Changing Healthcare System Types

This article classifies 32 Organisation for Economic Co‐operation and Development (OECD) healthcare systems based on data from 2001 and 2007. It shows that European countries are clustered in different types of healthcare systems and that traditional typologies are only partially represented in the four types of healthcare systems identified in this study. Type 1 represents countries with low total health expenditure (THE), high public financing, and low out‐of‐pocket payment (OOP). In‐patient healthcare is higher and out‐patient healthcare lower than the OECD average. General practitioners (GPs) are paid by capitation, and patients' access to healthcare is strictly regulated. Type 2 represents countries with an average level of THE, high public financing, above‐average OOP, and high in‐patient and out‐patient healthcare. GPs receive a salary, and access regulation is strict. Type 3 is characterized by very low THE, low public financing, and very high OOP. Both in‐patient and out‐patient healthcare is well below average, and GPs are paid a salary. Type 4 includes systems with the highest THE, the highest public financing, and the lowest direct payments by patients. In‐patient healthcare is below the OECD mean and out‐patient healthcare is well above it. GPs are paid by fee‐for‐service, and most countries offer free choice of medical doctors. The clusters for the years 2001 and 2007 are quite robust. During this time period, THE increased, and patients' access to medical doctors has since become more regulated.     

Mark Time: India's March to Universal Health Care Coverage

This article evaluates the efforts underway in India to achieve universal health care coverage and the conditions that fostered its contemporary evolution. It finds that India’s health system is characterized by private provision and financing, horizontal and vertical fragmentation, and weak governance arrangements. The article argues that these defining characteristics, which have solidified over time, account for poor health outcomes and make the system impervious to reforms as they deny the government levers to intervene and shape outcomes in the sector. While the government's recent efforts of increased public funding of national programmes have helped to reduce out of pocket spending, these are unlikely to work in the long run unless the government addresses the sources of the problems. The article argues that building health care governance, strengthening regulatory architecture, and stewardship over the system, in conjunction with increased public spending, are essential if the health care system is to provide affordable care to the entire population.     

‘Southern‐style’ National Health Services? Recent Reforms and Trends in Spain and Greece

This article analyses recent changes in the Greek and Spanish national health services. The aim is to assess how the period of austerity and further recovery during the 1990s and early 2000s impacted on them in terms of equity and efficiency. This is of interest because of the closeness in time between the universalizing reform laws and the arrival of the conditions for economic convergence established in the Maastricht Treaty. The analysis is also attractive because it deals with the transformation of already mature health insurance systems into national health services, a transformation that is novel in European welfare history. The article addresses the questions of whether austerity has hindered full implementation of the reform laws enacted in the early to mid‐1980s, examining reform trajectories and financing and expenditure trends. Furthermore, it considers the impact on access, understood in terms of population coverage, the array of services provided, waiting lists, and territorial inequalities. Finally, it discusses the introduction of new managerial formulas and attempts at enhancing efficiency. The concluding section states that divergent trajectories have occurred, thus rendering the definition of a ‘Southern model of health care’ difficult. It also provides explanations of the trajectories followed in both national cases and informs on prospects for the future.     

Transferring HIV/AIDS Related Healthcare from Non‐governmental Organizations to the Public Healthcare System in South Africa: Opportunities and Challenges

Almost two decades after the transition to a post‐apartheid regime, South Africa is still high‐ranking in the incidence of chronic diseases like tuberculosis, HIV/AIDS, diabetes and hypertension. This article explores the transition from HIV/AIDS related healthcare offered by internationally supported non‐governmental organizations (NGOs) in rural areas to the inclusion of this healthcare into the public healthcare system. This transition is part of a wider process that represents the exact reverse of healthcare reforms in Western industrialized countries. Instead of a transition from public healthcare to privatized or marketized healthcare, the transition in South Africa is from partly private healthcare to a public healthcare system in which the private commercial health sector as well as all services provided by NGOs will be integrated. In that process, many obstacles obscure intended outcomes, such as equal access to healthcare. Some obstacles are evident in the case studies of two internationally supported NGOs in the field of HIV/AIDS healthcare. We will conclude that governance structures of public and private NGO‐based healthcare are often difficult to integrate; implementation timelines and priorities do not always coincide; and the public healthcare system is still too weak to deliver good quality healthcare in rural areas without continued NGO support.     

Healthcare funding problems in Algeria

During the 1990s, a period of economic crisis, the health sector was involved in Algeria's broader transition to a market economy and the start of the process of privatization, with the result that the general level of health was affected by the structural adjustment policy pursued. Financing healthcare is an extremely serious problem. Seen as the primary source of difficulties in the national health system, it has become a major concern for both the authorities and the general public. Because of the difficulties, the healthcare needs of the population cannot be met, even though state, social security and household spending are constantly on the increase. This article attempts to analyse the funding mechanisms and the level of healthcare expenditure in Algeria.     

Child Budgeting as a Strategy for Policy Change

This article analyses how ‘child budgeting’ is used as a strategy to influence government towards better welfare policies for children in India. Though children constitute more than one‐third of the population, the budgetary expenditure for this age‐group is comparatively very low. The article describes the situation of children in India, and the method of child budgeting being practised by advocacy institutions in India.     

Crowding Out or Welfare Promotion? How Foreign Aid Affects Social Expenditures in Latin American Welfare Systems

Foreign assistance constitutes a significant share of government revenue in many low‐ and middle‐income economies and is targeted at poverty reduction and the promotion of social and economic well‐being. This study therefore examines fiscal responses by Latin American welfare states to the inflow of such aid. As a form of external non‐tax revenue, aid can function as a substitution for public welfare expenditure, with a crowding out effect being the likely outcome. This article investigates whether overall aid and aid that is particularly targeted at the social sector substitutes public welfare provision and, if so, whether it also substitutes its function. A time‐series cross‐section analysis of 19 Latin American countries for the period 1980–2008 provides limited support for the assumption that foreign aid payments influence the welfare budget. It is only the health care sector in middle‐income countries which experiences a small decrease in expenditures. Social security and education expenditures are not affected.     

Health Policy and the Politics of Evidence

National decisions on the drugs, treatments and medical devices that should be funded through public expenditure are a fundamental element of health policy. But despite a political emphasis upon evidence‐based policy, the results of rigorous clinical trials and statistical modelling techniques rarely speak for themselves. So, does the pre‐eminence traditionally accorded to quantitative data in the medical field underpin policy decisions on a consistent basis? Or are more subtle, less transparent characteristics of context and interaction evident in the shaping of attendant decisions? This article considers these questions by drawing on a study of decision‐making in the National Institute for Health and Clinical Excellence (NICE)—an organization established by the British government in 1999 to decide whether selected health technologies should be made available throughout the National Health Service in England and Wales. In broad terms, the findings point to the primacy of arguments based on quantitatively oriented, experimentally derived data but also to a discursive hegemony of clinicians and health economists in mediating, including or debarring more qualitative, experientially based evidence. A more complex, dynamic understanding of policy governance in the field of health technology appraisal—founded on a discursive appropriation of the idea of the “common good”—goes some way to explaining the persistence of this hegemony despite an avowedly inclusive, plural approach to decision‐making.     

An Analysis of Selected Pension and Health Care Initiatives for Informal Sector Workers in India

India's demographic trends portend moderately rapid ageing of the population. This, combined with the limited coverage of pension and health care programmes in terms of population, types of risks covered, and benefit levels has led to greater urgency in extending the coverage and reform directions of the current pension and health care programmes. This article analyses three pension and health care initiatives in India directed at the workers and their families engaged in the informal sector. The first initiative, India's National Social Assistance Programme (NSAP), undertaken in 1995 provides budget‐financed transfers targeted at older persons. It is funded by the Union government but implemented by the state governments. The second initiative, called Swavalamban, was started in 2010, but has been subsumed under Atal Pension Yojana (APY), in the 2015–16 budget. Both are voluntary co‐contributory initiatives aimed at providing access to retirement income to low‐income individuals (government co‐contributing with the individual). Unlike Swavalamban, the APY initiative has provisions for minimum guaranteed pension benefits, with contributions required by the members adjusted accordingly. Effectiveness in increasing enrollment and in sustaining contributions over a longer period will impact on the extent of retirement income security obtained by the members. The third initiative, Rashtriya Swasthya Bima Yojana (RSBY), is insurance‐based and aims to provide hospital care to low‐income households. The article argues that for improving outcomes of these initiatives, more effective implementation, greater fiscal resources, and an integrated and systemic approach which is aided by technology‐enabled platforms such as Aadhaar, will be needed.     

Class politics in the sandbox? An analysis of the socio‐economic determinants of preferences towards public spending and parental fees for childcare

This article analyses the socio‐economic determinants of public preferences towards public spending and parental fees for childcare and how they are conditioned by institutional contexts. Previous studies of childcare policy preferences have focused on attitudes regarding the provision of care. However, when it comes to questions of financing, we know astonishingly little about how supportive individuals actually are of expanding pre‐school early childhood education and care, and how support varies across different socio‐economic groups in society. This is an important research gap because childcare provision and how it is financed have redistributive implications, which vary depending on the institutional design of childcare policy. Using novel and unique survey data on childcare preferences from eight European countries, we argue and show that preferences towards expanding childcare are more contested than it is often assumed. The institutional structure of childcare shapes how income matters for preferences towards how much should be spent and how provision should be financed. Where access to childcare is socially stratified, the poor and the rich develop different preferences towards either increasing public spending or reducing parental fees in order to improve their access to childcare. The findings in this article suggest that expanding childcare in systems characterised by unequal access can be politically contested due to diverging policy priorities of individuals from different social backgrounds.     

Is ‘Candidacy’ a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis

Across the public sector there is concern that service uptake is inequitably distributed by socio‐economic circumstances and that public provision exacerbates the existence of inequalities either because services are not allocated by need or because of differential patterns of uptake between the most and least affluent groups. A concept that offers potential to understand access and utilization is ‘candidacy’ which has been used to explain access to, and utilization of, healthcare. The concept suggests that an individual's identification of his or her ‘candidacy’ for health services is structurally, culturally, organizationally and professionally constructed, and helps to explain why those in deprived circumstances make less use of services than the more affluent. In this article we assess the fit of candidacy to other public services using a Critical Interpretive Synthesis of three case studies literatures relating to: domestic abuse, higher education and environmental services. We find high levels of congruence between ‘candidacy’ and the sampled literatures on access/utilization of services. We find, however, that the concept needs to be refined. In particular, we distinguish between micro, meso and macro factors that play into the identification, sustaining and resolution of candidacy, and demonstrate the plural nature of candidacies. We argue that this refined model of candidacy should be tested empirically beyond and within health. More specifically, in the current economic context, we suggest that it becomes imperative to better understand how access to public services is influenced by multiple factors including changing discourses of deservedness and fairness, and by stringent reductions in the public purse.     

The Organization of Decision-making and the Dynamics of Policy Drift: A Canadian Health Sector Example

This historical‐institutionalist case study of public–private change in the rehabilitation health sector in Ontario, Canada, seeks to build on literature about the politics of policy drift, particularly with respect to health care systems. Rather than turning to higher‐order institutional factors, such as federalism and overall financing agreements between states and the medical profession, or to economic indicators such as change in expenditures, however, it posits that the particularities of how welfare‐policy sectors are organized with respect to their decision‐making contribute to drift. Such organization is framed by two factors. The first is the set of rules by which the public–private boundary is drawn, and the second is the structuring of public institutions that set legislation and regulation, and organize the policy networks attendant on them, around these boundaries. The degree of coordination or fragmentation among these, this case suggests, is a factor in the politics and dynamics of drift.     

The Choice Revolution: Privatization of Swedish Welfare Services in the 1990s

During the 1990s, the Swedish welfare state was declared by some to be in a “crisis”, due to both financial strain and loss of political support. Others have argued that the spending cuts and reforms undertaken during this period did slow down the previous increase in social spending, but left the system basically intact. The main argument put forward in this article is that the Swedish welfare state has been and is still undergoing a transforming process whereby it risks losing one of its main characteristics, namely the belief in and institutional support for social egalitarianism. During the 1990s, the public welfare service sector opened up to competing private actors. As a result, the share of private provision grew, both within the health‐care and primary education systems as well as within social service provision. This resulted in a socially segregating dynamic, prompted by the introduction of “consumer choice”. As will be shown in the article, the gradual privatization and market‐orientation of the welfare services undermine previous Swedish notions of a “people's home”, where uniform, high‐quality services are provided by the state to all citizens, regardless of income, social background or cultural orientation.     

Financing social security out of contributions: About origins,present discussions and prospects of a success story

In writing the overture to an issue on contribution financed social security one cannot but speak of Bismarck; it must also address Beveridge who saw contributions, although in their design and role clearly differently from Bismarck, as one core revenue tool to finance his vision. Beveridge attributed to the private financial sector a prominent role in securing people against the negative effects on income of shocks and crises, while Bismarck did not. Beveridge's concept, when first published, had, and still has today, the most attractive charm of rigorously satisfying peoples' striving for equitable and inclusive societal solutions. Bismarck's concept intrinsically offers income security only to those who contribute, while the level of protection depends on the level of contributions paid (with the exception of health insurance). In reality, both concepts, where implemented, had to face the realities of socio‐economic and political developments: Beveridge's vision was achieved in respect of access to health services where his proposal, in its predominantly tax‐financed version, has since turned into a worldwide blueprint for health schemes; in its other components, it was not resilient enough to achieve the intended standards and now is replete with means‐tested (poor relief) elements. Bismarck's scheme has proven its potential to achieve “universality”, not necessarily by theoretical design but as a matter of fact, i.e. covering people from cradle to grave (like Beveridgean schemes). With globalization, schemes of both origins have had to face massive neoliberal attacks over the last three decades. Which of the approaches is best able to survive must be left an open question: in the current worldwide context of rapid change, both have weak and strong points, and whether a symbiosis of the two offers the answer to future challenges remains to be seen.     

