Healthcare in India: Changing the Financing Strategy

The way in which healthcare is financed is critical for equity in access to healthcare. At present the proportion of public resources committed to healthcare in India is one of the lowest in the world, with less than one‐fifth of health expenditure being publicly financed. India has large‐scale poverty and yet the main source of financing healthcare is out‐of‐pocket expenditure. This is a cause of the huge inequities we see in access to healthcare. The article argues for strengthening public investment and expenditure in the health sector and suggests possible options for doing this. It also calls for a reform of the existing healthcare system by restructuring it to create a universal access mechanism which also factors in the private health sector. The article concludes that it is important to over‐emphasize the fact that health is a public or social good and so cannot be left to the vagaries of the market.     

The new privatized market: A question of ideology or pragmatism within the Swedish addiction treatment system?

Given its traditions of universal welfarism and social democracy, Sweden had already scored unexpectedly high on New Public Management by the 1980s. Health and welfare services remain primarily tax‐funded, but the production of care is increasingly transferred to a competitive quasi‐market. To what extent can this development be understood in terms of right‐wing governments, and to what extent in terms of other, socioeconomic and pragmatic factors? We examined this question through official statistics on providers of institutional addiction care since 1976, and through the total expenditure and purchases by local‐level municipal social services of interventions for substance users in Sweden in 1999, 2004, 2009, and 2014. We have analyzed the distribution across public and private providers within the addiction treatment system, and whether national developments and local differences across the 290 municipalities—which bear the major treatment responsibility—can be understood in terms of local‐level political majority, population size, and local wealth. The share of purchased services has remained stable, but the treatment system shows increasing financial turnover and an increasing share of for‐profit providers among producers of purchased care, especially in outpatient treatment. While venture capital enterprises emerged as a new actor, non‐governmental organizations lost out in importance. Bourgeois government correlated with larger shares of purchasing and purchases from for‐profit providers. However, purchasing on a market dominated by for‐profit providers has also become the “new normal”, regardless of ideology, and recent years have shown a reversed effect of left‐wing municipalities purchasing more services than right‐wing governments. Pragmatic reasons also influence local‐level purchasing.     

我国药价虚高的形成机制分析及其治理途径

药价虚高是我国民生建设的一个大难题。国家多次推出降价政策措施,实行药品招标政策,但成效见微。究其成因,主要是公共卫生支出不足、政策利益冲突、药品监管不力、药价制度漏洞、委托代理扭曲,这五大层面形成了药价虚高的路径依赖。因此,从体制上彻底切断药价虚高的生存路径,才是根本的治理途径。其关键在于完善制度设计：实行医药分业,加大政府公共卫生支出,强化药品体制监督管理。     

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.     

POPULATION AGEING AND THE PUBLIC PURSE: AUSTRALIA IN COMPARATIVE PERSPECTIVE

A comparative analysis of three decades of OECD public spending change is used to test propositions concerning the likely consequences of population ageing for public expenditure development in coming years. The World Bank and the OECD Secretariat suggest that population ageing has a direct impact on public expenditure through increased spending on pensions, health care and services for the elderly; and an indirect impact through increasing levels of public indebtedness. The analysis here suggests that only the pensions effect is supported by available comparative evidence and that, even here, the relationship is weaker than often implied in the population ageing literature. The vulnerability of different nations to problems arising from population ageing varies widely, with Australia among the least vulnerable.     

Older People's Family Contacts and Long-term Care Expenditure in OECD Countries: A Comparative Approach Using Qualitative Comparative Analysis

In recent decades there has been a suggestion that public and private long-term care (LTC) expenditure might be replacing traditional family care for older people. The decline of family contact is known to be more advanced in some OECD countries than others, with southern Europe identified as where family contact is still strong. This article explores at a country level whether there is an association between levels of expenditure on long-term care and the availability of family contacts. Qualitative Comparative Analysis is used as a comparative method, so as to use national quantitative indicators with a small sample of countries. An association between higher levels of family contact and lower levels of expenditure on LTC is suggested, but it is weakened by a number of untypical cases. Countries that defy this relationship have government care policies that seek to promote informal social care through the family contact that continues to be available. Austria, Canada, Great Britain and Japan are discussed in this context.     

Family budgets and public money: spending fostering payments

In this second of two papers based on a study of payment issues within foster care, the focus is on expenditure. It is argued that the hybrid public/private nature of fostering gives rise to contradictory pressures for carers, including the status of maintenance payments as both part of family budgets and a form of delegated public expenditure. For example, carers are required in principle both to spend fixed amounts upon foster children and to treat them in like fashion to their own children. In this paper, the issue of ‘like treatment’ is explored, along with the significance of payment for ‘children who foster’ and for relationships between carers and foster children. Also examined are the challenges presented by differences between carers’ material circumstances and those of birth families, especially when reunification is planned. Overall, the paper seeks to show how the handling of expenditure becomes closely entwined with inter‐personal dynamics within foster care.     

Gaps in social protection for health care and long‐term care in Europe: Are the elderly faced with financial ruin?

While public expenditure on health care and long‐term care (LTC) has been monitored for many years in European countries, far less attention has been paid to the financial consequences for older people of private out‐of‐pocket (OOP) expenditure necessary to access such care. Employing representative cross‐sectional data on the elderly populations of 11 European countries in 2004 from the Survey of Health, Ageing and Retirement in Europe (SHARE), we find that OOP payments for health care and LTC are very common among the elderly across European countries and such expenditures impact significantly on disposable income: up to 95 per cent of the elderly make OOP payments for health care and 5 per cent for LTC, resulting in income reductions of between 5 and 10 per cent, respectively. