcr i ssr.rc surrouncl i ngthc rati rl ni ne ()f nrccl i ci rlres()rrrcc sr t lr is \i (/hcl r rrs p c c t o f li fcsryl c 1.rr< l rni scs to bc rhe nrost poi enrurr. sl roLr lcl \W h o is l i l ' c s ty l cc ri teri rrbc crprcssl l ,cntcrccli nt< lrhe rrtti oni rtsc(l r.ri rti ()n? rc s ;ro n s i b l cfor cstrrbl i shi rre thc cri teri a? W hrrr i rnprrctl vi l l thrs scl cct ion p ro c c s sh rr vcon the practi ccof rnccl i ci ne ? W het l i rni ts,i f en,v,rrrether c ( ) r l tl rc c a rc o f pcrs< l nsw l ro conti ntrrrl l yhrrrrrrthcrnsel ves?(S cel i rx 4.(r ancl c o tts i c l c rw h at cl cci si < )lv()r.r l w ()ul clnl rl kc i n thi s cesc). A rr< l tl rcr Iri ghl v corrrro\rcrsi i l l aspcct of rrrti orri rrg centres on t hc d i s p ro p o rti r)ni rtcust: of hcrrl th carc resourccsby thc cl dcrl y, cs1' l ccially tl r< l s eo v c r age [J0. W i th thc rrgei rrgof the baby borl nrcrs,unl css s() nr ctl ri n g i s c l o rteto chl rngc thi s sl < cw cclspencl i rrgpi rttenl , tl ri s burg,co r r r ng c o h o rt w i l l consunrcal l i norcl i nrrtepr()tr)()r' ti on oi hcal th cl l rc rcs()u r ccs. Si rttp l yp u t, hcrrl tl 'crtrc r c()stscrl nnot bc control l cclw i tl r< l utusi ng agc r r se c ri tc ri o n i n rari oni ng si rl pl y bccr' rusc the cl cl crl y arc thc pri rnc rrscr sof tc c h n o l o g i e sthat i ncrcrrscthe cosrs of nrccl i ci ue . A l thoLrgh l oui cal l y t hc c l c l c rl yo ffer a pri nre ti l rget fri r reti oni ng rrndsonrertuthors(scc(.rrl l rrhr r n, l 9 tl 7 ) h a v c suggestecl thi s, any ettenrptsto crpl i ci tl y rrrti on nrccl i calcr r r e o n g ro r.rn d sof agc al onc i s i nrprobebl c i n nrarrvc< l urrtri cs ei vcn the po lit i c i rl i n fl u c nce of the el cl crl y.N ot surpri si ngl r' ,Lrsi ngagc as rr fact
Setting Prictrities and Allocating Rescturccs 125 pr ev e n ti o n a n c l h c a l th p ro m o ti orl si nce the el cl erl yrl re thc pri me bcnefi c iari c s o f th e fo rrn e r.
Efforts to control new technologies
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127 ScttirrgI'rirtritit's tmtl Allrtcttting Rcs
Box 4.7
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Evidence-basedmedicine in Australia
lrrlgglJ af or r r - r al} ] r ( ) c es s Lr s illgt h c c r i t c r i l r
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128
Crnltaratiue Health PctlicY
d e rn i s eagai n refl ccteclthc unccrtai n atti tudes both i n the pri vatc and p u b l i c ,.. ,.r., regi rrdi ngl i rni ti ng tfi e di ffusi on of mcdi cal tcchnglogy in th e U SA . In p a r t becauseof a l ack of effccti ve rrati onalgui dancc i n the LJSAand l ir t es l a .g e i y d ri ven by rapi dl y cxpardi ' g Medi cai d c.sts, i r.rcl i vi duirst 9f rrsscssm ent i n the h a v e b c gLrnt9' recval uate tl i ei r oncc-l i r-ni tcdrol e te w st et cs' tt4). ,r Irr n re d i c i rl technol ogy' (Mer-rdcl sOnet ttl .. 199.5: technologics' scl ected tl n condr.rcted bei ng i rrc assessntel tts d c ta i l e c l Tcchnol ogl , A clvisor y H cal th Mi nnes< l ra' s rl rc I_ e a d i n g thc w rry Aclvisory l.ffectivcncss Serviccs ()o,.r',,','rittce, l-lealth State's Wrshington I)ro gr ir m ' A ssesstl l ct.tt ()rcgorl T' echntl l ogy Mcdi cal Oo tl tn i ttcc, artcltl rc (ie llchincl leg t9 rlclccl te has rrnllrly in Mcclical techrrill()gy,,rr"rr,'t',.,.t, o th c r c o urrtri csrrtrclti rtti l rcccrrtl yw l l s foctl scclon thc l i ccrl si rl gof phar m2 rc c L rti calrrucl s nrecl i crrlcl cvi ces(l )crl cth ct al ., 1999). l l cyorrclth : r t , t hc Irs s c s s l rel ttof rtrccl i caltcchrl ol < l gyi s l i nkctl ttl thc covcrl rgcspccif ied ir r y e' c ()l l tra c ts w i th hcel th cerc provi dcrs. In thc case of rrrnbr.rl rrtr ) rcllr t 'f w h c re r cggl ati < l rr has cl cvc' l o;l cclftrrthcst, thc fccl crrrl c< l tl l ttrir t c': c l o c t< l rsatrcl i nsuretrcc i trrrcl scl cci cl csotl thc cfi ccti venessof tl cw t cchrro l o g i c sttl bc covcrccl[ry hcel th i ttsttrrrtl ccas w cl l as rc cvtrl ttrttccxist ir r g te c h n 6 l g gi cs!asccl < 1rtl rc cri teri rr< l i bcncfi t, rrtecl i celtl ccessi ty,r r lclcf f iovcrr l l tl te systetl l , ri n r eciical l l ts rl rc scct< l r-spcci i i c, c i c n c y . A s asscssnte (l { . l }Lrssc,1999), rrl thotrghclcver li s i ragnrcntecl te c h ri o l < ,gyrl sscssntcnr ' ' ()p u tc n tsl l t rcccl l t,vears6l rl rk 11l l l orc systctrl ati cl l pprgach (l l Lrrl ru200'5) chr or lic rtrc thc I)i scl rscMatl rrgcl tl ctttI)roqrrl l l l l l l csf< l r sc' l c' ctccl F .x a rrrpl cs cl i rri crrlgtri dcl i rrcser lclt hc i l l n e s s c s,w hi ch arc [rrsccl91 cvi cl cncc-brrsccl n c w l ttsti tutc for (]tral i ty rrnclF.i i i ci crrcy. y ti cal i rl ;l ri ori ty sct t lllll t l ' fA w i l l l l ccorl l ei r.rcrcesi rl glcri Itr s u ttrtrtrtry, ctl nfl i ct w i th thc i rl tc llsif ict l i r.rto e s tl rc r.,r.ci ty of rcsources c()ul cs of c l c rtrl tr rdsrtttcl prcssurcs for tl re cl i ffLrsi < l tt i tttrovrl ti vc tech r lit lucs' l tv i d e n c c-[tasecll rccl i ci l l c crl rrcl l tl y i s tl rc cl rtcl -rphrrrsc i < l r eff
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ScttingPrioritiesitnd AlktcatingResourccs 129 Table4.7
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tl cchl ttl i stl rs'
i trstrtttl tt:t.ttsttsccl fo cotl tl ti l t cttsts'
:.] lq
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ttltir t' r s:ll :lq r t ss
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r r r r cle tlttin vr tr ie s.
cl i ttcrerl ces ttl u'ei ght gi vett ttr tl etl rtttl tl vs sttpP l r''
S o l r tr ' : Ad ,tp te tlfr o n r lJle r r k' r r r dlJu r a tr( 2(X )(')'
-: - :ae "
-r
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: l. lt .. . - .1
crtend to contctl t rl trtl r s pe c f Oi p o l i c y g o i rl s a n d c l o cs not i l ppei l r to l l t thc i cl eati cl nall evcl , pol i cy ils t r u mc n ts . l )e s p rtes i g l s 9 f i t c ()rl vcrgcl rcc for i mpl emcnti ng such i nstrumcnts c on tc n t rl n c l th t: p re fc ' rre c lp o l i cy countri es.B y and l :l rge'coLl nthesc p( ) [ i c yc o n ti n u c to v i ]rv w i c l e l ya c ross w i tl -rsi mi l ar probl ems' dcal to t . i. r..,,.rti n u c to a d o p i c l i ffe re n tstratcl i i es Fo ri n s ta n c c ,w h i l e th e rc h a s b ecnasl ri fti ngoal si nal l -courl tri cs ()n rl n arrrl y of demandt ow i l rc l s c o s t c o n ta l n me n t, th c vari ed emphrl scs acrossthese c p ro a c h e sd i spl avs consi derabl edi vcrsi ty : ur cls u p p l ,v -s i c l:tp
130 CtntPuatit'c I-lcolthl'olicY
il'::i: *,, i :: :'::;:il: :l; ii:,i',Tli "i ^n11..;,l::: iiii:::::u ,tsr)ccts so,,,c oi integretccl .,,,,,,,'1r",,i,"u"
c t lt t t lt r ies . Als
il,".'.|-,::.|,:ii,liiili;;,:,ir, "ir thc rvi cl cvrl ri rrt t olr rcf< l rtt.ts' thci r tt" l " tt i f* ottgh l ecctl t
th e trta rk c t i rl to thrrt thcv r r r c gtl cs rrl l al nst thc corl cl ttsi tl tl i n b < l th f< l r rl r rrl tclcl cgrcc rrl i l rrl i kc t hc r-r." l rh sV srcur.l -ar i rorn i t! c o n v e rs l n s,,,,,,.,.,,.,,i .,i ,l i ri " rcl rrti vcl i ' rol l ttst rcgttl rlt
( ) \' ( l ' tl )i i l 'k('t t'()t'qt':'
l{ cg a r clir r gthel rl l
t l. r e. . lv l i cr ltrtltcc t r ic s t hr r t' ctrt cl ccci 'r
rs that ii t h c l i g h t t l f c r l c l l c s st cch f t t l t t i o t l e c l l r e c r r t t s c 'i r l
" t t 't t r r olt lgic r r lpo s s i b i l i t r e s . l l ( ) e ( ) i l l l t r \ ! 'i l l s e r V c e l l t h c h c r r l t h r r c c c l s o i t h c i r 1- l< lpt r llt t it l r r t t l t h c t t r I l t 's t . ( , t l t t t l t r i e s r r i t h g , l t t l l e l [ l t r c l g e t s t l r ttl ltrl cr ccrhslt.rrpt llirsl tyt-l sl r tl tl 1 'l . , . . 't . . r t i . , 'l i '. 'e s ic lc c < lr t t r t l l s l r r c l i |
bc cltrt?[-hislcacls"t l"l:lwhrrt othcr n"'*'""l*' t. wiclcl "tignt;* ir rhc rcxt chirptcr, ct>tltitrttc *f-.,,r.'"'r'*";i.,,ii pr'fessirr.rrrl, c < lr ls ic le r l l i l l e P ( ) w c , r l r r l c l h l r v e l r s t l b s t a t r t i l r l s t l t k e l l t l c l i t l t c r e s t i t l e t l s t h e a l t h p o l i c 'v i r l g e r l c r a l ' c ollt ll1nn l e n t , r , r t r o r l i r l g r r n c l
Chapter 5
The Medical Profession \tL' l rl \ft' otrlthe i rrct thrrt hcrtl thcrl rc f hc powc r O f th c n tc c l i c rlp r()i c s s i o rr c cl i rrg' .si s \ i l re l ' (' \l )()rl si l rlf.r . is llr r gc ly c l c fi ' c c l a s r.e .l i ,-l ,tle r' rreI)..t,1' el so pr< l vi cl c l )outors L i i l ' e l l et' rl \. r ut c l ir s s u c h c l c fi n c p i l ti c l tt\' h c .l l th tl rIectl r' < l r l l ' v t l rrs i tl r ol \' t' ' tt' l tl rcr t f c llt lnc llt, l tu t rrro rc < rtterl th ,rrl tl o t
". i -.1 .l .I
r c f c r r lr l) tl th c rh c e l th p rl rc ti ti < l rtt' rs ' s t tcl l .rsrl rctl i e.rl ' peer.rl i srs.l l tl rscs' [' hi s 1.' Lrrs.l .ct,rs l a S .re r.ry tc c h ri c i rrs.r cl i cri ei errs. nr - lir i. r , i. l " ,.p i s ts , ir r lr l< c , v p tl s i ti tl rl rc g l rrc l i rrg tl .,c a l l .l cet' .l rl < l i hc.rl tl rci l rcres()tlr'recs.l l cl rl th ttl rcl crsttl .tll r i tl l .trt l .ct.rs p .rl i c v e ,r.lp ,,l i ti c s c rtt ttt< l t.6tl - nr , . , r lr , ' t-.| ." 1 t6 corl si cl crrrl l l P c ()w cl -trtttl ere scel l rl s r r r r cvl ic c v c rs rt.l )o c t< rrr,,ft" rt c tl i o v rrrerrt rrtl clcl otl ti ttrrtrcc c re rrrl tl c< tie p r< l fc s s i tl tlA. rttotl < l tl r,v t hc r r r c h c t,v l trtl (l ()ct()l -s trl rrl i c ()i t. t< l the al l i l i tv t 6c hc r r rt .t rrc c l i c rrl1 i ^ " " r' " ,,.1 rc fcr r ti cotrcl i ti ()ttt thc cotl tctl ts l l rl cl thc r t ut ( ) lt ( ) t.l t()u.l,a a i rr,r,r,c < l ttc c rtl i ttg nr c c lic r rwl o rl < (s c ca l s o l l o x ' 5 '| )' i n spcci fi csttb-sY stct' tltlsf ful l cl i rl g,, lr es ' r trc 6 rrs(l ()c t()rsrrrcc rl Sc c l c l ccl l vi l l rl l w eys bt: ctttrti trg ,ru .r,r,,,,.a ,p .,,f.rs i o tl rrlrttl t< l tl < l rrl y pr ov is iO rr cottl pl cx rcl l l ti orl shi p " ,r.1 thc to gelt t alld .rc l rl ti v c , e rtd tl l i ' rtl s o 1 - l < l i rtts attt< l tl otrl yatl cl proi cs.si otl rrl tl .r. s te tc . Si g rrifi crrntl ,v, l) c t wc c , c l ,c t,rs " ,' ,1 i n rp l i c i t c o n tr act bctw cerr cl octorsrncl the strrtc' n rrrt o f tl re ' r ;hc ;;;'. .; l. i l l rctrl fl l ftl r cl rl ctors;l rtl vi cl i rl g g s t r l tc rru tts p rOfc s s i o rl ,rlrl tl t()l l o l l l v precstrl tcs'N ' l ccl i crrl tl i ttl ocl t' t' tt s c r . v ic eth s rrt rtrc c c n trrrltO th c l t' g ,i ti r rl .rcY i s.brl sctl 'rrl s< r l t" t " ' ' l " tl gc orr l vhi ch i t t ic c . bv v i rtttc o f th c " ' p c ' c i e l i " ti crrrc hcrrl rh rrl l oceti onof gi, . r ' t " gn i ,trrl c y r() tl .r"i p .,t.,,ti " l l V p r obl cnrrrti c) l l ctw eetr rcl rrti tl tr.shi p r, re rl t i r1tl l i s irl tcrcl cpcrl cl ctl t f c s ( ) ur c c sI. l < l r,.n ,c vi 'cl rc rtsthet betl vccn l rl ccl i cel l ycl cfi rrccl c lO c t r lr srrn c lth c s te tc i s c o n fl i c t, s ttch cssi < l rr' l l l < l r thc rrl ccl i crlproi l c i i n i tL rc l co f i i l l rl rrc i rrlfc soLl l ces' nc c c lr r rrcth si trl tl tr' tes s() stetc the rc.l a ti rl rs6i l ' rrvi th t hc c hr r l l c rg c l s .t(),r..," ,r,..g ..i r-' pr' rbl i c t. strrretl cl cri rl g w i th.trt t. rr' p r,p ri ,.ti l ' ry b l i . rrtl th o ' i tv ' c . us ly I( ) !) 9 :9 ( ) ) ' c ( ) t l t l ' ( ) l ' l M o t' lttt. . I itl the context ot cl
l3l
132 ComParatiueHealtb Policl'
l
Box 5. I
Understandingprofessions
haschangedovertitne'Early approaches of professions The understancling long by sf"cific traits (such as formal knowledge' d"lit;J prc,fessions Howcver' in society' role positive a ;tttttg'n"Jttigl-t socialstatus)and by huu. beencriticizei fu taking the self-image.f ;;;;;;;lti, 'rrofess i o n s a tfaceval uear-rdforremai ni ngl rrrgel yuncri ti cal .l nstead, lat er Freidson\1994\ for power' nf o'gut'i'itkln social the on focus .ffru".tt., prnf.r.iuns as being primarily conccrnedwith attaining .II*pf.'J.ln., (thirt is' c<>ntrtll an6 maintainlng.,rnr.,rl. C,rnt.ol cirntitts of aut.nor'y overt he (that control i s' donri nance and o v e r the professi ons' ,r* n," n' k) an indiboth has and work of others).lvledicalporveris highlycomplex individual of freedont the vidual ancla collcctivctlirlerlsion,c()nlprlsrng o{ doctors'profcsd;;;r, to practiscas thcy scefit as well as the activities am.ng cli'di sti ngui shes ( 199' 5).fLrrther t-i ght H .:rc, s i o n a l.rgani zati .ns. autorl onry 'ancl zati p' " tti tt and orgatri -F' l ttt' n orl al i c a l a n cl fi scal auton< rnl y, cul tur al (1991) acl ds o rg a ni zati onaland i nrti tui i t.l n" tcotrtrol ' (lttltr-rrirl refers authority powcr. medical to 6er un
p()w eI i s l < cv' F' clt r ally.as h c a l th c rrrc rcforn] afi ects cl octtl rs l l rl cl thci r systcl l l s'chrrrl gesi rl thc r cgt r hcal th n tu c h i t s cl 6ctrl rserc cl ttrrl l gl cclw i tl r w i cl cr chrl rl gcsi r r l'r er llt [ of l rrti o rrof rl ecl i cl rl* ,r.k al s,,gi vc rrn i ntl i cati ()n s y s te tn s(M< l rrrtr,19991. p()w cr attclchat lgc' ' l ' h i s .:h,.,1-,,.. crpl ' r.s thc i ssucs.i c.tbecl tl ccl tl ess, .fh c profcssi ( ) llt lsillll fi rst sccti (), pr.vi cl cs r' rnovcrvi cw of thc rl ecl i crrl 'f prrrcti ceof cl oct
Thr' Mr' di col P rofcssi t,rr I I l
Who doctors are Thc n< l ti on of s [ ) ( ) c t ()rsrtrc o ftc n th < l r-rg hot f rl s l r hotn< l getl ctl tl group. cl otrti trrrttcc rl nd rtutol l ()111v. f< l r rrl l ow s th rrt a c o l tc s i < l n s u g l 1 c s ts pr of c s s i o n i s a r.rni vcrsi rl pr< l fcssi ortrrl i snr m ccl i crrl i c l c a th rrt T ' [ is c g rrc s t-ro n c to l s th e l rl tl k ctl rs()rv at st:rti sti cs i l cvcl l phc lr 1 ;l tc n o n (s c c Bo x .5 .1 ).H < l l vevcr, i l cr()ss rl rl cl w i thi tl cottl l r c v c ll l s c ()n s i d c ra l )l cc l i v c rs i tt'rtl tt ol l g cl octors tl r t r ic s . f6 r c x l rl rp l e i rr tc rn rs < l f th c n unrber of spcci rtl i sts thc pcrcetttrrgc 6f f c l rl tl c c l ()c to rs .' fh c a rrrrl y s i so f stl rti sti csttrrtttrrtl l l retttrti trsotl tl rc s ur f r rc c ,Itrt e s rrn o v erv i c rv i t p ro v icl csrt trscftrlstrl fti ttgptl i rtt i tl r c()l l l prrris 1ln. ' l ' h ro rrg h h i g h l i g h ti n g s i rri l r rri ti cs rrrrcltl i i fcretrees.steti sti cs rrti se ' why ' cl u c s ti o n s w h i c h c l o rrrrn crn l orc rl etrrtl t' tlrtrrel vsi s.l -l tc rrtrrl rl l t' rof I p ro rrtl cs rr f-i rsti rttl i c.rti ortof the cl i rersi ft' p rc s c n tc (l i n T a b l c .5 . c lgc t o rs t lt r t t r ' x i s (s.l ( r-()\\ r' o rtl ttt' i t' t. l1 1 tr' rrryc o u rrtri c s , th c trc rrd i n tht ttrtl ttber of tl oetot' s pcr 1.0()0 inheb i trrn tss i n c c th c c e rl i ' l t)6 ()stcl l s the i rtrtti l i rrrstorv oi u cl frtrestete . c x pr rrrs i o rr,to s c th c r * i th rr s h i i t tot' errl s ctrrrttrve.sl l cci el i zeclrl rctl i ci tre I n t hc rl a j < l ri fr,' o i c o u rrrri c s ,rh e nunrbcr of tl oct< l rshl rs tttrl rc or l css c l< lul tl c c ll.l c y o rrd th e c o tttttto trel i tv oi gr< l w th ()vcr ti l l l c, thc ctrrrcrtt 6r r ut I c r o f c l < l c trl rsri ' u tg c sfr< l n r 1..5(l ()ctors pcr 1,000 i rl habi trrrl tsi rl S ilgr rp 6 rc to 4 .2 i rr Ite l y . I Io w e v c r, Ital v i s rt cl crtr otrtl i cr.Thc rcrrl rri rl i rrg l u g ,h l ytl ' rrc cg , roups:l l ri trti rt,.frtprrtrenclN cw Zerrl rrncl c < lulfri c s i a l l i rrt< ro wit h r rb o rrt2 d o c to rs p c r 1 .0 0 0 i n hrrbi tenfs;A trstral i aertclthc LIS A w i th
Tablc .5.1
. .t\ '' l l -
. :.rh :- jf -
.
l'l !t
:irc . J llt .1 . 1 1 -
:: r lf :- . , 1i i
n(t
Number of lractising (loctors 1rcr 1,000 inhabitants
r\ ustrrrIirr F r : rn c e ( icrrnrrtt,v I t rrl y Irrprrrt Ncth c rl a rrc l s Ncw Z c rrl a n c l S in g i rp o l c Slvcclcrr ti ti I ISA
I L)!19 l 991
I 97e
1 9 81
rr/rr t.i i n/rr n/a 1 .2
1. 8 2..r
2.1 .1.0
n/a n/ir 1.4
rr/rr rr/rt n/a
l .u
2.2 1.7
2..1 t.e
l..t
2.4 .1.2 :1.0 3.7 l.fl n/a 2.0
I ()99 2001u
2.4 .1.:i 3.2 4.2 n/a -1.| 2,.2"
2,.6 3.4 3.4 4.2 2.0 3.6 2.2
tr/rr
n/rr
n/ll
n/ir
r.r/a
| .-5
2.0
2..t 1.4
2.8 1.6
n/a
r.r/a
2.rJ 1.7 2.1
.t.0 1.9 2.2
3.3 2.3 2.4
l) I -.)
n/a
I ht lieLr r cs for ,\Ltstr itlir r . Ncr v Zc,tlr tr rd r ttl c l Sr v c dc tt ar t' fr ol l l 200 1' l r/i r = not availr r ble
''
:irc [) .ttr rfr o tl OU( ]I) { 2 ( X) 6 )r r n clSin ll rrpore\'l i ni strv of tl cel th (2006)' , S o r r r cc,s.'
134
Comltaratit'e Hedlth I'olicl
Frrrnce' (i crnl anY ' the i l b o u t 2 .-Sd o c to r s per l ,000 i nl -rabi tants;rrncl per l ' 000 i nl .r:' rbi tants' N e th e rl a n d s a n c l S w ccl enw i th about 3' -5cl tl ctors nO rertdv crplirtl:rtiotl for Thc varii,rtionis sigr-rificantarrcl,whilc tl-rcrcis i n thc l evel s of hcrrl th carc crpenci i tr.rre.l t rc fl e c t i ff" ..n.., n, n cioct
'lh c Madit:olPrttlesstttrt 13.5 prdctising doctors'..a;.a Tablc ^"j,ercentage -5.2 Female of praitising doctors' 2004^ il..0 ), -/ I -.6 l;..1 16.-+ l+. \
A trs traIi e F rl rttc c ( rCl-lllilll\'
Itrrl y . fr t pr r r t Nc r r ' / - c : r lr ir lc l Sr v c c lc r l Lll( LlSA Iltc tiqttr ts tor i\ttstr r llir t' Sr r ctlttr r tr t lr or r r l00i'
''
\olr tr ' ;
tt)
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/
Ll i .l Ncl
/'er r l 'l r r tl
( ' l) ( l( ) 06) ' l) r tlr t fr or lr ( ) l
t hc r r llljt lr it l, < l fc tl t-ttttri c S l tb ()t| t.rth i rtl < l i cl < l cttl rsl l rcw ()l l 1c11.' fhi sel rrrl .rt. chrtrrgctl c l c v cl opnrcrl tsw hi cl l r r t t r ibt r t c ctl o c ttl tttrrrl;" ti ;tt" tt' ' " ri c l l l l ;; stetc-i rl i ti l rtccl s o c i c tv :l l l C a l l s ()t() l l l ()fc s1-l cci i i c t llc 1- r t r s it i< l rl n .,f" .,' ,..' ,.i ,r ()t w ()rrcr cl .ct.rs (l {i sl < e 1 -l .si ti .u lr c r . r s . r esr v h i c 6 t-l " r,.,,,i .,-l g ,t-l .,l .4 ,r-t. prrl cti ceshrl s th c ' c ri c l,tocl i scri rl ri l l rl t< )ry .,.r,.t,,l 1 -' )t., l ,rl . l g g .5 ). wc ger , anr l sf.cl cl l ts. rts 6:rs thc i e rrrrl c hc lpc c l t ( ) i' c rc r.rs crh ;,-l ,,,-t.l i j .,.i ' rccl i crrl c.ttl ttl tl l l l ty ,.t' t,,,rl sw i t6 t6ci r erl rp6rrsi s.tt c s t r r S lis hr . c rt,,f rrc w i r..i i l " t ()rl l ,v i rl .| l rpl rrlu,' i tl r 16.4 pcr ccl l t w ()l l l C l l lr r lc lpr it lr er Y c l l rc rl l c tl i c i rrc . trrl tl i l c s sth l rn rr (lurrrtcrof rrl l tl < l ct,r' s" fhc c l' c t . r s c l, t h c ,vrl c c ().u t f.r g rrrl r.tsl l cetl rcsi stl tl -' ttttr t it lr llr lc l< lr ll i l l e l l c c < l ft.ttl rl c s i rrrrre c l i c i trci'l'l'.|t"lt" rl rl ctl tcrecl w ()l 11clhevc 1 t.)i tttttrtl ' rc r c her r gc ,r r lt h o trg h" " i n tl t" " ' i ' .' 1 1 fcrnrrl c oi pr.p.rti .' f,,. the s' ral l e' r r . ec lic ir r c , r fc c c rr r.;;r.' ' i i -l :...],,r,,,, l i rl l < ccit< r be rni ght c c ' r1 t)i s l c ss.cl cer'btrt i t doc t or s ir l t h c ti s A tZ S' f p t' cotl si cl crrrbl y i -rc i ,l th " l JS r\ tcncl s to t hc f r r c t t he t n tc c l tc J " " .rrl ..,.t,u ," tl f 4 1' g1115, sch< l tl l l ftcr (4 y c l l rs tl f rrrecl i cl tl lt lr lgc r t hlr t l i rr .,th .,..,.' ' .' | .ri c s of orl l rl ccl i calspcci al ti csi nstcad univ c r s it , v ) .A tr,' , tt.' t]' t" u tf t" tp n " s .i s ger lc r lr lpf il c ti c c rrl i g l rtl l c l c s s l rttrl l c ti v ct()p()tenti al l vrlprofcssi tl l el r.cancl thc on i si dates. t ' f tht mecl i crrl A not hc r r,,a i ." ," " .t ; ;l t; a l u tt' i ' u c liv is it lr r lle tl v e e tr* .' ,." ...r' ,." n c l s p c c i a l i stcl tl ct< l rs.A s' fal lspeciillists l e.5.3i l l Lrsas erc rlboLlt t*,icc rrs r1111ny trrrtcs, irr 6elf ,r-',..,,,-,n,ri.,r-rt.,.r. i rr atrcl prrl cti ce i s tl -rati n str' rcci rrl i st ger r er r r lis t sc.l ,r. p ,rrri t i ..c * p l a ,.,e ti .It crccl ' crtu i l l ness mt,.l e l of hcal th arrcl r c lar r on r o rrc L rre ." r.,i fr.,.I-l i J i c a l pcr * h " tt the nunrbcr of spcci rrl i sts T he r at io is c v e n h i ta l ;; i tt S;ttl t' n ' thc fact th rrt o f generrl l i sts'Thi s refl ects 1, 000 inha b i ta n ts i s th re e ti n c s carc' clominrrnt in the provitt":l :'j'11:"tth that hospitals havc'lt'ng l'tt'.t hclspital to specialisis irr oLrtpatiellt rvith prrtients havrng clirect access
76
CompdratiueHeolth Policy Table 5.3
Numbers of generalistand specialistdctctors Per 1,000inhabitants Ccncrttlist tktctrtrs
Au s tra l i a France (icrnrrrny Ita l y .fl p:rrr N c th e rl a nds N c w Z e a l artd Si n g a p o rc Sw c d c rr LJK T J SA ''
,\1r.'cl ,l /l sf t/r rt'1r,t s
1.4 1.7 |.0 0.e
1.2 1.7 2.4 rr/a
n/a
n/a 0. t)
0..5 0.7 rr/a
0.7 rr/e
0.6 0.7 1.0
.6 .4
Ilr c tigtr r c s l or i \Lr s tt,tl i ,t, tl r t N ttl l t'r l .tl l tl s
t
.u
r ttl d Suttl er t r r c i r or r r l 00 l '
S( ) r r r .? : l) r r til frorrrOl :( l l ) (2006)
. l f arl l l l trl et()rycl l rc htl s bccr t c l c p rrrtn tcnts.l l t col ttrrrst, thc pr()vi si ()l l< of gcrrcrr r list s p " t.h y . T h e < l therexccpti ()ni s I' ' rrrncc,w l l cre the tl tttl rl l crs ftl r l epa' r r r c l )ata a u c l s p c c i a l i srspcr t,0i )0 i rrhe6i tr' tts rrrc fhc srrtl rc. tIc gellcr i l l :rpr' 11 u rra v a i l a b l ci u l ti rrt bccrrusc,grrl i kc w estcrtt c6tttrtri cs, .f Mccl i cal precti ti ( ) r ler s rrl i s t-s p c ci rrl i stcl i sti rrcti ()tti s l rl ru()stl l l crl l l i l l gl css' i rtcl trcl essotl rc s1' rc cielt y' w hi ch c l . ct.rs of rl ecl i c,rl sci cucc, ,rr. "li < l r i tl rrl l rrl .sl ' tt.: t t l t 'i rccogtl i zccl Si g n i fi c a ntl y, the rc i s no nl rti onel l y s, ct Il Ll l l l crotl srtcrtcl ctttic s p e c i a l tytr ai l i ng 6r rcgi streti 6tt,rttl cli tl stcl cl c ti c s h rrv ecstrl bl i shcclthei r t' w tl tl rti rti rl ssystel l l s'
Types and settings of medical practice whrrt doctors lrre [n rnany wrrys rncclicel prrrctice g()cs t() tlrt: Ilcrrrt
The Medical Professirttt 137 Table.5.4 Typesand seltingsof medical practice Arnlttrlilrtyscl/lrlg,s ( ir t c it bc r s t t l r tt t r
Hospitdlscttittgs
erouf) l)rdctt(()
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138
ComPdrdtiuc Hcaltlt PolicY
that speci rrl i stscl ep er lcl rl l crl r1s a rv i c l era n g e of heal th prrrcti ti oners.Thi s the.v prrlctisc irl hosl'rital to 11grcat cxtcnr ou thc rvork ()f Others r,vhcn s e tti rrg s ' A s ctl rl l i l l cr< l rgl rtri zati < l ns,h< l spi t:rl sl l l s< l tl eccl tl l l rtl l rgelllcllt of tl ' rc l rrl l onr pl ' tl ccss 'I t l s tmc t' u rc stlrrrt coorcl i rr" i " th. cl i ffcrent prrrts l l l r' tl l rl scrspcrsrl rl i fl 't hc a c l c l i ti o nto bci ng,a,r ,r,-gani ri ,rgi orcc, hospi tal col l l e t() thc i tl re ()vcl c()l l ccrtts:tl lt lt t t o f ccotronti c* ,r,vhi ch-h,rs rrrti o tra l i t,v rtl l cl r cr r l c o s t p rc s s u rcs ttncl contrri ntncnt. N ot sr,rrpri si ngl r"1-rtl tcrl ti al tsst t u' prtl l l ti ttettt l ' t IcC tl ttrc have c o p fl i C ts[tC tW eCltt]l l l l l l l gcrsl i rtclcl tl C t< l rs of rnccl i calpow cr' a rrc lh i g h l i g ht thc cotl ti rl l l crl c-v l l l rl l l rlgcrrl " rl ..' t ti l cchrl tl i stl rsl rl tclc< l rrcsporl cl i rl g of J h e i n tro cl U cti on i l l l p()l ' tl Il l ti trrl cttrrci rt t hc ri rrl i s t rc f< l r' ts rl fc tl te' l < cr,l tcrc. Irl l " ri trl i rl ,r' tl l ' gcl lcr lr l rn thc N IIS w rl s thc i tttrocl ttcti orr< l f ri s c o f h o s l -l i trrl ' r," l l ,,g.r. l l ascclc()l l scl l stl lsl l i l l l illlc ,.,,,,,," g .,., .,.,.rt'l i9fi n 7, rcP l rrci trgprrl i cssi orl al l ,v ' l l tc Lrnrl crl ifrl g i cl ce w as thrrt hcal th scrvi cc l l l rl l l r t llc l n c l tt s tru ctU rcs. t
The Mcdicdl Prul'cssiort 139
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in ipclcl-rclcleucc.In (icrttttrlty rrtlcl.feperl tIc l.rrri6rity 6f cl()ctgrswork i s es1-rcw i th stl l o prtl cti ce rrss()ci r' ttccl s< l l ' p re c ti c c s .T fi e i n c l c p c rr cl crrce ' cl i n()tl t of so-cal l cc.l opcrrrtc cl octt> rs rvherc i n .f rrp rrn ci a l l r,;p r()n < tu l c e c l ic s ' , e i -,' rrt 4 g ;rc r c c n t ()t rvhi ch hrrvc sottte i rrl ' rrrti erlrlr cc()l rl l l l ()cl l rti ()l r ( N a l < a h a rrr,1 9 9 7 ). (l l i n i c s c a l t kccp a pi rti crl f i or trp to 4l J h< l urs,rnclrtrc l h e v i rrgfc w c r rhan 20 trcds.l )octors w orl < i rrgi tl rtl btti .g " l l " c i c fi n c crrs l a i < ,rVrc tti ,rg s d () l t()t h a v c rrcccssro hospi tel teci l i ti cs, el tl .ror' l ghrnost c l o c to rsh rrv cs < tt' t'tltcc g rc c tl i spcci rl Ii zrl ri ol r I' c .6 trrrs t. i rr th c L ISA , A u strrrl i rr,Ii ri t.ri rt,ttttlS u' ctl ctl .l l l ()st 1' rrttl rrtrt' ( .i l t.(.(l ()(.1 ()r\ rv (} r.l ttr < S t.()u I l )l ' l l rti rt.s. | ]r.' ti qrri l t..l tttt ()l trol l l l \(' tti l l gs i s p e rti c rrl e r-l ye y rp e rc n ti n Sl v ccl crru' hcrc thcr u < l rk i rt rtrtrl ti -cl i sci pl i l rrl r-v rt' fl ccts h c e l th c c l ttrc .sw Ic re tIc i r r< l l ci s n()t rtcccsseri l r' prl rrl rl l < )tl l l t" l ' hi s l l t' l )ec11 cl tl rl ri rl rttccl l ti l s l < ttts ci trc hcrrl th o f t l rc frrc t th a t tl rc p ro v i s i o rr ccl rtrcs he.l l tl r sct Ll p to i rri ti .rti ve thc thrrt h .s 1 -ri trrl(H s e rri s o n ,2 0 0 ,{ ) e r rcl ' crcl cs (i rl cl trcl i rrgthc N l i rri srrr i or . ,,' ,,. i r.r,,t p o l i ti c rrl -rrc l l tti r l i sfrrtfi ici l )' H c a l th e n .l S o c i ,rlA ffa i rs ) n ot thc nl ccl i calprol ' cssi ott((i rl rpcrl [r' . 2(X ) s< l l < l tr)r;l eti ti ()l l l .i l < c w i s c g, ro g p p rrtc ti c c srrc thc norrl i tt A trstrrtl i ew i th Itcccrl tl y thcrc oi practi ccs. trl tal 5 LL' 111 pcr | tl t,ttr l c s s f,,. .r, ,r..,,u ,rti ,tg 6 rrs l rc c rra frc rrc lt< l w rrrc l sc orporrrti zrrti ortttf prrrcti ccsw i th c< l rl t1-trtrl i er i < l trtttl tl cr c()l l trrl crto thr-'P 1' l cl i ti ttl t et' t' t rrl < i n g< l rrth c rc l ttri tti s trrrf strcl l sthC l ltIe p' si ti l tl crttl rrl s< l sctti l l !l g r 9tt1-r H ,,* .u .., 1 ;p c rrrti l gi tt rr i rl cl cperl cl crrt rcgi < l rrl rl of cl trcrgettcc the . f c l < l c t6 rs ,,r.l .,tt,,,' rtrrl tc ( ll )V i rr N ew Z.c:rl rrtl cl cl tl cttl rs cl trc tsl ' } As )of rl tl l l l Ltl at< )rV p ra c ti c c rl s s ()c i rl ti ()l (l e()l l trrl ef' rrl clfuncl e n c l A u s trrrl i a .l ' h c l l ' As e c t rl s col l ccti vc l l eqottrl tors, l n N cw h < l l c l c rs i o r c l tl c t< l rsu ' h o r trc ovcrw hcl nl i ngl l ' gcrl cr-rl l i sts' cstabl i shcclt< l provi cl e (i l )s Z c rtl e l 6 , f9 r c rrrl tp l c , l l )A s rvcrc < tri si l rrrl l ,v Hlcal th A trth< l ri ti cs rv i th e c ri ti c rrlp trts si 9 r l e g t;ti rrti ngl vi rh thc I{cg,i < l rrrl orsetti zati otl si tl r (i l )s i n rl cg< l ti rtntbrcl l e rrs e c t Il )As (l ri ' l rrv s < t1 ,2 0 0 l ). rcl g rrti < l rrc ' rcstrl ti ttgfttrrcl -l -rol cl i rl e ti ,.s w i t6 p u rc h rrs c rsrrn c lnrrl l rr' rl irrt\' i n l l )A s hes tncl rl [rershi p i ncrcrrsi rl t J' hc s h i P s ((.ra rr' 1 -,t,Il ' 2 0 0 l ). profcssi onl l l thci r prrl tcctccl rncl s trc .n g th e n c cth l c i r n c g o ti rrt i ng p()w cr (' trrrcrl tl y N c' v of per ccl l t r 7' 5 ove rtrrc il ' o w c l l , l 9c)6)' s trrtrrs(N ,4 rtl c o l rtr i tl Z .c :rl ru trl(i l )s rtre n tc rl b c rs
140 Comltaratiue H edlth I' olicY crtre i n an.rbul ator, v c mp h i rs i s o n prevcnti ve medi ci ne ancl pri nrarl , i s about.ne-thi rd arl d s e ti i n g s .A s ,r r csr-rl t,the h.spi tal acl r' i ssi .n rate the I-JS A(l kcg' rrmiancl th c s u rg i c a l p ro cecl ure," t" i , onl y one-quarterof C a rn p b e l l , 1 9 99). In th c n l a j o ri ty< l fctl ttntri es,htl sl -l i tal sl l rethC < l rl l ,vgl l accsi rl \vhi cl -l arc ttttttsttl rli rl thi s s 1 -rc c i a l i sdto c t ors prl rcti se.(i crr-nan1-rrrrd the uS A rlrlclis ttscclrts tratlsitiotrrrl r.ts respect. Irr (icrrnlr[ry, hospitrtl work is seell crtfc' l rr tl ' rc aml l ttl l l tt)rv cc i n st t.r rct up a s1-rcci al i practi a s 1 .,ri rrg b o a ..l Il rl w cvct, as lr U SA , u ri rn y s p cci al i stspracti ce i n arrl btrl i rttl rysctti rl gs. (i l )s i s gr< l w i rtg l l ccause tl i tl -rcir c,rrc, cl cr' rrrcl f.r re s u l t.f n -.," ri " g,..1 the ttsc
The Mcdicdl Profession
c x il l n p l c o fa s ,v s te rrrw h e rc th e c l cgrcetl fi ntegrati tl nofaml rul at()rycare 1990s' A s part of the i ntroducti on has a c tr.ra l l yi ,.t.r." r" d ' ' i n t" th e e ai l y ch()se to ltccirn1e'fr-rrrdlrolders' and of the interr.rallrarket, many GPs were g i v e n b l rc l g e ts -" ' p t' ttt.t" ' c cl i agri < l sti cprocecl uresi l ndel ecti vc (l Ps therebv crtcrrcl cclthei r nl anagcri alrcspol l s ur g c ry fo r th e i r p a tl e n ts . ttrrl vcdcl ()S ert() the tnai nstreat-n l e i r < l r' v np rl l cti cc atl cl s ibi l i ti e sb e ,v tl n cth
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Reforming medical Practice trf < l f hcrrl th svstcl l l sprovi dc' s' r setl su l) < l s i ti ..i .g , c l .c t.rs i 1 t6 c c 1 ;n tcrt rrls
142
Comporatiuc Haalth I'olic1'
speci fi cprovi si otls by the tl r< > re s g c i i l l i tts u ra l rcc,w hi ch i s cotl rpl ctrl entecl servi ces i rr l l ri tai rl, hcal th rti rti onal tl .re In coutrr' rst, o f s e l f-a c l rn i n i strrrti on. oi tr()\' crl l l l l cl l t to sl 1111 thc ol l brl sccl rtre N c w Z c a l i rn cl ancl S w ccl crt rccci vc tl l crtl ' As fo pati cl l ts < l f ri ght thc p ro v i d c s e rv i ccsl rs opposcclol l N IIS ,' l tl hi s IJri ti sh thc to H a rri s o n (2 0 0 1:279) 9$scrvcs i n rel rrti < )rr pr()p()l ' rl () lls i rtcrcasi ng (that i s, cap) e l rrb l c sg o v e1 1l l el tts t() " crtsh l i nri t" o f th c rrn n u a lN tl S [rucl gct' . (.< l n C e rtrsA l )otl t c()S tprcsstl rcsl rtrclC < l tl tl ti tl l l l el l t,ttl l i cther rvi th th c l l o v e to a ;l tr[tl i c c()l ttrrl ctrl l < l cl cli rl rl eti onel he:rl th scrvi ccs,l tor' r' cveL I eh ()l l the ;l < l l i ti calegcrl cl, r . Irrv e p u t tl rc i ssl c 6f l esrl i cti rrgtrcr' ttrl tutlhi rttctl l l -l tsto tl cti rl c crl re serl i ccr Zcrtl trncl ' s N cw l ty T h i s i .sw c l l i l lustrrrtccl (.hrtptcr crl scoi l ' ,ri tai rl ,rcsotrrccs i rr thc (p. S i nri l arl v, I l 7). 4 c l i s c u s s c ci n[ to l l l rl l l i l g,cthe ir crtc()tl l ' rrgccl w crc [c c rrl tc ti e h tc r a6cl Icel tl r authori ti cs l ccci vcclcotl sicl reti orti rtg Iu c l g c ts b y s ctti rrgpri ori ti cs. r\t thc sru]l cri nrc, rcsttl t P r< l bel l l yl ost i ts c ra [rl c rn e j c l i artrrclrrc,rrl crni cettcrtti < l rt,tttclrts a (l l : rrri sol t,t ,r1..2()02.).i \ rccetl f crrttl l pl c i s thc N eti onel i r.rr.r< rc c r.rcc -l ' hc usc of sci cttti fi crttl clcvi cl crl ccbrts et l Irrs ti tu tcfo r (l l i ni cel l .-rccl l crrcc. gi vc thc l rl sri ttrtcl cgi ti rl rrcy,yct i ts l vorl < i t ofte ll l sccl c ;i tc ri r i s s L t l -11.r
Thc Mcdical I'roicssiort
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144
ComParatiue Hedlth IlolicY
measr-rre ci'alit y :rucri t has bcen i r rrng-standi ng ..f. The ' rccri cal n -tn n " g " n..nt.A sal ni nstrttnl enttosystel rati c:rl l ycval u:rtecl i ni calcar e i t l .rasbeen pronroted heavily a n c l i n creasethe acc.untabi l i ty of doctors, clenronstriltcill thcir conlparaby g,ru.r,].erlts. I-{tlwevcr,as Herk c/.ai'. r.l1edicalrrtrclitclelrlolrstratcs llritain, tlu.'rtudy Of tl-reNcthcrlancls and trai ntai tl rl Ll torl ol l rvt hr
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The Medicdl Prrtfessirtrt 147 Boirrclfor Hcrtlth altcl Welfare ernergecl:1sorle of the kcy .lctors in cluality o11 lnt l l ti tl a e l l l c n t.T h e l i rrtrc l i te c r trl c rcsp()l rsi l )l ci or c< l l l ecti n!l cl rrti t of i ts l ' l rol l i t()ri ng hea l th o L rtc o rre sry rc l !l ()o c lp re cti cc rrl rcli l ttcl l si fi ecl g< l vcrntrrettt, hc a l th c rl rc p c rs o l l rte l a l td h c al th crre pr()vi cl cfs.F()l ' the < tfi ni l ucrl ci rl grrl l d nl ()l ri t()ri l l g b c c,'l n,tre rl ' l rcw rrrcrl tts q. r l l i ty ,-.,r,,,' .' ,,1 i a ,rr" w i th thc lr c a l tl -,c rrrc ' ((i rrrp c n b ,v ,l c )9 9 : 40c)). S i gni fi cerrtl v,ancl i n l i rrc tl nl l ' pr< l vi cl cgcl l crrl l i tgetl ci cs l rrl ti ()rr11l b rri l c l i r rg, c llp h rrs i s o l r c o n s e n s r.rs strrrtcqi cs tl cvcl < l ' t. cl tl ctors f()r spacc gL ri c l e l i rrc lsc,rrv i l g c o l ts i (l c re l ) l c trtrrc, srrtrtc A t thc 197). l t)c.)7: ((i erpe.51' , rh,a c lt .c rrl l c v c l ii. 1 .l .;," r1 .1 .,-1 tI1 ()l l rcl cv:ttl t alt h ,ru g h c l o c to rsc l o tttl t h rtv eetl V i orrl l el l -cpl -cscl l trrti ()l l thc. ()tral i tv N {ctl i cel thc s o v c n l n re n t rl s c n c l c sa rrc lc o n sul trl ti orrc()l )tttti ttccs, i for rccrtl i ti rl g ntl i i ' i cl scrvC srl s rt 1-r< l ol O , ,u ,rc i l ,I b o c l t,s c ttl p b y c l < l ctors.
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Paying for medical care rrrc p rri c li s tl < l ttlrcrcl y 11tcchl ri crrli sstrc;i rr frrct' systttl t tti I I9 w c 1 < tc t6 rs ()f r.1llrltcrlltion rtrc inrportrllrt p()ttrrcrsr() p()wer lrtrcltrrc llt thc celltrc [crs ttr hcrt t' e t 5 c rc g u l e ti 6 l o i rl o c to rs (M o r i rrt rrtrrlW otttl , 199.1).1)tl w er t h c p ri v i l c g c ()i (l ()c to rst() l )e rcw i rrcl eclrtccorcl i l l !lt() thc tl l ccl i crl ltrerrtll l (.n t tl tt.1 Prtl v i tl ... \y s tt.rrts ()l r' (' nl url (' l ' rl ti ()tl(i l tl .' i tl l t' r sttst;l i tl tl r cl i crscI d1.,2' 002).' l -hefec. c o l s trrri 6 th i s p ri v i l tg e (i o r.tn ot' r' t' r' l r' wscc.l prri cl for thc i rl tl i vi cl tral rl re cl octOrs l vhi ch u n c l e r f Or-s e rv i c c s v s tc l 1 1 , thi s tl t;l e of rnccl i cl rlpri vi l cgc stl pports se rv i c c s rc n (l c re c lt() p l tti e l l t s, l l v sal ary therc i s l i ttl c prryl l l el l t ll l ()s t c x tc l l s i v c l .v ' l tr c o trtrrr st' w i th pi rl rl clthe ' tynl el l trecci veclby c()l l l c c ti o l t l te fw c c rrth c s c rv i ccsrertcl erecl c l O c t< l rsIJ . c tl v c e nth e s c n v < l cxtrcnrcs i s prr,vnl ctl tl l rrseclorl ceP i trrti (}rl ' w l rc rel ry c fttc trl rsa rc p a i c lrrc corcl i ngto the tl tttl l ber of prl rti cntsrcgi sterccl r v i th th e ' i r p re c ti c c .' fi tp i c a l l , v,hosl ' l i trl lcl octorsrecei vci t sal rl ry,rvhererts 1 ;i fi c c -[rts c cdl g c to rs rtre p rti c lon ei ther rt fce-i or-servi ceor a cr' tpi t.l ti ()l l ltrrs i s .l r.rrrd c l i ti < l nto s y s te n tsof prryrl ent, rrtl othcr i ncl i cati onof rncdi cal p o w e r i s th c ro l e o f d o c to rs i n the cl eterrni trrtti onof fce schedtrl esl l ncl Iil ylll( 1 1 t \f r tle ttl r ( ' \.
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1.56 ComparatiueHealth PolicY of mecl i calassoci attonsat T h e re a re l i te ra l l y hul dreds, i f not thor-rsands, arl thoughthe A MA i s and U S A , i n thc l evel nati oni tl s ra tc and th e l o c a l . communi ty i s consi drnecl i cal the of vgi ce thc th e s i n g l emo s t i nfl uenti al , c()untrtes. e ra b l y n o re d i versethan i n other (i e rma n y p ro vi desanothcr erarr.rpl e w herc thc organi zati onof doctors' btrt rtl st r i n te re s tsi s c l i vi cl cd,n.t rnl y bctw cen di ffercnt types.f c1< > ct.rs, rnai n i s the Il ttnd Thc Mdrburgcr b e tw e e nd i ffe re nt types of Organi zati orr. Ilt-rt the ,trg,r,-,ir"ti,r,tirncl tracle union for hospital clocttlrs, pr1;fcssi1;nal i s m< l rcc6nrpl i catccl .' fh c ,i t.r,,ti .rns u rrguncl i l g aml )Ll l i rtorycare d< l ct< l rs excl trsi vel yrel y orl pri vate prectl cc canl l ot of thcse cl < l ctors v a s t n ra j o ri ty soci al l rcal th i tl surrrnc e. the uncl er scrvi ces a n d i n s te rrdh r rvc to provi cl c of i rl sttrassoci rtti otrs regi onal j oi ni ng of the onc IJ g w c v e r, th i s reqrri rcs assLl l l l cl l l l n)' " vhi ch rtgc a n c c ftrn c l c l < l ctors( l i tt sscni i rztli t h a vcrci rti gu rrtlci (lloscrtbr
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th e i n fl u crrceof cl < l ctorsrn heal th p< l l i cy,resul ti ng ,n t, ."* " rf..r.a " rrU rnedi cal p16fcsi1 a w i c l c n i l g ri ft b c tw e e n tl -rep:rrti es.S i gni fi cantl n the l ead to a mrl i or s i o n w i rs p ra c ti c a l l yc x c l u c l e df ront thc pol i cy rcvi ew that K ay (2001) sces r e fo rn i ri th e c a rl y 1 9 9 0 s (H a rri s.n,200l ). S i mi l arl v, ci P fund hol cl i rrg t h e c O n c c p ti O n ,rrrrp l e n l e n tati orlancl rtl l < l l i ti t)l lof the medi cal prtl fcsof the i rrfl trcrl ce w crrkcr s c h c l rc a s a n i n d i c a ti o rr o f the c()rp()rati stscttl cmetl t eerl i cr thc t() si o rr.T Iri s s ta ttc l si n s l .ra rpc o ntrrrst ()f ggvcrnmcnt i n cl ()ctors rol c t h a t w a s c h rrra c te ri z e cbly a s tr()l rsi trsi cl cr regresscd ( (i i a rn 9 , 2 0 0 2 ).Si m i l a rl y ,i 1 Austrel i e, thc Mccl i crrlA ssgci ati t)tr prcssl l re ew kw arcl f r ,rn , c ()m fo rta b l cc o rp ()rl rtcst),l cP i rrtl l crshi pt< l i l l l " l cgi sl as ovc. l rr' tti ol ralhcel th i ttsrtrrtrtcc f r,r.,p w h c r th e p .l i ti c :L l s tru g gl e (,.ve rntl .tct.ttl cacl crs ). i n l c )7 2 (l )c V i re atcl S h.rt, 2(X ).1 t i ,,n " ru p t" .l rltttclcrcl tccl fro rrr kcy pl al ' crs i rl thc hcal th rtrct.tr' f ,rc c csl tro rrg< l p p o s i ti < l rl -l -hi srcsul tccli n rr rcrrl i grl rl l ctl w evcr, ()i n a rrc c o ffe rs c k rc to rs n tu l ri pl c P ()i trrs i tcccS SS. i grri fi cantl y, by the strtc, rl nclafc c l g c t()rsrl rc i n v o l v c c li ,r e p g l ) l i c r()l c grrrntedt6 them pri vrl te i ntcrests' of feprC scl rtrrti vcs rl S l to t fi rs t a n c l fo rc n l o s t i rl v ol vecl abovc rrrl clcrtt' t di scussed i ntcrcst of l l ti s c rrr l e a c lt< tth c I< i n c l so f c< l nfl i ct oi doct< l rs' a l s o c o n s trtri nth c c .tl l c c ti v cpow er the sct' 1' ' c()f o v c r th e l a s t c l c c a d cth e fcdcral governl l l el l thas expandcd i ts,rcti Y i ti cs. s e l f-a c l n i n i s tra ti o nw h i l e rrt the sar.neti me ci rcumscri bi ng cvi tl tt' tti rtg frtr l -0 r c rrrn p l c . rl rc i ()i rrte ,rn r rrri ttct' i stt,rw Jl \() re\ponsi hl c trerl tnl ents' th e rn c d i c a l e fi i c a c y a n c l e conomi c effi ci ency of exi sti rrg
1.58 Contparatiue Hettlth Policl' nray l rc subj ect to i r ti nreti rbl cw i th tl rc possi bi l it v Is s u i n g s r.rc hg r,ri cl ance o f a u n i l a te ral cl eci si ortl tv thc tl i rl i strv. Thc pencl trl ttnlhrts sw ttl rs frotr . l tow rl rcl s hi crarchi cal cl cci si < l nsb,v thc strr t e a L l to l to n to u sneg()ti t.tti ot.ts (l l trri ru , 2 0 0 .5 ; Ltrzi 1;,20()4; W encl t ct ttl .,2(l r05). T-he govcrtrttrctrthas rttrclhes sct c l e fi n c c rn l o rc prcci scl r,thc substrrnti vei ssuesto be cl cci cl ecl l l ccotlr c have I)< l ctttrs reachccl . bc has t< l c l c rrc l l i u cbsy lvhi ch rrgrccrl rcl rt preci k e y rrg c n ts o i cost contrri nrrent through sel f-rtcl mi rti strrrti ()11 scly i s acl rrptabl crrrrclcl epol i ti ci zcs b c c rru s eth e s r,stenrof scl f-ecl nrrni streti on th e i rl p l e rn c nti rti on oi 1' rotenti al l rprobl crnati c pol i ci cs ((i i ertr< l rl rlcl M rrn o r,v ,l c )9t): t)78). \e t. rr,ecl tt vc,trs h,tvc bcctt charactcri zetl l l y r r llt' ( .iltr ' r stt.p 1 lqj 5;11 .tl r()ut
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Doctors, the state and health policy ertclsi l tccthc strrtcl oott r s i n hcel th svstcrrrs, l )o c t< l rsrrrcc l ccpl ycnrbccl cl ecl l a rg c i n h c rrl th systcntsencl pol i cy, cl octorsi ncvi tebl l l rrtvcrt cl < l scrcl r r ti o n s h i l -rrv i th thc strrtc. l ' hi s l ttcl tl ts trv< l thi rl gs: rl rccl i crtlp< l rvcr w ill trl w a y s l )c c < l nti ngcl ttorr thc stetc, btrt sti l tcscrl l tl tot cl tt' uvi fhotttcl octors. rtq rs' otl ' r' t'()tl : ( \v.l \ ol tttttl t 'r L i g l rt' r ( | ()9 5 ) rroti rrrrol ' tor.rr' ttt' r' vrri l iporvt' s te n c l i rts th c cl < l sc, l ttrt rr[tovc el l charl gcrl l l l c, rcl eti orrshi l l l l ctw ecr l e n d thc strrtc.l l crc, tnccl i crrlpow cr i s scetrto < tsci l l etel tctw ccn c l < l c trtrs h i g h s rrn c ll o ws. H i gl rs < l f nrccl i crrlp()w cr (cl orrti ttrrrcc)l trttcl rrcci rrtl ta lrrn c c strn c l p r< l vol < ccoul ttcfvai l i ng,p()w cr\ ol i * i rteri rtg i t' otl l thc strr t c, th i rc l -;l e rty p i tycrs encl peti cnts. -l ' hi s i tt tttrtl :ttl tl < l vcr ti tl .tc w crrl < ct ls rrrc c l i c rrl c l o n r i nrrnccrrttclstrcrtgtl tcl tsthc p()w cr ()f thc stl l tc. I1 h i s c l i scussi 11p 1l f thc l i otrcai rl rl i rtnttoti ott of ' sovcrtttrtcrrtel it y' (1 9 9 .5) .f< l h u s o rr l l ocs ()ne srcp i urthcr rrrtclsuggcsrsthrrt cl octorsatl cl thc s tr' ttci l rc i n ertri cel tl v l i rtl < eclthrotrg,hthc process of goverrti tl 13,. .f< l hrl s or l (1 9 9 .5 :9 ) < l b scrvcsthrrt' l cl rpcrti sc, rtsi t bccrrtrci ncrcrrsi rtgl li ,nsti tttri o t l of govcrni rl g '. forrn, becrrrreprrrf of thc 1tr< l ccss a l i z e c li rr i ts trrrofessi onrrl thc strtfe:th c rrncl rl octors It i s i rrp o s s i bl e to cl i sti ngui shcl cerl v bctw ecrt ()f (l oct()r' \ \L' ertrL i rs c.rpaci ty tt r [() s trttc d c p rc n cl ol s t thc i nrl cpcnrl cucc g o v c n t, l t p r( )cesstl trough l vhi ch (l ()ctorsl tcctl tttci rgel l tsof goverrri r r g. cl < l csIt()t rl tertttcl enyi rl g shi fts ir r i ncl epcnci crtcc H o w e v c r, rrcknow l ccl g,i ng rellttions bctwccn thc cloct
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160 Cctmltarotitt e H eahb I' rtlit:1' thc hei rl th system' the' vcan bc rernotc from to th e h e a l th o f i ncl i vi cl ural s' w c thcrefore anal ' vsi sof heal th pol i c' v L -rth e c o n te x t cl f < l ur conl parati ve rl otrl bl y carc < rutsi cl chospi tal s' ar.rd n e e d ttt fo c u s o n a speci fi i aspect.of to health s'vstcl.I-rs' of carc that is closel,vrclatcd pc.pl c crrc f.r .l cl er pc.pl c' Ol cl cr ""'^0." T h i s c h a p te . t..,.ur.* -,,,,' i ;,;. rc p re s c n ttl -re l a rgest.o" ,l .,..,upofcererl trtsi cl el rtl spi t.rlinslhc:rlth rrrcl i trtl refacc polic-v consitlcrrrblerlttcrltion Of rrgcingsocrcrrcs,;:. ;;,;:r'.cl hcl l th to cl oscl v rcl rrtccl i t" t.l l dt' ;" t' 1-' l c i s rrl so ' fcstcr tc rn ts . Il o n rc ." " \l L)96 76\ i rrvOl vcrrlnt e of nurses. s y s rc rl rsrts , c l c rnonsrr" ,.i i ri ,r-r. c l e s c ri b c s h ()l l l cci rrcl s.l l l l },11,pe< l fcat.cl rtl cl Sspeci tl pp()rt< l fi crccl ttl tl l ci b'cvr sctti ngs' el i zccl or nt" ' ttt' , * fi t11tt ordi ri ar-Y th e i r i rr tlt llctlvl1 -rc o p l c tl'rt-tgc Fltltle crrrc itrvolvcs ll rviclc ftlrtlrlrl lttlcl itlt
ers",,.1';i;;*';;';1ll;i;:]i c,,, i,,i,,'.,".r ;l[ iL:l'11;illill ;1;;l.l';;.iil itlrportrrllcerlllcl lll sccotrclrrr,v
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- l' h c rc i s n < ts h o rta g c o f p o l i ri c rrlrl cbri tcrtbtl trtthc r.' rrl trc of crl rc i l l thc i tl trrrl erl cl col l ccti vc i rttl i r cttt betu h' r t rc rrl c l th c rrp p ro p ri rrtc b rrl rrrct' tl l c bcr" orrcl i s hepperri rrg uhrrt r c s p .l s i !i l i ti c s . Il 9 w c ' v c r, i t i s l c ssccrtrl i rt i tl te r i s r.' l hi s tl rrcsti otl lc v cl 9 f rr1 ;l i ti c erh l c t6 ri c :rn c lrrt thc l ere l of pol i e cl trc \ Ie l ' speeti \ c l teel rttsel tol l l e c s t il te P l l l -ti c L l l a fl )'fr,rtl t .t e( )l l rP ' l l ' i l tiL' l cotl tttrr' costs,brtt,tre sh,tl .teibl entl d c n ro g re l .,hr [rv e rc p. lic :i c s 1 -rrrs h e c l provi ti ,,rr tti fttrtcl i rl g rrtl tl hou' tl tc i n c l Lrrl c i rrc to l s I(c v s pc c i i i c frtc fo rs . bottttcl rtrt' cl rrrn' thc svstcl rl s hc,rl rh r,r' h e re lr c e l th c rtre i s o rg rrn i z c rl . thc rl bottt i rssttl l l pti ()l l s ctrl ttrrrrl rrrtrl 6c t w c e p h c a l th ri l tl s o c i rrl c ,rrc , l rttcll l ctw cctl w ol l l cl l i l l l tl app r()p ri i l fc rc l l rti O n sl tetl v c c n th e gcrrcreti Otts ctt nr c i n ,w l t rtt l ' fe tr-l ' .fi i rrg c r (2 0 t)4) calI s' gcncl cr l tttrcs" Al e l y s i l g th c p o l i c i c so f h < l n tec:rrc i s l t()r ()l l l v topi crrl ,l l ut al so oi i e rs Il < l nl c carc hi ghl i ghts thc s1' stcttrs. , ' . r " 1 ' ,.,:r1 ' ,..-ti vocns l rc a l th ;r< l l i cVr' rtl cl of hcal th crl rc pr()vl sect()Is cl i fi crcrl t rrtl to trg i trtc rrc l rl ti < l rl s h i p s c ontl -rl e r scrvi ccs, as w cl l es w cl farc rl thcr etl cl c rrrc h c e l th s i< l n rrn c l b c trv e c tt ' fhi s f< l rccftrl l ycl cl l l ()l l strrl tcs crrrc. h cal th i rrf< l n n a l lr c t w c c p i 1 ;rrl e l rrl c l < l f hcel th crtrc rrri sccli n Ohrl pter l . H < l nl c t I e l tu l ti i a c c tc c l c 6 r[c c l c l c c l n c ss that tttarl v (( c llr e . i l s w c l l a s p trl tl i c h c rrl th .heptcr 7), el so cl cl l l < l trstrrrtc syS tcl l l s' hcel th < l f tl l rtrgi trs s c r v i c c s l l o w c c tttri tl t< l l rc e l th rl rc i tt thc of hcel tl r pol i ti cs I r in rrl l y h , o n ' rcc l rrc rtre k c sfo r rrrri ntcrcsti rtgsttrcl vof thc c r r rcl rc c rru s cth e rrc c l i c l rlp ro fc s si oni s l csstl i rcctl v i nvol vccl :othcr l l ctors l c rc fo rrl l a g c l rc l rl lsl crc. r r r c p r,l s h i l tlth s horttccrtrerttl c[hotl ' tccl trc pol i ci es T h i s c Irrp tc r p ro v i c l c srtn rrn e l r-siof crrrn.ri ttcsthc si ze rl ncl i tl port,rtl cc of s c c ti ()l r fi rs t A f . r i ;l c l e r p e g p l c . l o()ks evai l rt[rl ccl ate.-l ' hc l l ext sccti ()11 of h61 1 cc rrrcth r< l u g hrn l rn rrl y ' s i s l rtl cl horv orgtrtl i zati orl tl rc rrrtcl cr' rrc r ' . r c c l 1 ;1 s cal vt tl -rcp ro v i s i o rro f h < l nre w i thi n systcrl r of herrl th typc t hc l c v e l o f p ro v i s i rl n a rc s h rrpcclb,v the hor-l le tl f ftrrl cl i ng whi c h i t i s c rl b c c l c l c c ll.)ro v i s i on i s cl oscl v ti ecl to the gctrer,,ti tl ' ttf c r r r c . w h i c I i s c ]i s c g s s c cnl c rt. Tl .re rcl rrti vc scctl ri ty rrncl for the grtl w th ancl ci evcl 6pl l l cl l t()f f lr . rc l i n cu re fa v 6 u ri ' rb l ec < l rrc l i ti < l ns hon tc c rrrc rrsa c l i s ti n c ts e c to r tlf hcal th cl rrc pr< l vi si tl n.A n< l thcr i mp< 1rt r r n t i i rc to r i s th e re l a ti v e s trc n g th oi pol i ci es that erpl i ci tl y sr-rpptl rtthe substitr.rti619f iormrrl lrtlme care for both instittttitlnally bnseclcare anci info rma l c a rc (Bo o m, 2 0 0 l ). Thc fo6rth scctiolt l
lo2
L t)tl tl )J ro l i ut H t' tl l l t l ' rtl i tv
carc gi rers' by r.rnpai cl rn i rj o ri ty O f h o rne ci tre col rti nucs to l )c provi cl ed of rci ornl s are U n c l e rth c b rtn n cr of a greater w el fare t' l ' ti x,the obi ecti ves ftl rnl al carc arral l gel l l el l ts to l l l tc g ra te c a rc gtvers rtrorc expl i ci tl y i nto relatcclllerlefits. irrlcl pavnlerrts ,.,.r|.,ppOrtcirre givcrs tl-rr
Home care statistics ( .tr r il| ltr t.tl
t( ) ( )tl tt.r.\('Lt()t.\
tl t tl tt.l rtl rl tl l
< 1 1 h < lr .r r c Cilr c l tfc sC rl rcc l rl tl
rl ftctl
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i tl tt't'ttl tti ,ttt,tl T'[i s
st:tti sti tr
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cl l tl l
svstcl l l s'l )i vcrsc' i l l u s trrrtc sth c tnrrrgrnrrlpOsi ti onoi hOl l tccrrrci l l herrl tl r rl ral < ci t i l i fti ctrl t ttr of ftrrl cl i rl g s p o ra c l i ca i l ,.1
' l ' h e to trrl spcncl i trgon l Ong-tcIl l r cl l rc i rl ' frrl l l e 6.1, w hi ch i rrcl trc lcs th. rcl rtti vc h .' rc rrrc li rs tituti ,.al l ,v t' ,asc.icere, gi vcs a fi .st i l l di ceti rl ' .f totttl tIi c r of l l l ei ori ty rl ' rc provi si < l rl . s i z e < l f th i s s e ctor of hcel th crrrc (i l )l ' .' fhc of ccrl t pcr 0..5 s p c n c lv c ry l i t tl c < l rrl orrs-tcrnt crl rcr rl r()tl l l cl , vhi ch s' crl tl 0' 6 i i ,. N cthcrl rrrrcl se.i l S ' vecl crl r' ,.ta 5 l c c x c c p tl ()rs " r. M()l ' L(' ' " cl i;t i s l i hcl, v a rrrl0 .1 1 2p c r ccl l t ()i thei r (i l )l ) orr l ol l s-tefl l l L;.' tl u. i s trtorecrpcrl si vcthe r t th rtt tl ro s tg o c st() l l l sti tLl ti ()l l l l l l vl l ascclcare' l vhi ch h < l tn ec rrre . 'l l-rcpcrccntrrge()f 6-5-,vcrrr-
Hcalth Carein the Homc (2000) Estimated'sltending on long-term bome care as a Percentageof GDP
Tablc 6.1
I t tt,tl sl tt'rttl ttt.q
0..1lJ nir 0.47
A trs trrl l i a Frlttrcc ( i c rn tattv Ita l r . l ap arr N c th erl rrrl c l s Slvctlctr Lll( I IS A l . t lCs ' . l. t tl l
n/r l
-
163
n/rt
0.2.t 0.60 0.u2 0.4I 0..19
PublicsPcntling 0.30 n/rr
0.4.i n/rt
0.2.5 0..56 0.711 0..12 0. 17
Il( ) t r tlr tilr tblc
S o ttlr ' r ' : l) r ttr t fr or r r ( ) l:( ' l)
( J0( ) 5)
..:to . thc "l()l-C
Tablc 6.2
,. . lc t -- .lr e
settings ds cl Popttlation aged 65 dnd ouer in different cdre percentage of the total lxtpulation"
I n il tsttl ttl t()tts
r \ \15 -.
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Itrrl y .laprrrt N ctherlrtrrcls Sr'vcclcrr t il( LJSA
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| 4.7
n/rt .1.9 rr/rl
n/rr al
7.1)
n/rt .5..5 12..1 9.1
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20..1
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2.u
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\o rr r r ' i' : l) :ttr t fr onl ( ) l- .( ' l) ( 2005) '
the i l .nportanceof pcrc c l rtrrl j el i v i rl g i n i rl s ti ttl ti o tl s, thus hi ghl i ghtrrrg lr()r'lt(' r'rlr(' for t rltlt'r 1'rcoplt" rr m.rc in Tablc 6.3 i-t-," llrowrh of iristitutir)nalizatiorr rates 'ffcrs i nsti tuti < l nal l ybi rsecl of c l e ta i l e cpl i c tu re o f h o w th c re l rl ti vc i mportance growth of Sr'veden' ercepti
164
ComparatiueHealth I'olicy Table 6.3 The growth of institutionalization rates of people aged 65 and ouer ("1,) -0.4 -0.2 -0.2 l..t -0.2
A ustral i i t" A ustri ai N orw ay' S w cdcn' U S A .I
'' l ri grrrcrcfersto unrw ,thbctl vctn | 995 rrrrcl2()0.1. '' Iri gLrrcrefers to grow 'th benvccn 19961|9c)7an(l 2000 ', l ;i grrrercfersto grorvth betrvct'n| 99 | rrrrtl20(X ). I c)99 'r l ri {:trrtrcl crs to qrorvth hctrvcert|97.1IIt)l { 11y11l
S otr r r 'r ': l ) r r tr r fr or tr ( ) l r ( .1) ( 20( ) .5) .
Tablc 6.4
Number of long-term care bedsper 1,000 people I ()79
/ 9,9I
/ 9,q,9 199I
l99g
200.1
Arrstralia
4.1
4.7
4.4
4.2
4..t,
.t.0
Francc (icrnrarry ftaly N c th e rl a ncl s Swcdcn tl K
n/rr n/rr n/rr .1.| n/a n/rr
n/lr n/a n/rl .1..1 lrlit n/e
n/a n/rr n/a .1.4 n/rr 1.1
n/rl .1.7 n/a .1..t n/rl .1..1
n/lr n/a n/a 3.7 n/a .i .l J
n /r
-
L).1) I'ri.6 2.7 .i .8 n/ir .1.I
n ( ) f e v.ri l rrbl c
.\o r r r r r ,; l) a tr r fr orrrOl r(i l ) (2{)06).
rrl tc s rl rc n e l i rtti vcrl nd rtre rrl )or.rt0.2 per ccnt. In nr()stcountri cs, tl ren, fe w e r p e o p l c tcnd to l i vc i n i rrsti tuti ons. In prl rt, thi s rcfl ects pol i cics c rp l i c i rl y a i rnecll t cl c i nsti tuti orral i z.r.rri on. H ow evcr. es ' l afi e 6.,1 i 6d ic a te s , th i s c loestt< l r l l rcrl l r thi l t the nunrbcr of l on{ r-tcntrcarc becl sIr as fa l l c rt.Irr th e nrrrj ori tyoi countri cs, thc nunrber of bccl sperrI,000 pcop lt : Ita s i n c re a s e cl over thc l rrsttw () cl ccrl cl cs. l rr A Lrsrrrrl i rrncl a thc N etherl rrncls th c i n c re a s e shrrvc bccrt tnocl erl rtc,w hcrel rs i rr (i crmrrny i rl rclB ri trri n the n L l l n l )e ro f l o ng-tcrrn becl sl rasabotrt doubl ccl .In short, i n rnost c()Lntt nes i n s ti tu ti o n a l Iy bascclcl tre c()nti nr.rcs to be i nrporrrrnr. Irre s p e c ti vcof the i nconcl usi vctrends i n thc provi si on of i nsti tuti ona l l y b a s e dc a rc, thc spcrrcl i l rg, on other types of scrvi cesfor thc cl cl erl yan cl d i s a b l e d h a s i ncrei rscclsi gni fi cantl y. Tabl c 6..5 l i sts pcr capi tr.rpr-rblic
HcalthCarein thy Hlme Tabfc 6.5
16-5
PercaPitapublic exPenditureon seruicesfor the elderlY and disabled(USS) 19,8.1
A u s tra l i rt Fra n c c ( ierrn e nv Italy f a p e rr Nctl.rcrlirrrcls Ncr'vZcrrlancl Swcclen tJl( TlSA
rr/lr n/a
2 n/rt n/a
/ 98,9
t9e.l
n/a n/a 6 n/a n/a
n/a 6
27
.17
n/rr n/rr l. i Iti
n/l t
rr/rr 1/ :1 () .)a
.til n/rr rr/lr ll8 n/rt n/rr n/rr 84
1e98
200.1 nl'.t
4 912 129
157
n/lr
rr/a
4 6ll ru/rr n/rt n/a ll.0
l0 t'rlrr tt/rt n/rr n/rr l.l I
n / r : tr ( ) te r ' ,r ilr lr lc
,\o l t'tt' :
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Lompdrrttiue Haalth Policy
policy, providing cgrntrut'rity care scrvicesto the frail ageclancl ,voltngcr p c o p l e w i th cl i sa| i l i ti es. The ai ms 9f thc P rogrrrnt rl re to provi dc r r 'contprehensivc,coordinated alrcl integrrrtcclrrlngc oi ltasic rtririntcllr:tnce a n c l s r,rp p < trservi t ccs' for i rai l cl cl erl l ' peopl e erl cl thei r crl rc gi vcrs t o ty l i fc thus cnhi tnci rrgthei r c1r-ral i oi e n i rb l eth e m t o bc rn< l rei rrcl eporcl ent, nti r t l rrn c lp re v errti n g tl rei r i nrrppropri ate rrcl rl i ssi otrto l ortg tcrrtt rcsi cl e of c a rc (A u s tra l i arr[)cprrrtnrcntof H eal th rtnclA gci l l g,2006a). Thc t1' 1-rc s e rv i c c sfu n d ccl i ncl ucl cnursi nl l crrrc,rrl l i cclhcal th crrrc,rttcrl l s,pcrstl tt al c l trc , re s l -ri tecrtre l tncl couttscl l i rrg. S ontc scrvi ccs chrrrgc rl srl l al l fc c c l c p c n c l i n go n rbi l i ty to prty artcl the tttttrtl tcrof scrvi ccs tl seclbtrt this v a ri c s fr< l r.nstrrte t() strrtc. l )cspi te FIA (l (1, ottc ttrtti < l ttl tlctl rlfut' cttct ' A trstrrtl i a' s hotrl c cl tr c c o rrc l u c l c c th l l t' rrtnrprurt l )urcrrucl -i ' tc,v' rl ei rrtt rrrlcl . p ro g rru n l rc s for thc cl cl crl l ' l vcrci n cl i rc ncccloi rrrt ovct' l trrtrlF.xperts rrc l v o c a tc rrg s rccclthat crrri rrgtor thc cl cl crl ,vi n thci r hotttcsrtcccl ctlt< l l lc bctw ccr t . hcy'cnti ci zccl thc l tLrcl < -pessi rtg s i rl p l i fi e c l ru r clbcttcr frrncl ccl1' anclthc statcsrrnclargucclthc systetttw oLrl clbc l l cttcr th e (l < l n tn t< l l tw crtl th Itr respotrscto sttch cri ti ei srl l , ir l rl n l ty ()n c o r fhc othcr (\rV r< 1c,200.i ). S !rrrtcgl ,fi tr Ornrtntutri t\t(' ,dt' (-' l ' bc A N cl l rcl casc{ 2 (X)4 tl rc M i l istrv ' \X/L ty (i ovcrrtl l tcl rt' s vi si ort i o r A trstrel i an l -o ru ,trr l rhat outl i nccl thc ( s trc ru trl i rri n g l ontntonw crtl th frrntl cclprosri utl tttcsartcll trovi cl i ttgrr tttor c c < l rrs i s te l t el cl c1;1;rcl i rrl rtcrlcornrnuni ty crtrc scct()r (A trstrel i a r t [)c p a rtn rc n t of H cal th ancl A gci ng,,200(rb). T h e rc i s a si rrri l arl l ()vc t()w ru' cl s!l rcrl tcr pul tl i c i ttv< l l vctttctrti rr N cw Z c rl a n c l . L J ncl crthe rtrtti < l rtl rl' A gcrrrg i rt I)l rrcc' P r()sri l l l l l l l c i rl N crv pLrl l l i cl ystr[l si tl i zcclA. s e Z c a l rrn c l ,h o n re cl trc scrvi ccserc i ttcrcrtsi rtgl .v ttttl rc thrttt cl otrl l l ccl erpencl i rtrrc rc s u l t, !l ()v crnl l cl tt h< l nc sup[)()rt 9f I l cel th, 200.1: (N ew Mi ni stry Zcrrl rrncl l rc tw e e n l c )9 516apcl 2002/.1 rt w i tl e rrtttseof l totllc 4 0 ). T h c g o v cnl nent prrti rl l l y or ful l y strbsi cl i zcs c\pcrti \L' c rrrcs e rv i c c s,parti cul erl v thosc thet cl cpcncluporr professi < l ttrtl l ty rtcccls s u c h r' rsn u rs i ng. Il i gi bi l i tv arrcll cvcl of scrvi cc ere cl ctcrrrti nccl -f hcsc rcccl rI cl cvcl ol ' rncntsrrrc typi cl tl < l i rt crrrc rcgi rrrcthet rts s c s s l n c n t. c < l rrtl ti u c sv ery l i rl i tecl uni vcrsal i ty w i th l l l crl l l s-testi rl g arl tl w hcr c p ri v a tc l y p a i c lanclcheri tabl c scrvi ccscotnpl ctrtctttfrrnri l ycarc. l tt rcl rrti ot t i t i s rrl soi ncl i crrti vcthat tl rcl c are ecl cl i ti < l rtel cotttrtttr t t it l' t< ltl re l ;ts ti .rspcct, s u p p o rt s c rvi ccs thrrr rrrc rr< l t prrbl i cl y funcl cclsuch rts tri rl tsp()t' trl r i( ) t l w h i c h rrrerrl sooftcn provi cl eclfrcc of chrrrgct() persorrsi rt nced.J' l tc trtrr ir t s o u rc c o f frrncl sfrl r thcsc servi cesi s thc Lortcrv (i rartts l Jortrclw hi cl- t ttls. p ro v i c l c sfu n cl sto rtot-i or-profi t < l rgatti zrtti <
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ComParatiueHedlth PolicY
i ndi vi dual be nema k c s h o m e care an i ndi vi cl ual l yearned ri ght, al though social ctrre (as fits are ofren needs-based.Integrated funding of healtl-rand cirn acld further is the case in Australia, thc Netherlar-rdsilnd Sweden) and to ir lesser USA the In contrast, security to funcling ,.,.r,,,-,g",.,,"nts' (Teo ctal ' ' 2003)' This fundi ng pri vate h" " ui l y on e x te n t.s i ,' ,g" p.,..,1.1y sanl c ttt nt '. A t the i ndi vi dual s. for u n c l e rmi n e sthe sccuri ty of fundi ng as scrvices rccl ucecl beetl t' trrx-furri ed horne care have :rl so e n ti tl e n .re nts as lrerlnsdefinccl or h:rve been trlrgeteclto the very tleccly(as ir-rSwcden) toget hcr prcssures te s te ds < tci alcare (rrsi n B ri tai n). Thi s rcfl cctsfi n:rrrci al co Llnother l css, turn tow l rrcl sw cl fi rrc rni x. N cvcrtl .re w i th a n i c l e ol Ogi crrl covcr ir lg tri c s h trv e s..n th. i ntrocl ucti on of tl rr-fr.rrl dcclprogral l l l l cs tl f t lcw i rl trgcl r" rcti 1;rl tl l c vetl e rrnd U S A ) thc h 1 l mcc a rc (rtsi tt A ttstrrrl i aarl cl aparr)' l l tl d (rrs C i crrl l rrny i rr .f a c l c l i ti o n st o s< l ci rrli nsuratl ce servi ccs it . t Il ri ta i u r rnd S w ccl errrtre typi cal cratl rpl cs of nati onal l real th i uncl i rl g'Ncw trrx w i th w h i c h p u l tl i c provi si < l n< l i horl l c nursi ng coi rl ci cl cs tl ttrsttl gcrlr c ls h,tl rc Z c a l a ri c l i s e..ther rati oral heal th scrvi ce w hcrc of t t ( ) t t hrrl cl s i rl the te x fu n c l ccl ,rtl th< l trghtl -repr6r' i si 6rr i s rri xecl arl cl of s< l ttr ccs 1, c0ntbi nccl .w i thconl pl errl cl l tarv p ro fi t p r< l vi cl crs.' r:rxcs,,.l "1.," pcr l 0 i ,,n .l i ,i g s uch rrsor.rt-ofp.ckct 1' rrryrrctts,iS t w cdcrtrl .ratc,' sti ttl te H cal th a' cl W cl farc,2(X )0: 6) ' ,f B ,rrrcl (N ati ,.al c c ' t.f c rpc' cl i turc ' frtx fu n c l i n grcpresel ttse hi gh degrcc< l fpr-r[l l i ci tttcgrr.rti < rl l l tl clscctrlit yoi o'cr ct' rtl l tt' i us-rttlcl i l l l ()l )l l vrl r)' ftrrtcl i l l g thc l evci s fu n c l i n g , " l ti ,rugh cxrrntpl c,' fhornc nr-trsi rl g NHS < l i the prrrt rl rc scrvi ccs ti n tc . In Il ri trri n, for frce rrt thc point Irn c l ,rl s s u ch, rrrefuncl ecl< i ut< l fgcncrel trrxrrti otlrl ttclrtrc pri rl ci pl e, i tt p r r lco f u s c . A l th6ui :,hthi s i 1t;l l i cs scl tcrogscl l ti tl cl l l cl l ts i rr , ccti rl gtftc ti ght cas[ ti c e th c u sc < l f h< l 1rcpursi l g rcrui .e, i s rcstri cteclrcfl ttl ore lt t lcl l i rn i ts u trcl crw | i cI thc N ItS operl ttcs.Over the l l rst cl ccrrcl e, cr' rrc,rtt t cllr s n r6 rc s c rvi ccshrrve[ccrl cl ci i rl ecles s< l ci rrlrrrthcr thrrrl Icrrl th servi ccsl l ,v lt lct r l (.9rtrIi l ccl trrl ' gtti rrg,,f w i tI s n c h th e y i l cqr chargcs. rcl -vcit hcr t, hevc i rtcrcesi rrgl v pc.pl e t6rt < l l dcr rr.th ()ri ti cs,thi s ' real i s tl rcl crto pa, V i tr fri el rcl s arl cl ()u th e i r o wn furtcl s()r ol l the hel p of i arl l i l i es r r r lcl l Jrocl hrrrst (l l al cl ocl < ,200.1 ). i ,r s e rv i c esr' l d sta,vi n thci r ow n l ronrcs r r r blc ct' rrsi cle rt ( i l c n c l i rtni ng,(200 I ) sU l l l l cst thet thi s str:trcqV ui ftcts t hc Lrrlt il rc c l rrc ti o nof ci ti zenshi n' ,' i ght,i rl w hrl t w rts rl tl l l i vcrsal s1' stcttl e a rl y l 9 [30s. r sOci rrlri ght to hottl c crl re. l rl rrdcl it iortl
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Au s tra l i a i l l u s tri rte sa c o u n try w hcrc tax fundi ng i s embedded i rr a he a l th s v s tc l tlw i th s tro l rg e l c rn entsof pri vate ftrncl i ng.S i gni fi carl tl y,thc HA (l C , w h i c h c o v c rs h o m e tl ttrsi trgartclhorl l c hel p servi ces,w i l s onl y sct gf up i n l 9 l J .5 .l ts s c rv i c e sa re rn c : l nstcstecl .' fheH A (l (1, an i ntegral part (,arc prodw rrs the S tratcgy' l { cforrl l a s c t ()f c h a n g e sk n 1 1 w tra s th e A gcd uc r o f a 1 9 t3 2 C l < l n rmo ttw e a l thi rl cl tri r,vrvhi ch recorxnl encl cdthat the arlcl nlore honle care t:lltirc systell of ageclclrrc support lrc
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The interface between formal and informal care As tl re rrn a l v s i srrb o v c s u g gcsts,hornc crrrc i s rt conrpl ex pol i cy fi cl cl . I' u l tl i c ftrrrc l i rrsi s o i tc rr i n s ccurc errtl i nsul fi ci crrrencl hrrs t< l be suppi cn retttc c lb 1 ,o u t-o f-p < l c l < c1t -rrtvntcnts. Morcove r, prrbl i cl y fLrl cl crlscrvi ccs i rrc rc rrs i n g l l ' rrrc ti l rs c tc c le t hi ghl v cl cl .rcndcnt ol cl cr pcopl c ancl , i n nrrrnl , i tts tl ttrc c sth , c c rrfi tl c n rc l rtto ptrbl i cl l ' l uncl cclserr,' i ccs i s bci ng hol l < x,vccl o L rf. I:u fth c n n ()rc t o i tc n thc l cvcl of scrvi cc provi si orr i s brrsi c arrcl i ttv < l l v c se c l i v c rs crrrtrg co i p rovi cl ers. A s e rcsrrl t.thc cnrphrrsi s< l rrw cl i erc trl i r c tl tttl -l c tc sl v i th th c p o l i cv gortl to i ntcsrrl tc scrvi cesi tcr()ssveri ccl p r< l v i c l c l se n c l w i th rh c b o u l r cl err,l retr,r,ecn l rcel th rrnclsoci rrlcrrrc. ' l ' h c rrrre l v s i sth trs fa r h e s f oci rscclottl y ort i ornrrrl h< l rrrccrrrc fhc cerc pol i cy 1 tr< l v i c l c cblv p e i c l s ta i i l v i th i < l rrnal trrri ni ng/rl Lrrrl i ti crtti ons.' l ' hc fi c l c l h c c < l n rc sc v c n l l r()re c ()nrpl cx w hcrr i r i s rcal i zccltl rrrt thc bLrl l << l f Ito trtc c rtrc tre c l i ti o n rtl l r h rts becrt (artclstrl l i s) provi cl crl bl trrnri l v rrncl fri c rrc l s th : e t i s t() s rl )' ,i rrfo rr nrrl ,rrnl ' l rri rl crrrcsi vcrs. l cstcr (l 9c)6) i n hcr c o tttPl rri s o tto l c o trttttu tti tl ,c i trt: i tr l t tttttttbet-,ri l i rrl trl ' turrn c,runtri cs anrl th c L IS A,c s ti n ri l tc stl ta t i n fo rnrrrl crrrcgi vcrs provi rl e 7.5to l J0 pcr ccl l t ()f c rrrc .Wi rl r c ()s tc ()rtfrti ru i rcl rt i n hcrtl th crtrc rrttcli nacl crl urrfcres()rl rccst() c l c v c l o ph o tn c c l rrc s c rl " i c c st,hc [rtrrcl cnott i nfornrrrlcarc gi vcrs hl s ecttr, rtl l v i rrc rc e s c ci lrt rc c c n t v c a rs. S trbsri tttti ortpol i ci cs r' rl s
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thc t.n.tretrtrv ir e ' c fi t i .,r,i l .l .. p c o p l c c rrrc clf,r l rv thc i ar.i l v. A l th,trgh , berrefi tsi rl l < i ncl thc of thc that v r rl u eo f th c fi n rrn c i rrlb e rl e fi tsis orrl l ' hel f l l cl efi ts ci rsh ch66sc l t()l 1tc , , r ,.,j .rri rve f b c l e fi c i a ri c s re c ci vi l s crrrc rrt 6f strcr.rgtl .r ( ll rrr,rg t,t ,r1 ., f< l rth c 6 n i rrg ). Thi s re fl e' cts the c11rl ti rl r' rctl (\i 7erl gcr,200l )' c .l tu rrrl ,o rn rs rrb o u t th c ro l e o f thc fanri l f i rr carc gi vi rrg bccrl 8 1 , c o mp a r-rs o l t,th c c l rp h r tsi s ol r i l l forl l l l l l cl rre hl rs typi cal l ,v i r.rf()rprl l tl f sLl pport crpl i ci t ti l c rvhi l c rc g i ll ]es ilt o l i c i t i rr l i | c rrrl rv e l fa rc S i ngap.rc the U S A , rrei thcr i .r c r rr:cg i v c rs h ,.rsb c e rr w e a k . Si gni fi crrttl l ' , to i nfortrrrl cl l rc gi verscri st' In thc no r N c w Z c a l a rrc cl l o i tL rtrl i cI' \rr)' l l rcl l ts i n thc prrtvi si .tr f irs t 1 ,v 9 c o u l ttri c s , th i s rc fl c c ts strol l !l pri vrl te el cmel l ts bv the hi gh i s exaccrbrtcd 0 f h o n re c a re . In the LJS A ,thi s ir n c l fr-rn c l i n g
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i rr publ i c funci i ng.A s noteclearl i cr,i rl S i rl g apt lr c d c g rc eo f fragr-ncnti rti on arl it.t'lp'rtrrnt .rr .6ligati.rs .i fcr'ale crlregivcrs 1'rll.vs ,.,,ir,,,-rger-np6rrsis he: r lt h thc frrct that i rl cl i vi cl url l istl effect contr< l l tl -rei row [r l .,,1 .,,.r' .1,,.., sh< l ulclt hey C a rea c c o Ll l ttsattclcl tl t tl S ethcm f< l rl ()l l g-tcrl l lcrtrei l rsttrr' rnce is of thc rel rrti ve,vouthful rl css 1' l tl ptrl rlt it ln thc s Oc l e c i c l cl.| r N crv Zcrrl rrncl , g ir t 'r 's trl t' c fol ' \tl l )l )()rt of forttt:tl :r l tt,rs i l ' ,lt't' rP l rtttrtti ,rttftrl tl r.' :tl rst' l l tt' l tegtl rl ' ()l l httt rrl th o r-rgpttl h tl i c cl cl rere thi \ i sstte A u s trtrl i rti s rtrt otrtl i er rl l l l ol )g,cotl l l tri cs w i th a l i bcral rvcl frl re' t'eqit t t t ' f< l r hotl l c crrrc r' r' orl<'Thc e n c l l trtsrr tretl i ti rtrrtl f 1-rrl yi rlfarl g i l v tl etl tbcrs Af f : r ir s l )e p rrtn rc nt of I;erl i l i e' s,' (,ol rl rrl trrl i tlS cl vi ccs rrrl clIrrcl i gcrl tl tl s (l arcr rrllcl t hc A l l i l w l rrrcc thC e c l rrri l i s tcrstu' 6 i rl l < t* ' .trt!L\t()l ' e,trc' gi vet' t-, (.rtrc r-l )eY rrrcl rr (,.\usrrrtl i al )epartrrrcrl toi Fl cel th rtrl clA gci rl g,20 0( r r r ) ' ' I' h c (.e r.r-A l l ,,uvrrn.ci s en i nc' orncsttppl crtl cl l trrvei l al l l cttl 1' rc< l Plc'uvh
Policy trends and develoPments tl i vcr sc,yct I l o rtrec e r-ci s i rrl l of c()l l tfrr(l i cti ons.l l otrtc crl rc i s vrl ri cclatl cl vi siblc ir l hrrrcl l ,v i s i t i s rt l l rtsi chcrrl th ttceclrrcrtl ssc()tl l l tri cs.Il otl l c crrc i rl ercr sir r q l rl i n tc n trl ti()ni rlstrtti sti cs,Y et i t i s cctrtrel t() thc hcrl l th oi erttl prrl vi si orli s oftetr i reetlt cr lt ccl, opl c. Il ,l ruri crrrcftrnrl i rrg, n u rl l b c r O f 1-,e pol i cV rl gcrl tl rtoi tl trttl l ' c()tlllt r lc\ ' hcrtl th < ti l the 1 ' C th < l n tccerc' i s hi gh contrecl i cti orl si rl hotne crtrc.T' hc i n t cr cst T ' h e s ci l re s()l ne,,f ti tc s,rl i c,rt pol i cv trctl cl srrnclcl cvel ol'r lllcllt s rcccl l t i n g c l u c sti orti s rvl .ret,i f rrrrythi rrg, h rrv ec h a ttgcclrcgarcl i rl ghot.ttccrtrc' ' l ' h c p r< l vi si ,rrr,,i l ' ,,,r' ,re crtre scrvi ccsi s cl i vcrsc,rci l ecti rl g rt po lit icir l 61 a rtri rccl ccol l ol tl y 6f w el f:rrc ancl c6tl rpcti ti 6n. I)iver sit . v " ,.l ,p h ,-, rigrcrl , rer rrupr5cr rrucl1vi derrrrrt.tgcoi provi cl crs. [' hi s r': t lt r ir es ,' rc rl .s 1 1
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Chapter 7
P u b l i c Healt h
W c havc [J n ti l n o rv thc f< l cus< tfrhi s btl ok hrts l l ccl l ott hcal th cl rrc p< l l i cr" crl rc hc.rl th rl thcr rrtrcl doctors 1l r< l i es si0t lw i th hospi tel s, l tc err c o rrc crrrccl scrvlccs' cl l rc hcrrl th < l f govcrtl al l cc a l s rrn c lth c futrc[i rrg.rl el i ycrr rtl tcl (i haptc r . 5 L a rg c l y , i t hes ccntr-cclon thc c,rrc of i ncl i vi cl trrrlpl rti crrts. tl cctl cclfor t hc rl cti vi ti cs thc rvi cl e t' .tttguof st' ttttl gsrrrcl c l c n ro n s trrrtccl to i tlf e(.hrrptcr rl cccl thi s rr c\tcl l cl ccl e l tctl i .rrl errre. c l el i v c ry o i rtrocl rrt wit h thrrt g rrttc l te a l fh crtrc * ' i tl t tt,tl ht' rrl th i l fcl l rl s It tl cttl < l tl stl ' afi l l g, tt' ci l l l clt t - c' l t< l ttrec ttrc i t i s rrot l tttssi bl cto tl i sctl tttl cctherrl fh r-rl tt i t' ol l t I lr t ' llt ' : r lt lr o l t l t t . l i t r t f
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The growing threat of tuberculosis in
greetestthreat Ncw clrug-rcsistantstririnsof tube rculosis pose the clisease's t o Eur ope s inc c W or ld Wa r l l . 'l O l L r r m e s s r r g ct t l F I L Il e a c l e r si s : Wa k e u p . I)o rrot clclay. Do not lct this prohlcm get ftlrthcr out of hancl', states Nlarkuu Nisklla, secrctery-generalof thc Irttcrrrationrlllie'clerationof Red ( lr os s anc l llc c l ( lr es c c r r t S o c i c t i c s . T r . r b c r c u l o s i s ,a r e s p i r a t o r y i l l n c s s s pr c ad by c oughing and s n c e z i n g , i s t h c w o r l c l 's c l e i r d l i e s ct u r a b l e i n f c c h W H( ) e s t i n r : 1 t eksi l l c d 1 . 7 n r i l l i o n p e o p l c i n 2 0 0 4 . T h e t ious c lis c r r swhic c high lc v c ls of m ult i- c lr u g r c s i s t a t r tt r . t b c r c t t l o s i isn I 'r a l t i cc o u n t r i c s , F l a s t c r n Ilurgpe ancl (icrrtral Asia, lrtcl thc ctncrgcttcc 9f a ncw crtrcrncl.V clrugr c s is t ar r ts t r ain k nolv t r a s X D I {- T l } h a v e l e c l i n t c r n a t i o n a l p u b l i c h c a l t h officials to crciltc the 'Stop "l ll I)artnership in llr-rropc'. In lrurope, .50 l.rcoplcgct sick and eight peoplc dic of thc cliseasecvery hour. Thc ratc of c()trntrics that comprised the f,tJ inciclence of l'lJ irr the \#cstenr lir.rropcat.r berforcit cnlargcd in 2004 is l.l crtsespcr 100,000 peoplc evcry year. 1"l.rirt r uur nlt c rdogbles in t hc t c r t t l c w c s t l 'l t l r n c r n b e r s .l t t l o r r b l c si r g : l i n t o . 5 3 r n l(omirrri:r rrnd []ulgariir lncl yet ag:rin to 9lJ in tlrc formcr-Sovict repubircs farthcr Irest. llut nriqrr'rtionancl FILJcxp:rnsiot'tchangc things. For irtstirnce, ' l' B c as esin l. ondor t hr vc l t e c t r i n c r c a s i n g e v e r y y e a r f o r a l r n o s t l 0 y c a r s :rnclirr s
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\.,Vo rl cFl l c rrl thO rg rrn i z rrti on(W H ()) [-.pi cl cnriancl c I' artcl cttti cA l crt rtrtcl l l c s l ' l o n s c s(F .l ' l { ) l v c rc rl nthrl l x, rrvi err i rrfl ucrrza,cl )()l rrhacntorrhrgi c cl i scasc, fc v e r, F .. (.o l i o u tb re rrks, hcpeti ri s, i nfl uenzrr,rncrri n{ l ()coccrrl p l rrg l c , s c v c ree c u tc rc s p i r.l tor)' svn(l ronrc(S A I{ S ),srtti l l l pox,tttl rtrrtct.t.ti rt rrn c ly c l l o w fc v c r. A l th o ugh l l rl ur)' of thcse rl i scascserc cncl enri cttl Thi rcl \rV< l rl ccl()u n tri c s rc l c v c l opcclnr.tti ()rts , r rtrc i tt ri sk cl trct< l i rttttri grrtti t,tlrti I i l l ustratecl by l l or 7. cvcn cl i scrrscs A s g l o l trtl e c ()n()nl v. trrrv eI rru c lth e th rrt w c h a c lrh o u g h t w c hl rclc()ncl ucrcdrcnrrti ni ' tconcenr of publ i c heal th c x p erts . L h tti l W o rl c l We r l l h cal th crtre w rts l argcl y ccntreclorl ptrbl i c l rcal th n re rrs rl rc sH. o s trri ta l sw e r e l i rrgcl ychrtri tf i nsti tuti ons for tl rosc w ho cor-rl cl n o t rl ff()rc lrr p e rs o n a l phvsi ci ar.r,l rncl few rl edi cal techrtol ogi esor l i fcs i rv i n gp ro c e d u re sw e rc avrti l trl tl c.S i rl ccthc l cadi ng cal l sesof prcrnature sl l ch rrstubcrcul osi s,typhoi d rrnd chol era, c l c a thw e re i n fc c ti < tu sc l i serrscs ()l r rrnrel i orrrti ngthe concl i ti ol tsuncl er w hi ch they rrttc n ti o u w rts fo c L l s e c l To contrri nthc sprcad of a contagi ottsi l l ttess, s p re a c rl l c ro s sp o p r.rl rrti ons. p u b l i c h e a l th a n th o ri ti cs rel y cl n many strategi csi ncl udi ng i stl l ati on ancl c l u a ri rn ti n e(C c n te rsfo r D i seaseC )cl ntrol ,2003).Isol i rti gnof pcopl e w h< r h a v e a s p c c i fi c i l l n e s s scprrratesthcm from heal thy pcopl e and rcstri cts t s to p the spreaclof thrl t i l l ness.It al l ow s for the focused th c i r m < tv e n te nto