Informing Debate or Fuelling Dispute? Media Communication of Reconfiguration in Scotland's Rural Maternity Care

Public reaction to the UK's ongoing health sector reform often results in dilution of policy‐makers’ goals. Public participation in health service decision‐making is advocated in policy, but precisely how to do it and what role public opinion should have in formulating reform strategy is ambiguously described. Public opinion is formed through many influences, including media reporting. This paper examines how reconfiguration at a rural maternity unit at Caithness General Hospital in Wick, Scotland, was communicated in national and local media and considers potential implications of media communication on public participation in policy decision‐making. Content analysis of arguments for and against change revealed a high level of reporting of commentators against change in regional newspapers. Qualitative analysis identified emergent themes about how maternity service reconfiguration was portrayed. These included framing opposition between management and local people, and change drivers receiving superficial coverage. Findings suggest that media portrayal of the public role in change may promote an adversarial rather than a participative stance. More finely tuned understanding of the relationship between the reporting of change and public reaction should be attained as this could affect how planned social policy evolves into actual practice.     

Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

‘New Wine in Old Wine Skin’: Public Perceptions of NHIS Per-Capita Payment System and Implications for Health-Seeking Behavior in Ghana

Abstract

The article examines public perceptions of capitation payment system and the implications for health-seeking behavior in rural and urban Ghana. Drawing on qualitative approach, the study employed focus groups (n?=?20), in-depth (n?=?20), and key informant (n?=?14) interviews with community-based adult men and women, aged 18–65?years in Ashanti Region. Tape recorded interviews were transcribed and analyzed thematically. Results indicated that majority of respondents have heard about the capitation but only a small proportion of them understood what the whole policy entails and the rationale for its introduction. While general dissatisfaction with and negative perceptions of the capitation still persisted among majority of the study population, this did not translate into nonuse of health services. For subscribers to derive optimal benefits from the capitation, political commitment in continuing public education using the most accessible media modulation is key. More importantly, public and private healthcare providers should increase investments in improving healthcare delivery system. Future studies should employ quantitative approaches with region-wide sample in order to confirm the relationships between capitation enrollment and health-seeking behavior.     

The Organization of Health Policy Functions in the German Federal Government

This article gives an account of the organizational history of the German federal ministry of health (and its predecessors) since the beginnings of public policy intervention in health care. In doing so it analyses the role of ministerial organization and examines the functional and political rationale underlying acts of reorganizing the tasks and resources of federal ministries. This analysis has two sides: the first concerns the expressive function of organizational form, as revealing something about the scope and perceived importance of the policy field, while the second interrogates the policy‐shaping role of organization and the political influence of the federal health ministry in health policy‐making. The article thus considers the organizational location of health issues in the central executive from the perspective of what it reveals about government goals and priorities. Then it examines possible policy implications. It looks at resources and the size of the ministry as a first attempt to learn something about the ministry's political weight. The question of policy implications draws our attention away from organization and resource allocation and back to a focus on policy‐making and policy outcomes. The final section therefore examines substantive policy implications that might have emanated from the organizational consolidation of the federal health ministry. It concludes that one such policy implication might be the erosion of the social insurance model as a regulatory idea in health‐care services and financing.     

Balancing Efficiency and Legitimacy: Institutional Changes and Rural Health Organization in China

The aim of this article is to contribute to the understanding of the institutional arrangements within which China's rural health facilities are embedded and of the contribution of policy to the creation of these arrangements. Information collected through field observations and in‐depth interviews with the managers, staff and patients of a township health centre indicates that with the gradual evolution of markets, encouraged by state policies, health care in rural China took on more of the characteristics of a commodity. In order to adapt to this change, the health centre and its employees are adjusting their behavioural norms and reconstructing an institutional network within which daily activities of simultaneously fulfilling public health responsibilities and pursuing economic gain are legitimized. This article focuses on the interwoven relationship between politics and markets at the micro level and examines the negotiations between stakeholders in constructing new institutional arrangements. It also describes how health sector managers are creating regulations to influence the performance of their facility. The article argues that while government policies play a crucial role in shaping the direction of development, institutional arrangements strongly influence the attempts by rural health organizations to implement them. It concludes that it is critical to take institutional factors into account in analyzing China's rural health‐care reforms.