186
Contpttrdtiue He,rlth I'olic.tt
heal th ci trc to 1)copl cw ho are i l l and protec t s c l c l i v c ry < tf s peci rrl i zecl h c a l th r,;,..r' i" fr.nt gctti ' g si ck. P c< tpl ei n i s' l i rti ' r-r rnrrybe careclfor ir l hci rl th crtrc frtci l i ti es.In tr-t ost th e i r l ro m e s , i n hospi tal s.or rl t cl csi gni rtccl govcrnl l l etl tshave br< xrclrruthorit y | 6rvevcr, c rrs e si,s o l trti grri s v< i l Lrrttrrry; pul l l i c' the protcct to pcopl e to c o n rp e l i s o l ati ortof si ck havc i reerterl l oseclatr cl w ho pcopl e to Qu rtra trti n c,i l ) col ttrl rst,aptr-rl i es i l l . S cparati rl gcrpgsctl pc6plc ,r,,,y :,,.n tl ry l t()t be i rrfccteclbttt rl re l l ot yct sprcrtcltl f th r r t thc a l c i re s tri c ti l g thci r l l ovcutents i s i ntcrtcl cclt() st()P has provcclrl l t> steffccti vc i l l pr()tccti rl gthc ptrl llic .1 r,rr.r.,,' ti trc i l l 1 c s s ,.t,.,.l fr< l r1 c l i s c l rsc.A l though sovcnuncl rts gcttcrl rl l v hrrvc ' uvi cl cl rtrthtl ri t-vt t l oftctt i t i s l l robl cnr d c c l a rc rrn c lenforcc cl r.l rl rrl l ti ncl vi thi rr thci r l t< l rcl cr-s, rrl rni fi cati < l rl srvh ct l ri ghts hutrrr' tt.t scverc i ts of a ti c p < l l i ti c l r l l ,vbccari sc i rrrprct.' l ' hc pol i ti c al cc()l tol tri c i ts potcnti rrl encl c t" .i 3 .:ti ,r1s;1 ' l cci fisr()ups l l t' rerrcti vccel l s t t r i l l trstr.ttccl rvcl l arc .la,,g.r, < l i cl trrrrrrrrti nc ,..' " ,,' ." " ,' .1 rttcchrtrri srloir H I V thc [cf6rc s e g rc g rrtcAl t )S vrcri ptsi rt the rl l i cl l c)l J0s trrrn s tnsi s i o t trvl tsttttcl crstootl . l ,ro tc t.ti n g tl rt' P rrl rl i r-l r..,rl tl r.rl r,,t' ttt:ti l r rt rti tl t' l ' i l l l tl .(' ()l tttotti l ot'it t g to prcvcl l t thc sl l rcrrcl< l f tl i sc:t sc cl csi grrccl ,.,.,ccl .r" r,i srtts e n c l i rrs l ' rc cti ,rr, th rtl g g l r f6 9 cl rrncl w rrtcr suppl i cs, cnvi rotttttctttrtl ,rssrttrl tsel l cl ri s l<1 of thc rrrtttsi l ort:l ri otlof * ,,r1 .;r1 " ..r. A s hi ghl i ghtccli n l Jor 7.f . l tecrttrse thc tl rrcr lt rt:rti ()tl rtll t< l trtl cl rl ri cs, i rcr()ss 1;ftcn i e 1 ;c la c r< l s sl6rrg cl i strrpccs, ori gi rl oi t he frtl rl l thc i rtr prtl cl l tcts occtl r ci l l l i 9< l cl o f c < l tttl rttti trrttccl
Box 7.2
E. coli threats to public health
l.css than a wccl< aftcr thc LIS Foocl irrrd Drug Aclnrirlistratiorr liftccl its qrorvtl thcrc war ning on s 1 - r i n a cghr ( ) w l t i r r ( l a l i f
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Thc cr' tsc()f pr o c l u c t ()r p r()c e s s i l rgfa c i l i ty rurclaffcct u' i cl c l .ropul rrti ons. (l o r' v l ttorc reccrtt possi bi l rtv of thc thc 1 9 9 0s rrncl l )i s c a s e i n th c Macl hi ghl i ght thc rrcccl i or conti nuccl s p re e rl o i b i rc l i l u tl rro u g h h r rnr:rns wl rtc h fu l n c s s .Mo re o l ' c r, th rc ets of bi < l l ogi crrltcrr< l ri stl l ncl thc ctrcrgc n c c o f c \rc l rn r()rcrrg l l rc s s i v csrrrti l )s< l t I' i rtrscscl carl y rccl ui rcpr()rl crl vc ilt fc l tti o l r w i rh rc g e rc lto p trb l i c hcrrl thencl ttrntl i ne.S pccrfrcpubl i c l rcal rh i rtcl i vi cl urrlsusl s -l cctccl s t ri l tc l l i c s ,th c n , ru rr th c g rrn ru tfrortt tl rt,tr,urti rti rrg to l rc thrcrtts t() thc publ i c < lf h rrv i rrgc ()n ml u n i c r' rb l t' c l i s crrscs.l cenrerl fot' l rt' .rl th,trttl srrtcn. r< l rccl ttci rtg hca l th . r() rc g ,u l a ti n gth c u ,o rl < 1.l rtce rl rsl ' trrrtri t' to s. t' t' tl ttei ttggreetthrl ttsccttttsult c l l p l ()y l n c n t l trrtl c c ()n ()n ri c s io rrsrtn c lth c rl c p l c ti o tto f th c ozotrel .l r t' t' . Al th o L rg l rp u l rl i c h e e l tl r i s o l tcrr vi errctl rtsrr cl i strtnrrrndesotertc fi el tl i rr r v h i c h p c o p l c ,rrc rc g ,rrtl e rlrrsrr crc strtti sti cs,thc sprcrrclof S r\l l S i rr 100 l hig h l i e h rs th c i rn p o rtrl n c c o f pLrbl i c hcel th ancl rhc l ect thrrt, l rccrruse ir r i c c fi o u si l i s c rts c stl o n o t rc s pect borcl crs,i tttcrnl tti < l nl rlco< l pcr.rttorti s c s s c n fi i tl . S r\l { S i s frru rs n ri ttc(lvi rr cl ropl cts fr< l rn i nfcctccl i nrl i vi rl urtl s thc vi rtrsto cl oscconti rcts.A l though , lv h i c h , i l s i r rc s u l t o f c o L rg h i n gcarrv eftcr scvcrel nronths, duri rrg thrrt o f S AI{ S c l issi perccl r hc 2 0 0 .1c p i c l c n ri c c i rr S A ITSbcg,rrrr t irrrci t c a rrs c ci lt g rc e t c [c a lo f c ()nccnrrttrclcc< tttotrticosfs. ( lh i n e b u t w rts c 1tri c l < l y s p r crtcl rtrottttcl thc w orl cl l tv trrtvcl l crs. l{ cs c e rc h c rsi o u rrrl c v i c l c n c c< l f thc vi rtts i rt thc ci vct cet w hi ch i s ci l tcl t :ts e rl c l i c rrc v b l ' s o tn c (l h i n c s t' ( l { oss,200.1 ), btrt ttrost S A ITS vi cri rtts c ( )n trrrc tc c li t rrftc r b c i rrg ,i n cl osc cottt:tct l vi th err i nfcctccl pers()l ). A l rh o u g h th c rtu tttb c r o f p c rs otts ki l l cd b,v S r\l { S rvrtssrttrtl l[)v cl i scrtsc vLtl ncrrtbl c t() thc repi cl sprerrclof s t rrn rl ,rrrl s ,i r c l e n ro n s i l -rrtc chorv l rr rrge< l f ei r travcl rrnrl conccntrl ttccl i ur w c l l rc c ( )n l n u n i c l tb l c c l i s c rrs c s rnrrrtvof the vi cti rrrsw crc i nfcctccl . hc a l th c e rc fe c i l i ti c sw h c rc , i rrlni crrl l ,v, (.h i rrrr' sc rrrl v h e rrc l l i n g<,l f th c cl i seesc,i rr perti cul rrr'w , rrs sccrrbv tl rrnv i n southob s c rv c rsrrsrc p rc h c n s i b l c .Wh cn thc' fi rst S A ITScescsrt1' r1' rcrtrecl c r n (.h i n rr i n M e rc h , l l c i j i n g rl c ni ccli t rtrrcltri ccl t() stl [)pressthc ttcw s,thtrs i ts l ' rorcl crsbv ttnsusl ' recti rtg ell o l v i n g th e c l i s c e s cto b e s P rcrrclbc-v< l rrcl v ic fi ru s . In N l rry ,2 (X).1 ,IIc n c n l )rovi nce i n ccnfral (l hi na puni shccl800 r cl uti esr() protcct thc publ i c r fo r te i l i n g to perf< l rn' rhci hc rrl th r,r,o rl < c rs kc,v l cssotrs rcsttl ti rtrr i r,rrtt (Y a h o o of thc Ortc N e l v s ,2 0 0 .i ). hc rrl th ( . h i n rr' s c l c l e -vi rr rc p o rti n e th e outbreel
2 (X ).1). r\s m i g h t h a v e b c c n p re c l i cteclgi vcn i ts strons cotnnruni tv-cctttrccl svstcttt i tt c u l tu rc , S i n g a p o rc i n s ti tu te c lrtn egurcssi vch< l rne-ql teral tti ne i n Ttrrttnto, Orrnacl l ,si ntpl v h cal tl r oi fi ci el s r e s p o n s cto S AIj .S.W h e re a s S i rtgrrporc ir s k e dc i ti z c n s s u s p c c te col f S AR S expostl rc to scl f-cl urrranti ne,
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rrburg. 19c)7). Schrrle (iernrlrrly in thi rt the resporrsi bi l i tvfor pr-rbl i chcal th reselnbles Srveclerr rrs lrlcl restsrvitl-lc()Ll l ttvcottnci l s atl cl nl uni ci pal i ti cs is decerttralizccl
194
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prcventi vc rl nLlp()f)tl s e rv i c ep ro v i c l c rs(( i l erl ngarciat dl ' , 2005)' .thor" l gh tlf n.,.,rairrtegrrtecl into the cleliverY ltrttlr;'trr' measLlres latirtn-birscc-l "r. l l tl rscs t< l provi cl tl heal th c l trc s e rv i c e s .H c a lth ..' ,.r,r.r .n.tpl ,,r' scl ' rool ()lle-to-one herrltl-rctittcrttitltl cclucrrtiolrt. chilclrcr, encl cl.ct.ris prttvi.le w cl l -w tl tl retlcl i rl i csrrtl cli tl l rtl url i ze |l o rr c l i c t rrn c lttl c o h o l a,r,' rrurrl pri ,,,'l .r,,.t l cvcl i s t6c N rrti .' rl l ,f-,i r rrt i ,-.' f thc trrrti ' ttrrl c h i l c l rc r. C l ,r,r..' ;r l e,-.' .r.' .,i trl l ti < l tl l lpl l ' osrl l l l l l l l cs i or l n s ti ttrtcfo r l )rrl l l i cI l cal th,l vhi ch i s rcsl ' l < l tl si l l l c l l rel rtsof hcel th < l thcr prcvcl l ti ()l l . A s i rl rtur-lcl i scrtsc ()f h c rtl th p r()l n ()tl ()11 rcsp,rl si l l l c i s rtrl clW cl frtrc c :rrep r.v i s i o l r, t5 c N rrti < l .al l ' r< l arl.fcl H cel th c,' tttttV of l cvcl r,vhati s heppeni rrgrrt thc f,r s rrp c r' i s i rrgrrrcl ,.' .,,,,.' i t,,ri ,rg c o ttttc i l se n tl rrl trrl i ci l l el i ti cs' (,< l rtrl l e rc c l ttl S r,n,ecl ett.thcrcsl rtl tl sl l l i l i tr.i rl rptrl l l i cht' el thi sItl .l t.e r etrti t' tt thc I 989 l )Lrbl i cP .re c l c c c rrtrrrl i z .ci rr c ltl r c N ctl r.' rl a1.l s.i ' .,11.,r" i ,' g hcrrl th i rrcl trcl i rl g s' scrvi ce hcel th A c t, s < l tttc.,,r. r.r,' ' ,,' .,.i i ' ' l l i ti t't.r ptr6l i c ttr cl cl egrl tccl l l ccrl hrtvc cl i scrtscs, .1 ..ti ,rl -* i i l ' r .,,,,a,-.gi ' tts rr.ri t.ri rrs " rrl ' l hc ,rctrvi trcsof l ocel publ i c l rcrl th :rgcnci csrrrc < l tl l t' l .c e l rr.t6 .r-i ti c s . thc \' ourrl l 'cl dcrl f ' r11-cl .11l l ' ]t' ::: l Io o s c l v p rc s c ri b c t l ,btrt n pi cel l v focttsotr vltccllllltl()ll rllltl Iclrlth l]r()ll1()ti()ll rlllcl cclttCrtti()llr iga, r 1' , 1'lr, ,r.t,c l it t Clt lcl c 1 9 9 7 ) . i l h c c
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Box 7.3
Decentralizedpublic health in Australia
has lirnited ability wir hO ut ii s pc c if ic h e a c lO f p ( ) w e r , . t h e. ( l o m , t n o t r w c a l t h r c s L r l t ' t h e r c a r e n na patchwork of *t""titi dir.",t, iuti'"ri" ;; l;;'..ii,r* '.tttd lc gis lat iv c m eas uf e s . I f a n o u t b r e a k t l c c u r r e d o r r a b o r c l e r , o r l n S o l - n e a r e a thcre could be confusion .ver ir-rrisdicrvhere j'risclictic,n n.rry-i.,.in ciouht health.actsclo not adccluatclvprovicle ti'' since Statc a'cl t.rrit,,,ry public and cooperrtion' iut int.t-iuri.dictional conlmunicartion SoarcE:I-lorvsc(2004)'
196
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of Health iniury (Ar-rstraliirDepartt-nent by helping them rrvotd ilhrcssirnd P artnership tbe N rrti onal P ubl i c H eal th a n c lA g e i n g , 2002)' Furthc' n' " " e' llgthen alth anclstatesin 1996 t
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ComPardtiuc Hcdlth I'oliqr
Box 7 .5
Fighting obesity in Singapore
Overweightchildren The fight againstobesitystartsyoung.in Singapore' moreuntil they exercise to t"dttid fr.r- tt el.'.lot'-u"'t"tl areseparated pilT-1tJ,::n:,:'"' lose weight. Fo, .*r-pl., o' nl"rnbtr of a Singaputt " is compulsorytor overwetght krcls.)row .HealthLlub, *h.r. rnimbership educationcurriculum' .rn iup of ihe rcgularphy'sical doesspecialexerciscs While the schtrol month' every *elght antl Teachersmonitc>rh., t-t.ig'ht teachersmect her parcnts doesnot put restrictionsrln what she c:rn eat' their daughter'sInetrls prepare regularlyto recommendherrlthierwavs t() a th o m e .M orethanacl ecadeago,si ngaporedeci decl th:.rtthebestw ayt o heal th.care.costs' fi g h t th c w a r on expandi ng* ai ' tl i nes, and bal l oorri ng w a s to b e g i r-rw i tl rtl rey.,ung.Theg< l vcrrrnretrtcrcatecl asch< l < l l -baseclint er for overweightchildren vcntion program that rncliiclcsrigorottsexercise Thc health clubs have canteens' in on foocl solcl :rnclreconlmendirtions .l 4 pcrcentin 1.992t
(' i 4 pcr ccrl t i tr 2003) :utl ottgtl t ct r c l e c rrc l cr,r' s , i ththc hi ghcstrrl tc oi obcsi tl ' rbotrt $600,00() i rr t hc i rr tl rc i r 4 0 s.1' hc govcfl i l nent hrts sct esi cl e 2(X (l rrrrg,:rl < i , )6)' I l ee lt h 2 (XX r-2 0 0 7 ll ucl gctto cornbet chi l cl hooclobcsi ty cl i scasc l l eti < l rtrrlpl al r kl r heal th protl r< l ti tl tlancl .frrp rrn2 l ts e tcl l -v-ear W l ' rl botrr rrncl cl i er c' i shcclbl thc N ' li rri str-y.ofH cel th' 1 r.' .' u .rr,i ,,'cstabl .r ri ct ivrrtrtri ti tl narl clphvs,i crrl T h c p l a n c ()vefs,,,,.,.t.,.| .,r,rrc,rs,i rl cl tl cl i rl g chi l cl r cn' school i rl rrcl ul ts:rttcl obcsi t,v r$ ,,,w h i c h s ct i l ()i tl sf< l r cl ccrcesi rl g e el tcl ctl trc:rti otlotl hcrtl tl r" 'bo cll t," ,.ti , .t.t" .ti.r,, ,,f Ovcnvci gl tt stU cl nts schttol s i rr frl pr r r t r,v e i g h ttrtk c pl acc i ,r ,.,' r.,rtpri rnerl ' rtttcl sccorl cl l trv ( N l rrts trs h i t eat dl -, 2(\041. ()r ecl trl tsrl rc 11()wtl l l csc (17 pcr ccl l t) l V l Orcth rr n hal f Of N cw Zerrl rrl rcl pcr b' v Zcel arrtl i l l creasecl ' 5' 5 o v c rw c i g h t (' 3' 5pcr ccrrr)' ()l )csi tf i rl N cw toi rtcrcrl sct())9l l crectl toi i sprccl i ctctl c c l ttl )c tw c cn l c)l J9erl cl1997rrrrcl thc . Ncr v l. rt, rcsl -rotl se' i rl sti ttrtecl rl rc rrl l ,tc l rrl tsIt,v 20 II tf nO chl rtges ,f t6c ratc of .6esi t1'r r s Z c rrl rt.c lF l c el th S trrl tcl l .vtarg.i .,.l t;c rccl trcti .rl l )i stri ct H eel th l l trrr - t ls 6eel th' ,.c ,f t6 e l . l p.l .,.i ,v ,i .' .' ft" pt' 1' " ' l " ti .rr ()l t t' rvrrcl s crrch()f thcsc t() r.ep()rta,,,ri ," l l y (l )l l l l s ) rtrc recl rri rccl t
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s p c h a s A g c l tci csfor N utri ti ott A cti ott, H crrrt Founcl ati < l l r, o rg a l ti z i rti ()l .rs N c w Z e a l a n c l N u tri ti o n Foutl cl l .rti ot' t,l tncl [)i abctes N ew Zerrl arrcl ; s o v e n u l e l tt rl l a c l tc l c ss ttch rrs (l hi l cl , Y < l utl l arl cl Farni l v S crvi ces,the R c c re rrti rl l rru c lSp o rt Au ency, ancl thc rtti ni stri cs< l f Y otrtl r A ffai rs arrcl p c l rrc rrti 6 l ;th c rn c c l i r.r; l < l c a l corrnci l s;l )rrci fi chcal th i rri ti ati vcsrl tl clchttrcl -l a rl c lwci ght l tl ss i tl cl ttstrtcs' i o o c l th c a n c l s' r()u p s ; f< tu r-y e a rbi cl t< l rccl ttcci ts cscal eti rl g< l l l csi tVl cvcl s, i rr rt A s p a rt 9 f v i < l tl cl srrrtclcl ri nl < sfr< l rtlschool , 2 0 0 (-,N c w Z c rrl rtn c l .re rrn c.lt.rtf1' strt.tl Mi l ri stcr l l cl crr (l l erl < srri clrl t thc I)ri nl c (As s 1 ,l c i d tt' tl /' rc s s ,2006). s l r6 n s l rru rrc ho f th c N Z $ \(r7 n ti l l i orl erl ti -ol rcsi tl ' crl rrl pai sl lthrrt ovcr 30 pcr c c l t < l i c Ii l c l rc l e rc e i th c r overrvci ght rl r obcsc ertclthat i trtpr< tvi tl trl trtri ti e p rrl c l c l c < l u rrrg i rrgl ' rn rorc rrcti vc l i festvl c i s thc fi rst step i l l i i thti rrg th i s c p i c l c l ti c . Irrrrn i rrc n ts teps i ncl trcl ei rttrotl trci ns hcel thl ' f< l ocl , cl ri rl l < rtl c l c rc rc i s c p 1 1 l i c i cisrtro al l s()vcnuttcrttrtgcttci cs.A l ebcl l i rl gsvstcl l lf()r f9 6 c l rrrrccl l ri p l < sl v i l l b c i rt rpl enrcnteclrthcaclof thc 2007 scho< l lycrrr,rl rrcl ,rl t| 9 g g I tIc g tl v c rn n te rrtl vi l l n()t rcgtl l i ttcto l l ri rl g rl l )()utchrrl l ge,sch< l ol Ig e rj s rrrc re c lrri re c l to cl cvcl op pol i ci es tl l rl t pr< l rl l otc rl ttcl :rchi cvc h c a l th 1 ,,l rrrri ti ()n a rrc i rcrl ucc c()nsr.nrrpti ottof tttthcrrl th,vfootl s rrrl cl c lri n l i s . ()Sc s i tt' h rrs| c c 6 n rc rrr rrrcri rnoni ousp< l l i ti crtli sstrci n thc Ii S A ,rs w cl l (s c c t)S l )c p rtrtrn c l t 9 f l lcal th arrcl I l trtl en S ervi ccs,2(X )1. 2(X ).5).Irl tl rc rl ccclt< r 2 0 0 1 , th c L IS S L rrg e o n(i cncral ' s (l al l to A cti on cntphrrsi zecl rtfforcl ,r[l l c arl cl pr< l vi cl c rrcccssi l tl e w hi ch c n v i r< l rrn.rcnts c rc rl tc s u p p o rti v c phvsi cal rcgtrl rtr for opprl t-ttrrri ti cs convcni cnt h c a l th y f< l tl c lc [tl i c c s r' rn cl I). l rr Mrty 200 Il trrl att S crvi ces, rntl rrc ti v i ty (L IS t)c p e rtn te n t of Il eal rh to tcilch begrrtl proerrtt.ttntc 2(X)2. a 1i4.I ltillitln LISI)A Tcenr Nr-rtrition of i l l trnc rrtl cl .f c h i l c l re l h c a l th ,vc i l ti l g h rrbi ts(l (crsh rrrtclN {< trorte,2(X )2) Irri ri rrti vc thc IIe:rl th ertclI-i tncss t6 a t y c rrrth e Wh i te l l o u s c i ntpl cnrcrttccl to h i g h l i g h t p h y s i c a l a c r i vi r.v(L)S l )cpartnrcnt oi H cel th rrtrclIl trurrrrr Sc rv i c ' c s2, 0 0 4 ). L J n l i k co ther countri cs,how cvcr, pol i ci csi rt tl -rei rl tl i vi cl tra l i s ti c L i S A h trv c l tc e n rri n tccll rorc l l t cnsuri l ts thrl t obescpl rti crrtsrl rc l l ot s tl cl l css i l t cl l c()rl ri l !i l l l l { c l i s c ri rtri n e tc c l :rg a i n sbty nrccl i crtlprofcssi < l nl rlrl ctl.lphrrsisot'l hirs bcen corlsicierirl)le thcre In frrct, behrrvior-rralchrrr.rgcs. fcel irlfcricsitv
2-06 C,ompmttiueHc'tltb I'rtlicy
Box 7 .6
Preparing for large Patients
rtr thctnsel vcs l ti gger'hospi trl sare rcvarnpi ng As An rcl i canskecpg:,etti ng cl"reck.inro patients yhen these accomm.dar.nn inftu*'.ri;;::. ;"ri.,rts. in ir room with a themselves find i., a hospital,they are t"-""ti*it'rittiy up to l'000 holds that bed a ;t"'nJ"'a' wiclercloorwirvthirtrtt:;;-i;t"h bathro.nr' T.ilcts in the poundsand ir ccilingli;;t;;t;;t;., '"""111;',t'.t'r flo.r insteacl.f a wall' irnclm.unted t. the suchir r..n.r ,rreextr,r-stt,rdy like i"t" chr.nic rnedicalai'"'e'ts The .bcsc irreirls. "tt"':'iti:i;';;l"rrtt As a hospital' the int' thctn l'"inglng diabctcsrncl scvcrclt'i;;';;;;l'i;;;t' capitalinvestrrentsto sct trp separilte nttki"g t.t"l it,,rpit*l' ;;il,";t;;;. to keepup with dernarrd' wings antl wholc floors for obcseirrrtierrts Sotttct:: R c r ttc r s ( 2006 ) '
pr()qri l l l l l l l cscl ctlt r ct ible phvsi ci ' rrr-pr-cscri l ' rvci rccl g' ht-l oss o l tc s i tv .nl rrl < i rrg rn c c l i c acl xpcrl scs(S hortt, 2(X )4)' tl rc pri rrrrrv frcrrs.f prrl l l i cScalt h r\1 th .ug6,t,.,l " r,,,,l " l l cucl rc' r,ei rs i rrtcrrr : r t i't r r r l i rc.rcrrsi rrglivri ti ,rti vcs rrt t' c p .l i c i c s . ,-, ,bcsi rv, ,h;;. ;r; l c v c l .l rrtl l ccorrtcxtofl ' trro1.rc' tht' l { cgi ol r' rl ()fi i ceofthc\i l /orl tl tl calt h t' c l rrtc l c)90s ' I r r it ir r l ()rp * rrri z.rrti ' ,tl ' ,,' ,.l ' ti ]" n" ' ti tt' i " ' l t " tl t' ut ' i " tt lll i tt l 1 cottl ttttfl l l c l l t cttl tl ri rratccl ' l 'his hes i l l l l ()l l g tt''ttttl ''t'stl 'ttcs ctlttsttltlr t i tl tl s l {rr.v' cr,2(x).5) l )l errs(l .,rrrs,rrrcl 2 0 0 0 t. cfcrtteN .t.i i ,ru A cri .' rccc.rl l ]i ,' l tt, LttroPer lt r i rl i ti rrti vcs' rl r()st b c c rr fo l l orvcrl u1-rbY otl l cr ()i l tcgi orrrl l fi cc i or Ht r r ol- r c' (,h rrrtc r ()rt (,otrrl ter" tti tt* i ' f" ti tt' (W t l ()' tnot' cpassi r' t" ],tl l .1:1.:l ,l'cilcct ir r g 2 0 0 6 ). l tr cotrtrrrst. rtl rtti rl tl to tl thcr p()l l cYlsst l( 's' ' l tl l Li ftt" t' l i ' ti i tctl i rt ,r.' " rgi ' ' ,r1p< l si ti .rr9f Ic' rl th i l ol i c' v ,1 .' .1 high t() c()l l l pctcw i th tl tl rcl ' nro l'c i l l i tl etl V ct)l t t' l tt' i t-u " i " ]) 1.' t' ArrVp < tl i c,v srlfct\"' rtrrl',liclr.,iltl.risstrcsstlch tts foocl
Box7.7
Obese peoPle denied.some
ii"t"Jt."iin
surgical
niat6 cutcostsin the NHS
" with a boclymass -I'hrccSuffolk prrrnarycare trLrstshtrvcruleclpaticrlts i rrd cx(t}Ml )tl i tl ver.j ()w i l l l l ()tget()pcl ' ati ()nsl i l < chi pandktlltl"5 cc r epllr irncl ce*tighi *t"'ltt 1".:.t-"tt*t t'f l''tt*t"l' rlents.A pcrsonut pletend 'Wc cannot saicl: P()T' 'utt"it .,f ipt*itft 24.().I)rBrirnKceblc,*i""tt"? LJnder by prcssingfinencirrlprtlblcrns'' ti'"ttftita wrrstr't w
Pttltlic Hctltb
207
Tobaccoand alcohol PolicY : - (rlsclvcs to ' : . ; hcck inttr -! )nl \'vith a '( , - -: p ro 1, 0()0 " ' . ' T -orlcts in - - , . i ,rt I ll, lll. . - . ri' rrcntlike s ' , ' pit rl. A s a '- . 'lI scPilfiltc . - ' -. trr.l.
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(.rrrtru l rrfi v e l yto, l )rr cco,al cohol ancl i l l i ci t cl rugs' prcttrrttttrelki y l l ab< l trt7 p ti l l i 1 1 rr i s ri si l l g' (l l ctl tcrs, thc tttttttbcr artcl c p c o p l c l v o rl cl r,r,i cleach -vcer 2 (X ).1 ).T h c re f< l rc ,l n()st c()untri cshrrvc i rrsti tutcciptrl tl i c hcrrl th tttci l stl res oi srnol < i rrg. Thesei ncl trcl crrri si trgthc pri cc c l c s i g rrcto c l rc rl rrc cthc i rrci cl cncc e rrl l ow cclt< r o i to l rrrc c op ro d rrc tsthrough ti rxcs,rcstri cti ttgl vhcrc pc< l 1tlarc hcrrl th w rtrtti ttgsott recl ui ri rtg of rtdvcrti si rrg, tr' pcs s n to k c ,l ta rtn i n gc c r tri rr (f< l rspcci fi c age rrri ni rrttrtn purchasi trg thc rtl l trrc c tlp ro c l rrc tse, nclcni < l rci ng S otttct cotrtttri cs,l i l < c c ()s l rtrv rc { u l rrti o r rs,scc l vrvw .S .rvl ro.i rrt/tobacco/). (scc l i < l r 7.l l ). Si n g a p < l rch, rtv ct' c r t' rcstri cti vcrttl clscvcrcpol i ci cs Al th < l rrg ,hs y s tc nteti cc()rl rpi rri rti vccsti nrrrtes()l r thc c< l sfsof stn< l l < i trg tttttrtl l cr e rrc lrrl c o h o lrr[ru s cr rrc rrnevei l abl c,stntl l < i ttecrtttscsa si g,rti l i crtrrt tnore l rc,rl tl t ci l rc rcsottrccs o i rl c l tth s , l tn d s n r ol < o' sgcncrel l v c()nsr.l rl rc tIrrn rro rr-s n to k c rs.Irt thc LJS A ,for crrtrl l l l l e. i t i s csti rl l rl tcclth:l t l 9 pcr ) e cettsccll tv c c p t 9 f e l l p rc n rrtturc cl c,rrhs(ab< l rrt400,0(X ) arrrrtrrrl l i 'et' (i i vcrt l l S r\ hes rrl i cl 199.]). thet thc (J V l c ( i i trni s Focge. rrncl rg [rc c o trs c (sce fr()rl ) stttol < i rtsi l t l ), rrrtcs Lrbl c 7. cl crrth re rrg c l c v c l s o i s n rol < i ng to l l c si rrl i l rrr,i i rr< l thi gl l cr. o th er c o r-u ttri c srrrc rtsstttttctl
Box 7.8 packets
Graphic health warning on cigarette
Singaporc's littcst rltti-sn1ol
20ti
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("/o)' ranked Smoking rcftes,ftten and uomen bt' tuomen' 2001
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tl f srntl kcrsrose (w H O' i n c rc l rs e si n p o p u l a ti < )l tnl cl l ut thrrt tl l e ntl l nl )cr rrrtesbetw ecn thc l ow cst 2 0 0 .1 a ).M< l s tc < l ttn tri csshow 11l l rrPi l l snl oki ng Itl sol rrc coLl l l tri cs, thc poorcst ,rr.i l chli g h c s t s o c i ()-cc()l tol l ti cgrotl ps. Thi s rcport i trrthcr fotl rl clthat s u l o k c th rc c ti ' re s rs l l ruch,rs i he ri chest. i l rc L()l l vcrl l i rl g,el i r" l l i l :trro1' rr: i l cross s rtr< l k i n grl tte sa l r()n 1 lv()ul tgpcopl c gcttclcr gcogrilphy, arld that illrcl to ,-.'"firrgi,r.,-u",..liifcrcrrccs e.i',,..1i,.tg tl ,ttc acl trl tst' tr< l ki trg' i rl a l th ,r,.,g hs c v c rrrlc 6 tttl tri cs rcpol ' tc(l t' ccl l tcti ' tl s l .rl acl cl i ti < l n, y()tl l l g l )\' ,h .r* " .i s i g ri fi c rrrrtrc cl rcti ,ts i tr sttt< l l < i ttg c.trrl l 2 i tl l rl scrs: ' c,pl c. rtl tt()l tstccl i i . g .r.,a .r' * l rph a s 5 cc.' rc l csssi grri fi crl ttt (W H O' 20034)' 6' ys i .i .J g i tf t rn r,rt ..l rl s tl tttc6 rl s,ol ' l rl orc t6arr' hcal th pr.6l ct.s, erl cl thcrc i s scverc crr' scs f ;i . s rr.l < i .g , rrl c.6.l l t f6 w 1,rl cl f thrrt rl l cohrl li s rr si g,rri i i cal lthrci ' s l fi i c i c n t c v i c l c ttc cttl i rl cl i crrtc ycrl rsof l i fe trl orc i ,rr cotl tri btttes h c e l th ,(\(/H O, Z (X)l ). l rr frtct, rl l cohol corrl l l i rl ccl cl rttgs i l l cgel c l i sabi l i t,vthrrrr tobrrcco,rrrcl I.s t t, c l c rrth 'r thci r i rr ri g()r()tl s 11s S ectt tt.t l rei ' c rr()st c()tl l ttl -i cs t* r rtl , 2 0 g l ).' l i r c l rrtc, bttt t< l l l ecc< 1, heV c i l s theV rrttc l n p ts fo rc c l u c c rrl c0l rol cOtl sttttl l ' rti < )l l otl l cr cl ri rl ki rl grrrrclcl ri vi rrgrtrl cl ' rl c< l [9]i n s tc rtchl rrv ci tl c tts c clotr rccl trci trg N ot i l l trstrrl tcsthr: rrtrtqctrf e(}tl srttrtP ti ott' 7.2 tel tl c rc l a tc d l tc h a v i < l rrr. trrrtl i ti rl rrel l yhrrcl c c()tl tl tl ' i esi rl .l rtrr< l 1.lhrrvc s U rp ri s i rrg l yw , i l rc ,p r().l rrei rtg (scc l i .r si rcc 199.5tl ' rctrcrrcli ncl i catcsthrrt thc t)l r i h .' l ..,i 9 6 ..:ri ,l ,rrc s , 5.t S w ccl crr.cl trc ()f S ttrc1i cs,2002). 7 .g ) i s ' c l o s i rl !lrh c g r rp (l rrsti tutc A l cohol rcgtrl l rti tl l rserl cii ts stri ct pri ccs, hi gl r cl trc.t< l h l .i ." ,, e rl c lSi ngap< l rc, t., l -.| i g p thc l ow cst cl rspl av hcrtl th, c rrrp h e s ts ,r,.,1 -' ..r.rr," 1rcsporrsi l l i l rt,vf< l r c( ) llstllllPtl( ) 1 1 r :1 tcs.
Thc nun-rberof middle-aged men drinking thenlselvesto death in llritarn has more than doublecl since 1991. Deaths amon!! women in the sarneage gr oup als o n e a r l y c l o u b l e d , {u e l l i n g c o n c e r n s o v e r b i n g e - d r i n k i n g a n d rising alcohcll consumprion in Britain. Canrpaignerssaid the link betwecn people drinking mrtre a1d the rise in alcohol-related deaths was estahtharr 50 ycilrs allo. The numbcr of alcohol-related deirths irl iished rr-r<,re 200- 5 s t ooc l a t l J , 3 [ J 6 ,c o n r p a r e d t c t 4 , 1 4 4 i n 1 9 9 1 . D c a t h r a t e s a m o n g nr iddle- agc dm e 1 n r ( ) r et h a l c l g u b l e dt 6 3 0 p e r 1 0 0 , 0 0 0 9 f t h e p o p u l a t i g n , witlr the highest rate 6f {eaths alnong nten ancl wornell i1 the -5-5tp l et
T h c 1 1 6 s tc ( )nunop f< l rrn< l f el col r< l lregul i l ti ()rli s thc sctti rtgof e rl l i rtiS ttrcl i cshevc l ottrtc[thet srrc h n l u l r i .rg cfo r prrrchesc()r c()nsr.l nrpti ()rr. rc s tri c ti ()l l srl r c cffccti vc i rr rccl uci ngnr()tor vchi cl c crash frrtrrl i ti escve t l (W l rgenertr attcl\X /ol fstl rl I, 99.5 ) . w i t| rc l a ti v c l , vl < l w l cvcl sof cl rf()rccnrcrrt Ar p rc s c n t, Austrel i e, thc N cthcrl rttrcl setrcl thc Ll l ( hrrvc sct thc l ega l c l ri n l < i n ga,l l c at l l l ;.f rrpen,N cw Zcrtl enclertc[S w ccl crlrrt 20; thc LJSstetcs g c n c rrl l ,vrrt I I; errclFrrtncc,Ital y rtncl(i crtrrrtrtyrrt l (r f< l r l ' rccrrrrttlw i tlc rrn c ll l i i o rc l i s t i l l ccl s;ri ri ts(W II(),2(X )2). 1(eytorhccffccti vencssof srrch rrcro ss p rc v c r)ti v ce ff orts i s cnforccnrcnt,w hi cl ' rvi rri csc()l tsi cl eral l l y' l l tl th a n c lw i th i n c o tnrtri cs. over ()tIc r e l c 1 1h1lc< l l rrtrolpol i ci cs i ncl ucl c prohi bi ti < l n, ttttl tt< l l tttl tcs < l ttrtcl vcr p ro c l u c ti o n rtnc[/rl rsrrl c,l i ccnsi ng,,w rrni i rtl ] l ebcl s, rcstri cti ()l 1s l rt trtrl tti ort. ( i r' rl trrtlr() .l l l v c()l l l [)rc ti s i n g rtrrrlp ronroti < l n,ccl Lrcl rti < etrcl h c n s i v ch c e l th stri ttcl l ,yf< l rrrl coholi s thc provi si otl of rttl t' cl tl rttr' trci .l tl llcllt l l tl t l rcc< l rcl i rlftt g W l l (). vcrv ft' w C ()tlll fa c i l i ti c sfo r e lcohol cl cpettcl ettce, fortl rs of trcl l tl l l ctl t encl th c vrtri otrs tri c s h a v c ' s y s tcl neti cr' rl l ycval uatccl l' ( .\( ) yt' ( ( ' \
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p u b l i c h e a l th :u rclhcal th pr< > nroti onstrrrtegi esl rncll rcti vi ti cs,prrrti cul arl l , th o s c s u rro u rrc l i ngobcsi ty l rl rcltobl rccoanclal col rol usc. It i s evi cl entthi l t m rrn y o f th c s c e f forts l crrclus fer fr< l nrl real th carc rl s rnecl i ci nei rrto thc rc rrl rn o f h c a l th edtrcati on rurcl soci rrl w cl farc pol i cy. Thc ncrt tw o s c c ti o l rsc x tc n d thesc l i nkagcs evcn furthcr afi cl cli nto housi ng rrnclcnvi rl l r()nl l ()thcrs.S ti l l < l thcr cl i nrensi ons < l f pu[rl i c ro n rrrc n trrlp o l i c y rl rcr' rs, h e rrl tl rth a t w c rr rc unrrbl c to cl i scrrsshcrc cl rrct() sD r' rcc l i rni ti rti orrsrrrc h c rr l th, foocl safctv, cri nrc/vi ol orcc, o c c r.l p a ti o l rl rl cl nru abusc ancl rnortal i l l n c s s . In c < l l rb i nati on, rhcy rrri sctraj < l r hcrrl thc()nccnrs< l verl o< l kccl by tl rc p rc v rriI i n g n rccl i celnrocl cl .
Homelessness and inadequate housing O n c h c rrl th fa c to r vi rttrel l y i snorccl b1,thc nrcrl i crrlrrrocl cl ,bur w hi ch trrl < c so n n rc rtn i n gi tt thc rrrorci rrcl trsi vcsoci rrlnrorl cl ,i s hoLrsi rrg. l .rrcl
212
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OomDttratiueHedlth Policy
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poor housing and heafth ; Homefessness,
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The poor health of h
L^-r-r^ i- rl^^ ITIl' ^^----:,-^ ^.^ -L^ ^f 'rough -1^^^^--' the UK sleepers'in health of the L^^l.L health services, as two reports on suggest.A report by the hous:ingcharity Crisis highlighis the fact that
homeless people are often denied the right to register with a GP (Carvel, 2002b).Instead, homeless people have to rely rln overstretched casualty departmerrtsin hospitals when their health problem has become an enlergency. Medical treatment can also be rendered uselesswhen homeless people are dischargedback on to the streetswithout any adequatesupport. This is echoeclhy a governnrent report, which states that the health needs of homeless people are n()t mct in r systcnraticand effective way (Ward, 20021. For ex a m p l e , o n l y o n e - t h i r c l o f h e a l t h i m p r o v e m e n t p l a n s o f Prirnary Care Trr,rstsmentiorl homelesspcople. One need not be homeless to suffer adverse health effects, however' A report by the London School of Hygiene and Tropicrrl Medicine (1999) lis t s t he m any h e a l t h a s p c c t so n w h i c h h o u s i n g h a s a n i m p a c t , i n c l u d i n g home heating' respirirtory cxccss winter morbidity becauseof irtadcqr"rate pr oblem s bec au s eo f d a r n p a n d m o u l d , a n d n o i s e d i s t u r b a n c e b e c a u s eo f poor sound insLrl:rtion.Howe ver, it is difficult to quitntify the arrrount of ill health caused by poor housing becausemany health effectsarc qualitative in nature and concern poor clr,ralityof lifc and social isolation. Housingrclateclhealth prol'rlerls :lrc particularly :rcute iu l,ondon, where the hotrsing stock is comparirtively old and often of poor cluality' l-ondon also has some of the most deprived populations in thc UK and a high proportioll of r c s it lr t t t s f r ot t t ct l t t ti c r t ti r r r l r i ti t 's .
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Environmental health ( i l o b e l c n v i r< l n r.ncutrrl cheng,ei s rrl ti rnetcl yrl l l rr' tttcrof hcel th. I l ow e vct, w h i l c tl re h e a l th cffccts of cnvi rorrnrcntelchangc hrtvc rccci vcclcottsi tl cr, rrb l c p rc s s c o v e rl t gcrscri orrspol i cy rrttcrrri ()nl res bcert trrorc sttl tcl trccli rt l ocrtl probl errns. A l thoLrgh l )e c :l u s c rrs trr.ursl l rl ti onl rl th c y arc vi c' uvccl tr)i rrt rrn c ln r' rfi o n rrlc n vi ronnrcntel heal th hezercl shrrvc rrl w eys bccrt crtcl cttti c (s c c (l u a h rtn c l Ii l < 1n,2(X )3),concenl I' resrccerrtl l ,bcert rrri secl()vcr l tcw g l o b a l th re e ts . [] or i nstrrr.rcc, cl i rrretccharrgc rcstrl ti ng frtl nr the 1-:,l obel i rc c u n ru l rrti o no i grcenh()uscgrrscsi s l i kel v to l rrrvcrr si gni fi crrnti tttprrctot.t th c h c rrl th o f th c poprrl ati on (K crrti ngcrrncll )ol tel cl son,20()4; S nri th c/ ,l /.,2 (X ).1 ). Ii g l o b a l rvrtrrni ngprccl i cti orrsi rrc i rccurrrtc,the i ttcrcrl sci rl thc n u tn b c r o f c l a y s rvi th tcnrperl rturesover 100" f' (.l l J" (.) w i l l procl ucc a shrrrp risc irl hcrlt relrrteclnlorrrrlitlj frtlrrl hcat strokes, helrrt attrlcks rttlcl c e re b ra l s tr< l k e s,e speci al l yi ul r()nsthc vcry yotl l l l l r the cl cl crl y,arl clth< l sc (l tsevi cl encecl by eventsi n I' ' rrrncci n tl -rc w i th c h ro n i c re s p i rat()rycl i serrscs
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pl ' ()tecti otrw he re thi s i s rcl evrrrl t i .s tru n rc rts i ' th e a re r r.i crrvi ror.rnrcntrrl t< r N 4cl l 1berstrl tcs cotrl tl ri tteclthctl l scl vcs to h c ,rl th . T ' h c p a rti .-i 1-rrrti ng F.trvtr.tl tl retl t ,tr P l rrtts ' N rrti < l rrrl i ," 1 .,i .,r-.,.,rri r6 ,rgc l )l a r rthr< l i rgh _A cti .r r' rP sct \)v]l ,o offi cc.for Iuropc, 200.3c). e n c l Il c a l th ' (w l { o , l {cgi on,i l Il cel th (' tl nl nl i ttcc t() stl pP ort thc i rrl pl crutvt l r()ll l l l c' rl t,rrl cl tl -retrU r< 1 1 -rcl rl l { cgi rl nel oi fi cc fi rr F.ttrol ' l c, .i th c A c .ri .. Irl .ur (w Il o. ' re ,trrti r. 2 ()().j a ).' fl tc rl rc rl l l l c r stl rtcstl ftl rc\fl l l ()h,trrtl pcl rrtl { cgi < l rl hl tvcrcc< l t.tC i l rl i cr ptl l i ci cs l rs 1)l trt < l f thc Ftl trrtl -r i i rrl l c c l tl rc i r c tl tl l rrl , .,* ' .l , t() N l i rri s tc ri l l l (,< l rl fc rc r rccrl rl F,rl vi rtl rl tl -tctl tl ttl cl l l cal tl l i rl 2()()4(w tt()' rs (' ol l rl l rl ttcc 200' + ).' 1-hc w orl < of thc i a .* i ,,' r" f ()tfi c c fo r F' trro1-rc' tl rl (i l ol l rrl (' harl gc rtrl cll l ci l l tl l ' c o rn p l c rr.rc rrtcbcvl th c \fl l l () l )rosrrtttrtttc t[c' ,fcrrl tf i ttl l ' " tet6f tl l 6rl i t< l 1i rl g, * ,h i c h i s c ,.c c rrrc c l * ith " rr.rr' ,l g " ,.l .1 l ' l tcgi < l rl el ()i fi cc frl r l l ttr< l P c' g l ()l )rtl c l l v l r()l l l l l c l rtr l l charl gc' i W f l t 2 (X).3 b ). hcrl l th l tr i tl l portrttl t i sst' tc' rtrclhrrs Sw c c l c nc o n s i rl c rscrl V i rottt.l tct.ttel prl i ci cs ((i l crr.g,rrrr-lt' t t\..200-5). h .:i ,, 1 r;,r,r* ri rg r.l c i ,, " ,,ui ..,,,,,rcrtrrl f,r e rvi cl crrrrrgc,i r* ci l s ()i l rr S w c c l c ' , th c rrrtrri c .i ' :i ;;i " , " r.,-.rp,,r,ri 5l c prcvcl l ti ()l l , i .< l tl tl tral i tv' w rl tcr cl i se' asc c rv i r.rr.c r.rt" l l .,.a l t h,' i ncl t,.l i ,tg, Mrrrri ci prrl i ti esrrrc rrl s. cxpr:ri urc.t ;.,,..,;.;.,' -.,.,'at ,r.l c h e,,r' calc,,,rtr,,l . w cl l rl sw i th rl cw tl rri fi s l rccotttrti rrg,rs i trg w r, i th n c w fo rrr.rs ,rfat,di ti ,rgrtl cl -l ' hc-vh;rvc rtl str rrtl clforl cl scctrri ty' to i n tp ro v c c n v l r()l l l l l cl l trrlpr< l tccti otr thc LJN ' s l ..crrl A gctcl rt 21, a rrt th c i ' re fr.rt < l i i .rpl c' rcrrti ug l v6i ch i rl cl trtl cs p r()c c ss' ei ,t.l " .f s.stai ' abl c cl cvcl ,pt' crl t' 'Dc rrrti c rr c l p i rto r-.v " , 9()l t)' i r,,.rl tl ri ttttt' s l l rt' k t' rlrel ' g' ' ' ' ' 1" 1
model in perspective Public health: putting the medical c' l t' c crl tr l l c cl cci si vci rl i ncl i vi cl trrrl w h i l c th c rc i s n o c l oul ' rtthet rrl ccl i crl l t6l rt i t i s rr rcl rrti vcl yrrl i rl rl r i rrtt' r i tl c rrs e sth , c rc i r r,,l .,rt,,,ti i " lcvi cl errcc gorrl of hcrrl th crrrc i s to i nrprove tl tc th c h c e l th ,rr p ,,p ,,L fl ,r,]r- tr thc lrlind rrcceprrrrce.f the nreclicrrl'.r,clel hcalrh ,f p.p'lrrrri;;;,';'.,;-, ,,,.r. ' fhrec cl ecrrcl es rrgo, l vrttr l l l i ch (1976) veherl 1el l tl y trrr.rsbt c rc r.rs s c s sccl . llot 11ctlre' tli illr-ress' nenlesis lttlclrt cr'ruse, criticizcd ntOderrt ntcclicirlertsa Al th o u g h l l l i c h ' s t' i ti ti ' ' tt' < l i rl rccl i ci rrcw crcunci ul vharsh' hcrrlin i secl ftlrcecl plllcenlct.tttlf rr-reclicilrc lr s
21 6
w c l l .r\r l vrcIetrtl l l shi l l l l ctw cctl rl l ccl i cl rIcarcl ttl cl hcel tl r,cV cl l l l llt s ttl < l thcr cl ctct.tt t it t . t t lt. ', i c< l l l tl rarecl l l i l rr()w l l hysi cl rl ,.' ' ,.. i , rl l i rri rrl el l ' cl ' " rui t' ttr'rl rl clthc ph-vsicelr t r lcl h c rrl th strrtussrrchrts hcrccl i tv'pcrstl ttrrl r' ccl i c' rlcrrrci s ftrrt6cr l i .ri tcc l Scc. t t t sc s .c i rrl crvrr< )..rcrt' . i i r:' ;;;; 'f r r t r clf or n n rtv hc,rl th corrcl i ti onsare scl i -l i nri ti rrg' ,l " ttt-.-l l .i .." t;i :' ,:tl l l "' l l l l l l l \' ()thcrsthcrci sl i ttl ctl rrl < l effccti V ctrel rtl l l C l l t.' I.hccl rscsrvhcr c r r cs o t r t cor effccts si g.rfi ce' tl ' i ,..i ;f-,.,,,.. i ,,.tt..ri u. ' c.rl-t' too st lr r r llt
PultlicHeoltb 217
'': \ta rfi c lc l,
Table 7.3
Total health care expenditwre,life expectancyat binh and infant monality,2004 (rankedby % GDP)
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cl i scesci s assunrcrlto bc the resul t of i rttprcssi vc fr< l rrrc e rc l i o v ,rs c rrl rrr i n n Ov rrti < tnisl t trc r l tl i l cnt,cspcci al l vc()r()nrl ryby prrsssurgeryattclatl si ()p l e s t.v .H o w c v c r, cvi tl crtccsrtsscststl ret tttost, i i rt< ttrrl l , oi thi s drop i s e ttri b l te b l c to l i icstyl c cl rarrqcsrefl cctccl i n thc cl ecl i nc i n snroki ng, i l c re l ts c i n e x c rc i se,ancl cl ccreesci l t si tttl ri rteclfrtt c< l rtstrtttpti < l rr.' ()nlay tcchnol ogl ' ' ((.trrtcl i ffarrcl s n rrrl lp a rt, i f e n y , crrn bc attri btrtccltrl rrrccl i crrl l l rrnl < cr c/ rrl . concl ucl cthrrt ' cttrrcnt cl rrtrr Mc (.a rth y , l L )9 1 : I t3).S i rni l arl y, rccl ucccl rnortal i t,vw hcn rtl l p ro v i c l c n o e v i c l c nccthrrt l ncdi cel cerc l ' ras ttlgctl.rcr'( I 994: 2.3.3). cnlrccrsrrrc rrclclecl T h c s c fi rrc l i n g srcgercl i ng the i rtabi l i t,v to crpl rri n hcrrl tl -rstattrs b1h e e l tl -rc rrrci tl o u e havc si gni fi crrnti rnpl i crrti onsfor rl ny ci forts to rcstrtl ctg rc th c Irc a l thc i l r e systcnr.l f rr systerl rcal l y w rrrrtsto rtchi evethe gorrl< l f rcsorl rccs w < l ul cl l l cttcr be n te ri u ti z i n g th c hel rl th of i ts 1-l optrl trti ott, rccl trci rrgcri ntc, changi ng l i festyl cs p()vertv, a l l cvi rrti ng to w :rrc l s c l i rc c tc c l not ncecl nrecl i crtlcrrrc! A s notccl by person cl oers rl rc l s o f< l rth . A h errl thl care ancl l --l u ro w i tz ,' (i o o c lh eal th ofrcrrcl ocsnot rccl ui rcaccessto rrrccl i crrl ( of s< l ci cty' 199.3: 130). i s l ;-rrg c l yc l e p c n c l cntol t thc c< trrcl i ti orl On th c s eg ro u ncl s,rccerttci forts to ref< l rnthcal th care systcnl snl ay be no rl m()Ll nt()f rcstructuri ngl real thcrrrcal ol tg the l i nes n ti s g u i c l c cl te l c rru se p ro p o s c c lb v th c refort.nersw i l l havc rr maj ttr i rrtpacton thc hcal th of thei r p o p r-rl a ti o n sR. e fo rrnsfor uni versalaccess,i mprctveclqui rl i ty tl f care and
c t" i l tl t P r' /l cr' 2 I 1 3 (.rtml ta t' ,rti L'H cere systel r' but thel i mprtl vc the m.ccl i cal ot c o s t c o l l tl l i n nl ent r-rri gl rt sr'rbstarrtially " lLt: l:l]::',1:'"1ttt' c,lnr1ot bc erpcctccl t 'n.'ptuut ur.ri vcrsal that provi cl i r.rg evi dcl rce rc s u l t, ' th e rc i s l i ttl e f:lv
: - ir. l )u t t hc Y -rr.'.tl tl r. A s a -. rq u tti v er s lt l -. rn t i l rr'o r r r lt lc . ro e c
Chapter 8
Understanding Heafth PolicY Comparatively
cotttcrt, thc prt' cctl i rl gchel l h e rtlth pol i ci l l l i r c()l l l P rl l ' rl ti re In rtrrrrl l ,,s i rrg tc rs Ie v c c 1 l v c rc rle rvi cl c r,rnge of to1-ri csi rrel tri l i rtgthe Iri stori crrlrrrl cl c g l trrrrrlrrrrj c c to ri csof hcrrl th pol i cy; systcl l s of ftrrttl i rrg.provi cl i l l g erl tl rcs()tl rccs:l terrl tl tertre 9 6 v c rrri rreh c rrl rhcrrrc;pol i ci csof al l oceti rrghcrrl th thc cl i vcrscpol i ci cs tl tet consti ttrtcptrbl i c hc.l l th. ' \s rrl ; i rr th c h 1 1 n rcrrrrcl rl tcrtsi on cnl crgcs l -rctw cctlsi rrl i l rl ri ti cs i i l tV c ro s s ,c o u l tf ry c< l ntl ' rrrIi s()n, pol i cy trcttcl s,sttch rts fhc trl l i tl tl rtvof conrn()n rl rc l c l i i fc rc n c c s l. tctw ccn sttch rts' uvcl i ercrtri x i rt thc prttvi si orl,ri ra ti 6 p i l u , rrn c lp o l i cy cl i vcrgcncc, h o s n i ra l s c rv i c c s. ' [' h i s [rri n g s rrs becl
Health systems and explaining health poficies -fhc use of tl-rcnoti
219
220
('omltaratu'e Hea\b I'olc't
o fh e a l thc:rre(amongothers)w hi chshapeheal thpol i cres(anclpolit ics) 1997b; R affel ' 1997; S cott' 2001; Wall' (s e e ,c.g., Freenran,Zi i tl 0; U ' -, 1 9 9 6).C ,rtl ss-c< l untryc< l nl pari s()ngel l eratesarrl rbunc]atrcc
Healt h s y s t e msa n d in s t it u t io n ael mb e d d e d n e s s oi hcalt h syst cllls J a l tlc l l .l rtraps()ut ()LtrcOU rrtri esusi rrgthc tvptl l < l gy i rl rllt lr c clct r r il cl cfi ncs i n trocl rrcccli n (.hrtptcI I as a l l rrsi s,l l trt i t rrl so fgrl cl i rl gr r t t clpr 6vii l l v()l vcl l l cl l t i l 1 tl re .,f' o.,u.r,.rrr.,cnt c l i ffcrcnt r-rspccts prece clir lgchep i rt s i o r r < tf herrl th." r. f,rl l .r* i ne ()l l fr()l l l thc cl i sctrssi orl of hcal th cr lr c llr c tc rs.' l ' hc i nsti tutrorrs of g< l verrl i rl g the ftrncl i rl g peti cl l ts It r lvcr t cccss c ()nccl tcclw i tl r thc tl l ecl l rttl i st.tlIys w hi ch i ncl i vi cl Lral trllt it lclllcllt s) i tl sttrr' rtl cc crrrtl ecl erl cl to servi ccs(such as sOci rrlci ti z.crl shi p t' l res( ) t lr ccsr r ll
LJntl crstdn tlin g H ealt h Policy ComPdrdtiuelY
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Table 8.1
)'21
Health systemsand tbeir poliues
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222
C)omltaratiueHedlth Prtlic,t'
s y s te n l s th us rrri l ki ng categori zrrti on probl cml rti c. The same pr< l bler ll appl y to the cott' tpl i ri sonof the govcrnrrnceof fr' rndi rl gar r cl ,.,.,i g l .' t,rl so p ro v i s i o u . publ i c c()ntrol of the t()tal res()Ll rcersllloAc c < trcl i pgto thc typ< l l og1,, to l rc hi ghest i tl nrrti onal hcr - r lt h l rc erpcctccl crl n c rrte c lte h cel th ci rrc ott s()ci rtlci ti zcrrshi ;lrl ncll owcst l )ased c.l rc s e rv i c c sr,vi thrrcccsst6 heal th t< l hci tl th ci rrc i s b:rsed ot l l l cccss i rr p ri v rttc i ttsurrrttcesysfcl ttsw herc hcal th syst ellls p ri v a tc i 6 surrrncc,w i th pul tl i c c()ntr()li n soci rrli trsttrrrtrce l l r" i r i 1 1 g l tcl r' ccn.' l ' hi s i s truc i or four of our c()tl l ttri cs, rttl ' rcpi cttr r c is ' ,.r fi vc countri cs,1' l oi nti ttgto thc i rl l ptl r-t r 't llcc l t9 rc c < l l tpl cr i 1 thc rctnrri rri rrg 9 f c < l rrrrtryspcci i i c i nsti tuti onrtl cotttcxts. Irt A trstrrrl i a, i or cral tlplc. i c tl c rrrl i s r l c6rl l ri pccl rr i th rhe l cl :..tcr',rf thc pri v:rtc i tl stl rrl tl cesvst cllls tori tl ' tl ' " ' crl trrl cl i ttg(l ' el rncr rttl clS hort,20 ( X) ) ' g()\' ertttrtcl lrttttl t \\,c rrl < c l ts pol i ti crrl svstcl tt i rt.fal terl hcl l l s to col l ccl lt r r lt c tl tc rrpi terv Irr c 1 .1 p tr rrst, tt i arl rpl l cl lrl rrclIl < cger lr i, a L rth 6 ri l i l tl re hel cl s of ccrrtrrtlg,()vcrrtrttcl (( hcrtl th scrvi ccsrrtl cli lt st t r of It)9 8 ). [)c spi tc si eni fi cerrttl cccntrrrl i zeti < l rt i l l 1 1 rc cl )l ry r s,for crrunpl c, el l bi l l i ng rrtrcll tavtttcttt .frl l l erli s ccrrtre lizccl tl tl o rrg h tl r c prtl ,nrcrrtfrrncltl f thc N rl ti onal I Icel tl r l l l sttrrttl cc. ' l ' h e N ethcrl rrl cl srrrrrlS i ng,aporcrl rc pi l rti ctrl erl y i l l tcrcsti l tgcrrttt lPles sl rrl .rcthc;l trl l l i c c< l rl tr t llt li 9 t l te rv c () Ll rrry-spcci fi icnsti tuti < l rtrrl cotrtcxts be tw t' t' t.tet,tl tl rri ctprrrti ct r lar l, v rl i i fcrcrtccs rrraki ng c()stsJ thtrs l tc e l th c i l r c c()l ttr()lof ttrrl cl i ngrcf lcct s ptrbl i c hrgh tl re p c rti p c p t. I1 thc N cthcrl rrrcl s, r,vi thstrorl g,trtl i vcrsalist i ttsttrettcc soci ,rl c9r1[i 6eti 9rr 9f rr th e 1 1 p rrsurrl l L)97).I l calt h Mrtrtrsc, 2004 ,t1., c l c n rc rrrs(i < rrrtn overvi cw , scc F.rtcr t' t i rrcl i rcl i rrgpr t Vr t t t s< l ttrccs, c i vcrsi tyoi fu l c l i l g c < l prIi pcsrr corrsi cl crrrblcl i l s u rrrrrc ci 9r rrcutcrrrccl i celri sks i or thosc u' i th carrti rtgsrl l )()vee ccr t r r it r l c v c l , l u rc l conrpul sorv soci el i ttsurl ttrcectl tttri l l ttti otl s t() c()vcr cx ccp 'l ti rl n rtl rrrc cl i crtlri sl < s. hi s rci l ccts thc hi stori cel l cgrl c.vof rl s
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' - I k e g rrrrri , .- . r t l ittsl tr. , -: r rrrl l i zc(l .* .'r. t t ttp l cs , -, , ntrtl l tl f ' . 't '. t ictrl rrr'l ,v ' -r ' g rrf l ccts : |\ 'efsi l l i st - '- .lleel tl r . .. rq lln vl l rc . - .l ccrtl-tlll , . . 'r-cxccp - . 1 \ ()cl cty " , ' r q o f th i s ' . , , hc l p s to ' ' , " i. r rrl cl ,i rr ' , r cl . i-- . ue l l th rrt - . : . but l l str '') l; llltn t, ' 'r . t lth crrrc "- i. ilin 'a rrcl -:. . . tI srrvi n g s . - ' rt ri l )u ti o l l ' .: . )rc , cl cfi cs ' a e()rrtro l . r r . . rl c o l l ce l l - I \ t ro l l g l y . '. lr,tcl rti
223
pr()sriurlres rrre ainlccl ar lo\\,crilrfl tl.rcclcrnrrnclfor hcrtlth crtrc attcl alstr c rn p h a s i z eth c i rn p o rtattcc of pri trl rl r-vhcrrl th carc ancl prevctl ti < l tltl vcr publ i c hertl thpol i ci cs rl rc strott!4,rrrtcltl rc h < l s p i ta cl e rc . N o t s rrrp ri si rrgl y, g ()v c l l n c n t h c rrv i l vs u l l si cl i zcshcal th pr< l trroti tl ttartclcl i scrrse prevel tri ()tl p ro g rr' u rn l e sth a t c n rp hl rsi zcthc rcsp< l rrsi bi l i tl ' ofthc i ncl i vi cl tralttl l < l < tl < e ftc r h i s o r h c r o rv n h c al th. ' l -h c i rtrp o rtrtn c c< l fc o r.l nfrvspccrfi ci rtsti ttrti < l rtal c()rttcxtsrrl soapi tl i cs, t[9 u g h t() rr l c s s c r c x tcnt, l vhcn conrl ' rl rri ngthc g()\' cnri urcc< l t ttrncl i ng ebovc, l tes a e n c l p r< l v i s i o n .Si n g l rp orc,frl r cxrtttrpl c,errclrts rrrcrrti ()rrccl h i g h l y c ()l tfro l l c c l h c e l th s,vsfcnrbLrt ()tte brtsctl tl tt i rrtl i vi cl Lrel\i tvi l tss cotttrol ovcr rrc c ()u l ttsth :tt g i v c th c i nrprcssi onof rrri rri rtrelg()\' cntrrrcrrt i trsttrrtttcc rttttl rr pri vrrtc e stl ci el l i nc bctl vcctr frrrrc l i rrg .' l ' h u si t, c r()s s csthc gi i .' cs thost' pcrsotl s i l s rrr:rrrc ch c e l th s ,v s fc l tl .I-ttrthcrrtttl rc,S i ttgrrporc w tth s L rfi i c tc rrtM e c l i srr\rcrl ccor.nttbrrl rtttccscorrsi cl crrtl tl cfrcccl rl rrttl f c h < l i c crrsto p u b l i c rrrrclpri vetc ckl ctorsarrclhospi tel ses w cl l es rtl l orvi rrs th c rn to p trrc h e s cp ri v etc i nstrr:tttcew i th thci r rl cc()url tshotrl clfhcv srl hcal th svstcl rt,a l rtrgc c l c s i rc .Wh i l c p ro v i s i o n bcst fi ts rt pri vrttc i ttsttrr.rttcc s p ro p ()rti ()n o f h c e l th crrrc i s provi cl ccli n ptrbl i cl y ow ttccl h< l s1' l i tal[rr" q ()v e l 1 1 e l tt s c t s e l e ri c clcl < l ctors.l )cs;l i tc fhi s, thcrc rrrc i cw c< l tl frol s< l l t thc i n thc cncli ncl i vi cl trrtlhrtvc s rrrc rl i c ailrrtc rv c n ti o ni n S i ngep< l rcl rccrrttsc c h < l i c c o f w h a t s c rv i ccs f() ttsc l vi th thci r cotl rpttl sorv l l ttt 1.rri v:tre IlCCOLllts. r
' l ' l rc a n rrl y s i ss u g g csts tw () tl ti l l gs. Fi rst, thc col l cctr)toi thc hcel th s .v s te nh) < l l c l sa s rrn a p p r oxi rnl tti otrof ' rcel ' hcel th svstcrtts.l t i s thcl cfol e e c l rrs s i c ailc l c e lr.v p cth r rt i s rrscfulrtse hcuri sti c cl cvi ccthet si rrtpl i fi csthc c rrn rp l c x rc rrl w o rl c l < l f q()vcrl l i l tg hcel th crrrc (fol l o\vi rl g,W cl l cr, 1949).
-t)A LL1
Crnnp drat it,e H edlth I' o Ii c1,
Si g n i fi c a n tl y, then, there i s i r.rsti tuti onaIcrl l teddecl nessbeyond the govertl i ng hcal t h sLl l l gcsts, h e a l tl i s y s tc l l t.A s thc arral ysi sof ottr cot-ttl tri cs l l rc br< l :rcl crthrrn th< lse that c a re i s c n tb c cl cl edi n i nsti tuti ttnal c< l ntcxts i l l sti tttti < l ni rlcontcxts tha t i n s ti tu ti o n s n r aki ng Ll pthe hcal th systent,and i rre o ftc n a l s o hi ghl y spcci fi c to i rtcl i vi cl ualcountri cs. Ottr arl al vsi s,f
Health systemsand non-medicalhealth policies ' I' h e
rrrre l y s i srrbovc sugl l cststhat thc i nsti tttti otrrrlcorttcxt of et,vcrl tilt l; X ): 7) s h c a l th c rrrc i tscl f i s hi ghl v cotnpl ex.' l ' hi s cchocs Frcctl trtr.t'(2(X o b s c rv e ti < l nthet thc orgrrrri zl rti rl rroi hcal th cere i s rrcturrl l yrrot vcr v s y s tc l n rl ti c .' l -he corrrpl cx hi stori cel el l rcrl l cnccof pol i ci cs of l rertl thca r c o ftc n c l c fi e st l rc orcl cr i rnpl i cclbv thc troti otr < l i a -sys/r' rl A . s a rcstrl t,tlt c f< l r orcl cr w hcrc thcre i s l i ttle. l < toki rtg tnav l tc h c e l th s y s tc nrpcrspccti vc hi ghl y cl i ffcr govcrrri rrg hcal th crtrc i s In s tc a c l th , c i n sti tLrti onrrl contcrt of c n ti rttc c l t() , th c cxtcl l t thrtt such c()l l tcxtsrrreoftcn sonrew l trrrspcci fi ct o i n c l i v i c l u a lc o r.rrrtri cs. Inrportrrntl y,tl rcrc i s al s< lspcci fi ci tl ,i rt rcl rrti ottt t r s u l ' r-s e c to rs o f heral thcrrrc,rttclpol i cy.-I' hi si s perti ctrl arl yapprrrcl )ti rr rclaberettet thc rrtrtrgi rtsof ti < l rrto tl ro s c srrl t-sectorstl )i tt h:rvc trrtcl i ti orr,rl l ,v y cvcnt to Itcrtl th pol i cy. th c ' h c a l th s .vstcnr' but r thrrt arc i ncrcrrsi ng,l rcl l ro c rrs i n g< l n h orrrcl l nclconrr.rruni tybascclheal th crrrcrl s rrrrcxrrrnpl c,this s e c ti ()nrl s s c sscs the rrser of fhc conccpt of thc heal th sysfcntfor crtl -ttur llt q th c i n s ti trrti
LlnderstdndingHedlth Polict' Oompdratiucll, . . i. ci 'o n cl t hc - l. lli l rs h crr lt h - :- r. t i rrrn th os c . ( ) l l tcxtSth l' t t ' '. t rtl tl '"'si sf,t lr 't ie s o f p olit , : . : r e s (sttch r r s . riLrcs(su chr r s ' - , govcrn i nu< lf ' -"t l tsl -rcct<s lf ', . 'l h crcfo r c , - ' rf .u 'c h i g h ly
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I l rc OF- ( ll) . lr rcl e cli tr oLt r ' : : i. rti ve srclat *. . f.tco b z< lt t e, -: r .ri n r rrt t l. r e ;: r c rs b -v i t r t c --'-: u l .tro rg a lt i( rf l ' l l l l - l l l V
ltn d
225
exatnpl es.S tarti ng i rr the Iate 1980s,the govcrnment l a p a rr a re i rrc l i c :rti vc i n .frtp a rri n tro d u c c cla publ i cl y furrcl edscheme,the so-cal l ecl(i ol cl P l an, t< l c x p a rrc lc rrres e rv i c esftl r ol cl cr pcopl e. Thc schcnrcw i rs extencl ccli n the l a te 1 9 9 0 s a n c l i n cffect becanrerr seprrratebranch < l f soci rrli nsurance, fu n c l c c l l ry ,r m i xturc of soci al i ttsrtrrrttce premi tl trs ancl trl xcs. (i 6 rrs i c l c ri n gtl .rctrrrcl i ti onrtlstrcngth of fanri l y responsi bi l i t,vfor crtre of th c c l c l c rl y ,th i s i s rr si gni fi carttpol i cy' cl cvcl optl cttt(Ii ttrusc, 1996). ' l l h i s c rrrc re c n c c< l fnorr-rl ccl i crrlbascclhcel th crrrerl ri scstl rc cl tresti ort
226
OtnrtpttrtrtiuaHcttlth Polic,-
rl re of l i ttl e p ro v i s i o rt rl l tc l cl octors as provi cl crs.of crl re l :f.:)rtancc' cltrc lssistlrtltslrr-rds
Possibilitiesand limitations for cross-national learning ot i tl t6ve col l ccrni tl g the extetl t t< l w hi cl -rthe t,vp< l l ogv T h e c l i s c rrs si ()n Fi r st , thi ngs. thrce sul agests pol i cy h c i rl tl -rs v s rcnrshcl ps to expl ai n hcal th
226
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.l1lt cnrbccl cl ccl(1999) rei ct-ttl thi s ai ' ctrl ttrral p o l i c i c s .F rc e tr l .r' ttr It' u' i ti ' .t .trcl ' tr.t.5l v' . " " tl t' t1" t" tathc t.rrcr.l cvcl l c rc 5 y nt);t;;;;;i ' ;" )' i ' y .c s s ' rttrcth tv 1 -l c < l fc l i v c rsi tytl .," ti ' shepccl l l ytl rgeni z,ati tl tl l rl l rl l scstl rl rtl rrcctl rrri c. thrrrr[rrrtiorrrrlrrnclptrblic' gcnclcrcrl,locrll rrrtcl;t;-;t;tt"i' rrrthcr i rs thcy i n-sti tuti ortrrlrrrrl rtl gcl l l el l ts W ' c rc c l ' c s tl .ri sl cr.rvccrrpturi ng corrcbascclhcelth crtrc |rtrclcxplrriilirrg :;;;t;t;"ltt r.l,"-l,. ""a "n,rir'r,, s p < l n c l i rrg t,,,,.t-,,tctl ' c^l hcel thptl l i ci csecr()sstl tttctl tl tri cs?J' hccotlcclrrtrci lt ot hotnc totlwhich usc, rrotebl-vro rhc cxtcilt the hcrrlth svsrerlrir ,;; ;;;,; rrrcclic:rlhcrllth is prrrt the orsl.tttizrrtiotrtlf courrntilrity b"r.d n."ltir cerc hcal th svstctrlhes tht' tt" ' t.' 1-' t.f tl rc c rrt' c .l l .w c u .,, ttt" tl " ti t1" ' tt" ' ' i ti g r'l'hercl'ts itttl-r
lear ning and limitationsfor cr oss- national P o ssi b i l ities ot the cxtent to rvl -ri chthc typol ogy fh e c l i s c u ssi tl tlrtbove cotrcerni ng l "ir st ' thi ngs' pol i cy sul l l l cststhrce svstclllshelps to erplain healtl-r t",.,-ttrt-t
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227
rn < l c l c l l c oc l r p rrre c l i l l m a ti ccrrscstl rc concept of thc hcal th systcnrhol cl sas rr uscful spri ng, such rhc hcel th systcnrpr< l vi cl cs i u r i c l e e lt1 .p c .Se c o n c lrs b o rrrrlfo r th c rrn e l y s i so f hcal th pol i cv, but otrc w hi ch nccdsto l rc cornpl ccxpl rrttafi otrs. Thi rcl , thc cortceptof rn c n tc c lb v rro rc s p e c i fi ci nsti ttrti < l rrel th c h e a l rh s y s tc n r i s l c ss appl i crrl l l c to i ncrc:' rsi nul yi rnportrurtr l r()no f h c rrl th ;rol i ci r.Instcecl ,cl i ffcrort rrspcctsof i nsti trrti < l nrrl rn c c l i c e lrrrc r' rs c o l rtc x t c ()l n c i n to p l rtv rrnclthcv crtrr bc cotttbi ncrl as pl rt of a l < l < l scr ' < l rg rr n i z in g i rrrtre w o rl < '. rur.rttl ' xcti vcstri l tcgy N e v c rth c l c s s cr r()s sc ()untrYcotrl tl tri sott t' unrrti ns i o r s < l c i e cl n c l rri rv ,l ro t l crrstes i t crttrel so provi rl e rt brtsi sfor i cl cnti fyi nu th c v l rri c t,v< l f p o l i c v ()p ti ()nsther cxi st i rt hc.rl tl r1.rol i rt.,\s stt.l t. e()nrprrri s o rrh o l c l sth c i n rp l i c i t p ronri scof l carni ng fr< l rnorher cotrntri csarrcltl rci r p < l l i c ys u c c c s s c srrn c lfri l rrres. H cel rh pol i cv l cerni ng ()ccursnrl trl rel l y as i rrfo rn re ti < l nrrb < l u t()th c r c()untri cshas bccottrcrn< l rcrcecl i l vei ' ei l ebl c rrs p rtrt ()f th c p ro c c s s o f gl obal i z.rtti tl rr.l )ol i cv l cerrri rrgi s al so crpl i ci tl v zrtti otrssucl t rrs thc ()F.(l l ) encl thc l c n c o rrrrrg ,cbdy i n tc rrra ti ()nrl orseni !(/[ I() ' u v h c rrth c y c l i s s crni nefci rtfortrrr.tti ottrrbout herrl rh sy' stcrnsr.rncl c,ttt1.;tri rc f< l rn rsi n d i ffe rc n t c o u ntri cs.' l i r prl l i cy ttrrrkcrs,cr()ss-c()ul l tt-y ttorks to i cl crrti fl 'w hi ch hcel th p< l l i cy/systct'w s < l nrtrrc lth c o 1 -rp o rtrrni ty ' h c s t' i s rtrtrrl c ti v cfo r s c verrrl rci l s()ns.l .ool < i ngi l t ()thcr countri cs ,rti crs,t v i rtrrrrl' tc s t' ()f c l i ffc rc rrrpol i c-v()pti ()rrsrrttd rrssLrchpronri ses' evi cl cnccrrtrcl ,rtbovc rl l , pol i cy sr.rccess b e s c rl ' p o l i c y n re l < i n e ,; rol i cyi trtrovrrri < l tr (S to n c . l c )9 9 ). F l o w c v c r, th c rc rrrc in fect cl i ffcrcnt trtocl cl sof p< l l i cy l c:tl ni ng rrs a rg,ucs,tw o of w hi ch are prrrti cul erl y rcl uverrti rr I' rc c rn ru r(2 (X ).5 ,2 0 ()(r) tl rc p rc s c rrrc ()n tc x t. Iri rst, p< l l i cvl eerni ns rrsfri ursfcr i s brrscclort rr rrrti on a l i s t c o n c c p ti o rrrh rrrp ol i cv i nl )r.rtrutclpol i c,v()utput rcl rttcfo crrchothcr rrs c r' u .l srrn c c lc ffc c t. l )o l icy l crtrrri ngctrrcrscsrrs rrn i nstrunrcntl rlproccss l errrni u rl rcl crt< l l n c v i c l c n cc.l n othcr rvrl rcl s:pol i c,"ntrtkcrs th e t i s b e s c c o { )ncc()untry t() pol i ci es casi l t tr,rrrsfcr fronr rrncl p ro b l c n r s rrrl c l rc sss1 ' l c c i fi c pol i cl ' l crrrni ng as trenspl rrnti s brrsccl th c o th c r. Irr c o n trrrs te n cl sccortcl , ()l t rl l t i n s ri tu ti o n e l i s t p e rspccti vc encl sovcrnnrcnts i tre sccn to sh< l w ' l ' hc proccssof l crrrni ngi tscl f rs rcl atcclt< r s r l crrrrri ng. c l i ffere n t c rrp rrc i ti cfo e rp c ri c n c c rrn c lc x p e ri n r cnt. Il r < l thcr w orcl s, pol i cy nrrtkersl crtrrri rr rtn i tc ra ti v c w rrv th ro u l l h trr al l rnclcrroq rrncltl .rctravcl of pol i ci cs froru ortc c o u l l trv to th c n c x t i s c o nti ngent upon therc bci ng rr spcci rl li nsti tuti onal c o rltc x t. l ' l re w o rl < o f th c Ol l (l l ) ancl i ts rccent OFl (l l ) H eal th P roi cct pow erfu l l v re p re s e n ts :rrn o c l e lof pol i cv l carni ng that i s based on transfer.For c rrrm p l e , i n th c i o re w o r cl to thc frnal report, thc D i rect (l encral of thc Ot' -(l l ) s tre s s e sth rrt th e P roj ect offcrs a mcans for metnbcr courrtri csto l c a rn fro rr e a c h o th e r, cl raw i ni ; oIr ' thc best experti se' thi l t cxi sts (O t.C l l ), 2 0 0 .5 :.3 ).C )o n secl ucr-rtlthc v. report l i sts goal s of heal th systems a s g c n c ri c to h e a l th p o li c,v and l vhi ch, as such, i rre appl i cabl e across
228
CctmParatiueHealth I'olicy
policy initiatives in inclithe r_eport.presents different coLrntries.Similarly, optioris..ln sh.rt, this is ab.ut .o;;t;;';rt.rit.',t. poti.y vicrualcount.es for trirnsfer' wherc the ", tn identify bcst practice health in evaluatirrg "k"n-" to lcarn is assunrecl'The :rnalysis prcsented oi capacity of governnlents i t" e* pl i ci tl y chal l errges' thi s'r n. dcl th e p recedi ng .l ' tnptt' ;' n;;;' transferrrr.rd 'best' iat'.ttiiying what is p.licy learrrirreth"t ;;;;'-'t.'nt T'he tntiil-t"' is straightf
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Untlcrstanding Health I'olicy (tmtporatiuely : r : lv cs i n i n d i -:. : his i s rrb o u t -.-: . r.n' h cre th c . - :. r es cl l te cli l l . :'l \ l l l()C lel ()f : ..n 11f rirttsfcr^:' , r u ercl. ' l-he -- i -
i': e l l l C f { l I ) $
229
A ctors i n H eal th C are
Users
Payers
Providers
The State
Auality Go a ls o f He a lth Po licy
X
Equity/Access Cost Containment/ Efficiency
X
- - Lrn S
Figurc 8.1
The goal orientdtiort of actors in health care
, , 'r 1''e clclecl irr ,: : nt if i es cl u al- - . ': r . 11g o a l s of - ': r llr c()n rp c t - '-r. t ke sl e l rrt- : is i u rth cr : '. r \ c tl i ffcre tt t
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T h c c li s c trs s i < lrt trb
230 Compardtit,e 17edlth I' olicy Ou a lity De fin e d as... H i gh: U S A , Germany and France Lonr S i ngapore, B ri tai n, Japan
L e ve l o f heal th care spendi ng lnor.ant^^a
n{ r:l-lP\
Sp e e d of access to medi cal technol ogy
Fast: U S A , Germany S /ow : B ri tai n, N etherl ands
Nu m b e r of doctors ( p e r 1 ,0 00 i nhabi tants)
H i gh: l ral y, Germany and S w eden Loru S i ngapore, B ri tai n and Japan
Exte n t of pati ent choi ce
H i gh: S i ngapore, U S A Medi um: Germany and S w eden Low : A ustral i a, B ri tai n, N etherl an ds , N ew Zeal and
Co m m itment to publ i c heal th
H i gh : S i ngapore, S w eden Low : Germany, U S A
Access/Equity De fin e d as... Pu b lic fundi ng of heal th care ( p e r ce n tage of total expendi ture)
H i gh: S w eden, B ri tai n, Japan Lor,,rS i ngapore, U S A , l tal t
Co ve r a ge of popul ati on
l -li g h : B ri l ai n ( uni versal i ty), Japan (soci al sol i dari ty) Low : U S A
Co st Contai nment/E ff De fin e d as...
i ci ency
Co n tr o l of costs
H i gh (di rect budget control ). B ri tai n, Japan, N ew Zeal ancl , S w eden Medium (contractual control)'. Germany N ethe rl ands Low (decentralized, ntarket oriented systems )'. A ustral i a, U S A
Su p p ly s i de rati oni ng
H i gh (nati onal heal th servi cesl : B ri tai n. N ew Zeal and and S w eden Low (market-based health systems )'. S i ngapore, U S A
Figurc 8.2
ldentifying'best' heqlth systems
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Guide to Further Reading
Comparative health policy: an introduction
I
a r l tl h cl l l th p 9 l i c1 Th c r c l r r c p r r t p l 'u s c i g l l t o o k s o n c o r n p r t r r r t i v eh e r t l t h s y s t c r l r s ( 2 ( x ) l ) P r o v i d cs r ttl a r l r r l l 'i. r r c a c l c r st . c r p l o r - c t o r n r o r c i n f o r n r r r t i o n . N l e t c h r r ( i c n r r r r t t r ', t i K a r l clth e L ISA. e p r l r l , ( . e r r a c l r r , S r 'v c t l c t r , . f s is . i h c r r l t l rc i l r c s y s t c n ) si n I {e f i c l ( l c) 9 7 ) . l ) cvo c o f s c | v i c t s . c l c l i v c r V inc l u d i r r g t l r c h i s t o | i , f i r r , r n c i r r gr r n c l ( s p c ci i i cl l l i ' l ..l < r r t 1 9 9 9 ) Wc s s c r r r t 'c l I '. 'v c l l ( 2( X )l ) , i l e ' 1l 9 t ) 7 r r r r r t l 6 ) r r . c l ( 't ( l c ) t ) l l ) c re r tti tl t'cr i ti ce l d l . S l l l t t l l , r t t c ( ) r l t c x t . r | l t c r n r t t i o n e l he r r f t hr c f o r r r r i r . rr r | r ( l o o 0 ) ,ti fe Is l t g o o tl l i r e e t t t , l t t l l t l r o l 'r c . i n r c f 0 n n c l r r c l r c r r l t l r c h r i l l c r r g c sf o r ( I 9 9 9) . ( 'o r r l tcr r tl l cl . , u . r u , " r " o i t l r c P o l i t i c s o l 'h c r r l t h i n [ '. r r r 0 1 -rrrcsc l o c s] \ l o r r t t l Il 'r tr t tr ttcl r e t i o r r i n g , r .tr r cl Ha r r r ( 2 0 ( ) ( ) )s p c c . i f i c a l l vc l i s c r r stsl r c g l O b r r lc h : r l l c n g co f ( i r c c r l r t t l d 'l l l o r o g o o cl ( |9 9 l l ) I { o b c r . t( 2 0 0 . i ) p l , r c c i t i t r t l t c i n t c r n r t t i o r r e l c ( ) l l t c x t . ( 20 ( ) 5 ) ( '\'l r r r i r l c N 4 c r r i c l < a r r c l l i l r r r l l < , r r r r r l y 'shcc r r l t l t p 1 1 l i c i c isl c f ( ) s sr r : r t i o t t sr v h i l c ( 'r r l l : r l r r t r rr ttttl \\l r tsttr l ttr t ( l 9 9 l l ) ' ) I {r i l r t c l c , , i l i f c p 1 ; l i c i c s i t t I c 6 t t t l t t 'i c s . ", ,. 1 9 f th c 1 6 l c 6 f ( 2 0 0 6 ) : r p c l I I r t r r i s ( ) r r{2 ( X ) '1 )6 f f c r v r r l t r r r [ r l c ( ) t l r p : r r r t t i y ee t t r t l l 's cs r ( ) l cs i r r h t'e l tl l p t r I l i c e r r c l p r i v r t t t ' c ( ) r l l l ) i l r c s ( 2 0 0 s p c c i f i c e l l y 1 ) lr r r r l <e t s .S c ( ) t t i c s i l r l . L r ro p ce r r clN o r tl l s ) , s t c n r s r, v h i l c S c l t r v l Ut r ( 1 9 9 7 ) : r r r t l v s c s s c v el l c ( ) t l l l t f ( l ( x ) 6 ) c r l l l or cs Atl l t'r i cr l tl A,, , " r i a a r r s r c g r r r t l sl r U r l g e t sr r r r cnl t r t n r r g c t t r c r rltJ. t 'l l e r l ( l l r r a t l r t e r l tl i \tr str e l i r tr tr ttl t t i hc : r l t h c r r r c p , , l i . t , f " i l , , r . 'b r ' l o o l
Z
The context of health care
fr r t'( ) tl r co L l l l a . 1 1 '1 lh e r e l t r c r l , r l l , v , r l r r , r l . ; 1 lrge s s r r r c e s( ) l t t h c c ( ) l r t t . \ r , t f l r t . r l t l l tl l ttr r r ts l vcl l :ts '[ l t r ' c t t r r c l t t r t s c f r t l t l r o s t t l l c ( , r r i t l c s c o t t t l r i t l s Wc l l s i t e to t r i es . l ) t rcl i ctt ( 2 0 ( ) 4 4 ) ' c ( ) n t c \ t r . r i l l i l r f ( ) r n i r t l ( ) ! 1 . I r o r A L r s f r a l i r r ,t h e k e v b o o l i s : r r e e o ( i r r r . t l n c r( | 9 9 5 ) r r n c lI r r r l r n r r ': r r r cSlh o | t ( 2 0 ( ) 0 ) . A v t '1 1t' r s c f t r l r r te xttt,i lb o o l <
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Guidc to I'urthcr RcLtding 239 pr ov idc s , t us c f ul r t r t ic le o n v e l t t e sr r r r c h l crrlthpolicv in Sinuaporcrurd thc r,vork of ( lur h ( 2( X) . 1)r r r r cl.l in ( 2 0 0 4 ) a r c n r ( ) s th el p f u J i n u r r t l er s t i r n c l i n st h c S i r r g a ; r o l c s v s t c nr . Klc ir r ( 200 |) pr o i 'i r l e s r r c l c t r r i l c crl t n a l v s i so f t h e p o l i t i c s o f t h e l l r i t i s h NHS s inc c it r v r r sc s t r r blish c t lr, v h i l c 'l 'u 'e c l c l l e( 1 9 9 9 ) f o c u s e so n p o l i c i c s o f h e n l t h r c f or t n in Sr v c dc n.M lt r nr o t e r r d Wi l k i n s o r r ( l 9 c ) c ) )o f i c l r r c o n t c r n p o r l l r i r . 'r , i t 'r v < r f ' t lr cs oc i: r lc let c r nr inar t t so f h c r r l t h: u r c lK a ', v r t c hLi 'ta l . ( l 9 9 9 ) d el v c n r o r c c l c c p l v int o t hc r c lat ions hil' rbc nv c c n i r r c c l u e l i n 'r 't r t cplo o r h e e l t h .
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3
Funding, provision and governance
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Suggc s t ions f or ir r r t hc r r c l t c l r n g( ) l r t h ( 'f t r n c l i r r e , p r o v i s i o r r r r r r c lq o v c r n l r n c c o f hc , r lt h eer c nr us t nc c c s s i l r i l v b c l r i g h l v s r 'l c c t i r , c .S c o t t ( 2 0 0 1 ) r 'r r r r n i n c s p r r b l i c iln( l pr iv r lt c s c c t ( ) rr ' ( ) lc si n h c e l t l r c e r c f t r t t t l i n g . p r o r , i s i o n r r n c ll c g L r l r r t i o r rr,l r : t l v ir r g on t hc c r pc lic nc c s o f A u s t l r r l i l r . ( l e r r r r c l r r (, i c r r r r r r n r , , N c f h c r l l r r r t l s , N c l v / - c el; r r r c l,t hc t J l( r r nc l t h c l J S i \ . H c n c l e r s o r t r r r c l l ) c t c r s o n ( 2 ( X ) 2 ) c r p l o r c t h c r liv c r s c r r c r ilr ingsr r nc lr r p l 'r l i c l r t i o n o s f t h t 't c n i l 'c ( ) r s u n r c r ''i r r t h c h c a l t h s v s t c n t s of ALr s t r : r lir r ,t hc Lll( r u r r l ( i r t n , r r l : t . l 'h c c d i t c c l v o l r l r r c s l r v A l t c n s r c t t c r r t r r c l lijiir l< r r r en( 1997) , I I er r r ( l c ) 9 7 : r ) , i V l o s s i r t l o sr r r r c lL c ( i l r r n c l ( 1 9 9 9 ) , r n c l l {r r n r r t l c ( l99ll) r ( ) gr t lr c r lv it h r r s l . r c c r r itsl s t r co f t h c . l o t r r t t t l t l l l a t l t l : I 'o l i t i c s , I 'o l i c t , t r n d / . , lr r ' ( 2( ) 0. 5,v olr r nr r ' ) 0. r t r r t t t h c r s| ) ) c o r r t e i n c h e p t c r s o r r I r u r o p c r r nc ( ) u n t l i c \ , f oc us ir r q on I r t ' r t lt h polic v f r o r l t h c p c r s l 'r c c t i v co l r c f o r n r . I n c o r r t r r r s t , t h c r c p( ) r t s bv t hc I r r r opc r r n ( ) h s t 't 'r , r t t o r vo f f t 'r c l c t e r l e t lo v c r v i r w s o f t l r c I r c a l t h s v s t c nr s in ljr ir r r in ( 19 9 9 ) , ( i e r t n r r n r " ( l l u s s c r r n r l l {i c s b c r g , 2 0 0 4 ) , t h c Nc t her lr ur c ls( llx t c f c 1 , r / . , 2 0 0 4 ) r u r c lS r v e c l e r(r( i l c r r r r r : r t r d( , t . r / . , 2 0 0 . 5 ) . F o r t h c Nc t hc r lr ur c lss c c ( ) linr e ( l ( X ) l ) . l ) r r v i s e r r c l A s h t o n ( 2 ( X )l ) p r o v i c l c r r r l e t r r i l c c l : r ec ( ) untof Nc r v Zc r r ler r tlh t 'r r l t h r c f o r n r s r v h i l e r \ s h t o r r ( 2 ( ) 0 . 5 )r r r o v i c l c sr r r r s c f u l s r t nln: lr v of r ec c r r t c hr t r t g e si n f t r n d i n g . A c ( ) ( ) ( l e e n c r i l l . u v o r l r rr r i f o r t l r r b l ch e r r l t h c r r r c p r r b l i s h c c lb y t hc Siner r por eNlir r is t lv o f l l c r r l t h ( 1 9 9 5 ) i s i n v a l r r r r b l ei n c r p l r r i n i r r g i t s r r n i t l r r t ' s v s f c nr . l: or qoot l s r r r nr tt r 't t 'i cosf t h t '. f r r p r t r r c s ch c r r l t h c i l r c s ) 's t ( 'n l ,s c c I l
- . . 'r r (2 .0 0 '{ r r ) , .. : L r lrlbt lttk ott r lc)'),1)ancl l here rtrc - . r n rrccllcnt ()f t ht : : r . 1 lV sls . : l rrs irrto tl- rc 1 00 I) rur cl ' . ' . rlth crrre is ' re v lt nd soc iI l e r n (200l) .: , .
4
Setting prioritiesand allocating resources
' l' ' "r ' er lc llc ( 2002) look s r r t l r i r r k e t o r i c n t c d h c r r l t h c r r r c r c i o r r r s i r r n u r l e r o u s c ount r ies lr nc l anr r ll' s c st h c r c c e n t c o n c c n r r v i t h t h e e i f i c i c n c l 'o f n r e d i c r r lc l r c whilc . f ec obs et Lt l.( 2006) c x r l n r i n et h c p L r r s u i to f c f f i c i e n c l a c r o s sh c r r l t hs y s r e n r s r r nc lt lr e t c c hnic luc sav aila b l c t ( ) l r c A s u r c i t . ( i e r r e r a l b o o k s o u r r r t i ( ) n i l r l ln r e c l i c i n e ir r c lt r c lc[ - r r m r nr r nc lI ] lenk ( 2 0 ( ) 7 ) r r n c l[ . ] l r c l( 2 0 0 1 ) . R . [ J r r s s e\ l r 9 9 9 ) r 'u r cll) c r l c t h t ' t al. | 1999) s pec if ic r r ll v f o c u s o n i s s u c s o f r a t i o n i n g a n c l t h e r c g l r l i r t i o n o f nr ec lic alt c c hnologl, r r s s c s s n r c ni tn ( i e r n r a n y , l v h c r e a s [ . o c o c k ( 2 0 0 0 ) c ] e a l sr . l 'i t l - r
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Sinc c public hc elt h c on r p r - i s c ss u c l 'ra b r o a c l r r r t t g co i r l r c i l s , n r l l n v o f r v h i c h i r r l l out s ic lc t hc s c ol- r cof hc l r l t h c i r r c , t h c r c s ( ) u r c c sh e l c i r r c c r p a n s i r " e . A n r o n g t h c bc s t r c c c nt ger r c r alr v or k s o n p u b l i c h c a l t h p c r s c r l r e T L r r n o c k ( 2 ( X ) 4 ) ,S c h r r e i c l c r ( 200. 5) ,M er s on ( 200, + ) ,I l c n c l e r s o r tc t a l . \ 2 0 0 l ) r r n d ( , r r r r c t t ( 2 0 0 0 ) . I l c r t u c h r r n r p r r nc lSt c ir r boc l(( 1999) o f i c r c o r t s t r L r c t i v ci n s i g h t s o n t h c c t h i c r r Jr r s l . r c c fosf p u b l i c hc r r lt h, r v hilc N4ec l< c n z r(el 9 9 l 'i ) p r c s e r r t sr t n h o l i s t i c r r p p r o r r c ht o p u b l i c h c a l t h polic l' . O nc of t hc bc s t g c n c r : r l b o o l <so r t h c r r l t h p r o n r o t i o n i s l ) i ( l l c n r c n t e c l r l l . ( 2002) . l: or r r c or r t pr c h c t t s i v cg t r i c l ct o t h c f r r t t t t e r 'v o r k st.h c o r i c s r r r r c ln r c t l r o c l s r us r c lt o c v r r lur r t c her r lt l r p r o r r ( ) t i ( ) n p r ( ) g r : u l n r e s s c c V e l c n t c ( 2 0 0 2 ) . M o r c s pc c if ic c oLnr t r y -pc r s l- r c c t i v c so r r p u l r l i c h c : r l t h i r r c l r r c l ch o o k s o n l '. u r o p c [ r 1 ' I I ollend r r t t d Nlos s ir t lo s( l r ) c ) 9 ) , t h c L I S A b v N l i l i o ( 2 ( X X ) )r r r r c (l . r t l r r r r t n( 1 9 9 8 ) . Aus t r alir r [ r i. ,Lc c dc r ( 19 9 9 ) e r r r l H r r r r c o c l <( 1 9 9 9 ) , I J l i t e i n b v l l r r g g o t t ( 2 0 0 0 ) e n d f r r pr r r rb1' ( ) k anr ot o ( 2( X )l ) . I {c c c r t t b o o l <so r t r n v i r o r r r r r c l r t r r al n r l g l o b r r l l r c r r l t h inc lut lc lt all ( 2( ) 06) .Nk r c l l c r ( 2 0 0 4 ) r t r r t lt h c n t r t s s i v ec c l i t e dc o l l c c t i o n s o f N , l c r s o n r t al. ()0(12). L' Idl. ( 2001) enr l Koo1. a
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USA r \ gc r r c l f o r I l c r r l t l t c r t r cl {c s c r t r c hr l r r c (l f t r e l i t l ': r v w r v 'r t l t c p r 'g o v h tr'<'rg A tttcricltrt t los 1titlt I r\ssocirrtiotl : rv'nvrv'lt ( lc r t t cr f o r [ ) i s c r r s c( ] o r t t r o l : l t t t l l ) r c v c t l t i o t t: r v r v r v 'c t l c 'g o v ( , c 1t er i ( ) r l \ l c t l i c r r r c : r 1 t l \ 4 c {i c r r i t l s t 'r v i c c s :r v w \ v . t l l c t l i c r r r c . g o v l) c per t t r t c r t tt t f I l e e l t h r t l l c ll l t t t l l r l l l S er v i c e s :w l v r v 'l l h s 'g o v l) c pr t r t t r r c r t to f V c t er e r t s A f f e i r s : w w w 'v : l 'g o v l: rvlv.ltrsll.96v I lc elt lr l {e s ( ) u r c c sr t t t c lS c r v i c e sA c l r r l i p i s f r r t t i ( ) t w I r r s t it u t eo i M e i l i c i r t c : r v t t 'r v 'i o t t . c ctl t Nr r t ior r r|r ( , c r t t c r f o r I I c r tI t l l S t e t i s t i c s :r v r v w 'c c l c 'g o v / l t c h s Nr r t ior r r r Il n s t i t t r t t s o f I I c , l l t h : w r v r v 't t i I l 'g o v Nat it lr l e l l , i l l r e r v
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Bibfiography
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Ar t r or t , f l. . J . ( 200 . 1 )'S I r o u l c l ) u b l i c l ) o l i c y S c c l tf 'lo r r sr vr , v r v . f r . c r t r o l o t t t t r l . c L r . i r t t / p r r b l i c r t t i o r r s / l 'i l c s / tl 0 r F70l :.N l .pdf Allr c r ' , f . : r r r t l I I . K o h l c r ( 2 ( X ) 6 ) I l c a l t h a t r l ( . , r r L ' i t t , u t I : . r t l t r g c d l : , t r r o 1 t a, , rrlopeerr l. ux c nr bor r r g,( ) i f i c i e l l ) u b l i c l t t i o n so f t h c I : u r o p c r r r r( i o r r r r r r u n i t i c s H l: ot t nc lr r t ionf o r t h c I t r t p r o v et r r c t t t Wo r l
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,Privilegc ancl Hcalth - what is the (-onnection?" Ncr AnSiell, M . ( 199 3 ) L-.ngland.lournal of' Mctlicirra 329 (21 126-7 . Anrtoncrl, A., f . Ilalc|rck ancl f . Sipili (eds) (2003) Thc Yrnng, thc old dnd the (lhcltcnham: F.drverd State. Socidl Carc Systertrsht Fiua Industridl Nallr.irzs. Fllear . (.lrc irr Five Anr onner r , A. , . f . S i p i l r i : r n c l. f . I h l d 6 c k ( 2 0 0 . i ) 'l ) r r t t e r n so f S o c i l l a n c l. f. l ] r rlclocl< A t r t o n t r e n , . [ . i r r A . I lc lgs t r ir r l Se c i e t i e s :F l r p l a i n i n g I ) i v c r s i t , v ', irt Fiua Oarc Systattts Srtcial Statc. tha ttnd Sipilri (eds.) The Yourtg, thc Old (lhcl ga r. rcl l'.1 rl : l-.clwl hl tcrr I n d u st r i a I Nilf lorr-s. Applelr v , J . ( 19 9 2 ) I - i n t r r r t 'i n gH c a l t h ( i r r c i r t t h c 1 9 1 ) 0 s .I l t r c k i r r g h a r n :O p c rr t iniv c r s it y l) r e s s . l rl t a r t g c t t t t d I 'r t b l i c I l c a l t b : A o l t i t t l Ar < r n, f . 1. .r ur c lf . A . I ) r r t z( 2 0 0 1 ) l , . c r . r s r s l r , o Pc r sltt' L'ti t't'. 1]rrlti rrorc: .fohns l loplt r w c r r l tohf A t r s t r r Iri r r . ( l o r t t t l t t t t l r tr At r s t r elir r l l) c 1' r r 1 't r n t 'notf I l c e l t h e n c l A g c i n g , ( 2 ( X ) l ) 'l l o t t t c a r t t l ( )rtrc', r'vrvlv.hcrt lf l'r.gor'.rt rr/rtcc/hacc/rrltler'htttl r \ us t r r r lir r n [ ) ep : r r t l r c p t 6 f I l c a l t h e r r c l A g c i r r g ( 2 ( X ) 4 ) 1 1 N c r r ', t l r , r l t '. g r '/ 'r r ' Cr nt t t t t gr ily ( r t r t ' T 'h t : Wa l 'I : r t r u 't r d ' ( 'e t l b c r r : t : A t r s t r l t l i : r l l[ ) c l l a r r r t t c r l tt ' f Hc : r lt h r t r r c A l tcing. ( . ] o t t l t l r t t l l ttY Ar r s t r r r liel l) ep a r t p t e r r t 9 f I l e a l t h r t n t l A g e i r t g ( 2 0 ( ) 6 r t )'I l o r l l c r r t t t l ( , ar c l) r ogr lt t t t t t t c ',t t , l v '" v . l t e l t l t h . g o v . , r L r / r l c c / h r t c c / i l l t l c r . h t r r l Aus t r : r lir r r rl) c pr r r r n r e n ro i t l c r r l t h r r n c lA g e i r r g ( 2 0 0 6 1 ) )'l 'l v r r l t r a t i o rtrt f t h t r I l o t r te c c a r A p p r ': l i s r l" lr s r l ( l111r s r u l i t v ( l r r r c l ) r o g r r r r n :N a t i o n : r l S t l t r t c l r t r c l s 'l 'h r cY I t t p: / / r . v ww. I e r tl t h . g , e v .a r r / i n t c r n et / u , c n rs / p r rb l i s l t i t t g .n s f / ( i o r l t c r l t / r l g c l r r g,IrtrtfioIr-strrttclertls.h trll hrtcc-hrrcccvrt lJ : r bc gc k .1. .alc l A . l t c l e t r i ( 1 9 9 '1 )'l ) e l i r r i n g r u r c l M c , t s t r r i n g H c r r l t h o v e r L i f c ', i r r ( i. ' I ' 9llc v . l ) . K c p l i c l r r p c l I {. l r a b i e n ( e c l s ) \ / i r l r r i l g I l c a l t h f l t r I 'o l i c t : Att L: . t ' or t r t r t ttit\ p' p r r t a t l t . O l t i c e g o : L J l l i v c r s i t l 'o l '( . l l i c e g t >P r e s s ' ljec hc , l. epc l M . F l i l c l e r s ( 2 ( X ) 4 )'N , l r r l t i - l e v r :(li o v e t 'r r : r t r c ac n t l l J r i t i s h l ) o l i t i c s ', i n ()xforcl: ()rforti l. llr r c he r r r r d N , l . F l i n d c r s ( c d s ) f u l r r l t i - l t 't , a !( ) o t 'c r n r r l . ( '. LJ niv er s it ,l) v rcss. ( ) 9 . ) ) l n t r o d r t L 'l i o t r t o I I L 't l t h ( ) c t 't t p a l i r t t t s . N c r v Y o r k: llr r c las c h, S. A. ( l Hrrll. Reg,cnts/l'rcrrtice llagggt t , l{ . ( 2( X ) 0 ) l 't r l t l i t . I I c , t l t l t : l 't t l i c l ' t r r t t l l 't l i t i t - s , l }a s i n g s t o l
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lJ er t els t t t a n nI r o u r t d a t i o n ( 2 0 0 3 r r ) 'I ) i r r g n o s i s - B a s c cHl o s p i t a l l l e i r n b u r s e r n cn t', l . G i i t e r s l o h : B e r t e l s n r i r n n F o u n c l a t i o n . ww w . . fapan S u r v e y N o . reforrn rnorritor.org I lc - r t els nt r r t tFt ro u n c l r r t i o r (r 2 0 0 . 1 1 )'l) ) H l I n c c n t i v e S c h c n r c ',A u s t r a l i a S u r v e y N nr, v r , v l v . r r h r r . r r l r ( ) n r t {) r . ( ) r . {l I lc r t c ls t r t : t t t rlt: o t i n r l a t i o n ( 2 ( X ) . t l ) )'N l r : c l i s h i c l r l l . c f o r r r r ',S i n u r r p o r cS r r r v c yN 6 .4 . ( iiir c r s lt > h :l l c r t c l s l t r l t r t nl : h : l l c r t c l s n t : t r r nl r o u n c l l t t i t >r w r , w \ \ '. r 'Lf r ) r 'n t n t ( ) r i t {}1 . . ( ) r t ] I J c r t c ls t r t r t t t tIrr o r t t r t l r r t i o n( 2 ( ) 0 f i ) 'l . i b c r a l i z r r t i o n o f M c c l i s r r v c I l s c ', S i p g .r l 'r ,r r .e St t r v c v N o . 7 . ( i i i t c r s l o l r : I l er t el s r l : r n n F o u n c l : r t i o r rr, , v n , l v . r feo r n r n r o r r r t or .1 l r { I lir c r r lr r t t t t r rA, . ( 2 0 0 2 ) t N o r u r d r 'dl 'r o f L 's s i o r t :\ n t t 'r i c t t t M c d i t 'i r t c l : . t r t c r st h t r \g c of M,utagcJ (///1,. Wcstp(>r't,(ll : l)r-rregcrl)rcss. lJ ir r c ll, I J . ( 2 0 0 2 ) l l i t t e r l 'i l l f o r l {r r r r r l A r r s t r r r l i e '. w n , r v . r r r o n r r s l r . e r l r r .r r r r / "on \ t:tgc 97 ()2/pi I l. lrtrrr p u l)s/nt()ntitg,c/r\1 llit t on, A. a n c l . f. ( i . I ( : r h n ( - 2 0 0 . )1 '( i o . n , e r n r n c r r t s h r r r c o i I I e : r l t r r t.r r r l I : r pt ' nc li t r r r c s ', . l o t r r r t dol f t l t t i \ t r t t 'r i c , t t tM t 'd i t 't l A s s o t - i t t i o t t2 l t 9 ( c ) ) :| 1 65 . lliiir l< r r r r t r rf,. W. a r r t l l ( . ( ; . 1 1 . ( ) l
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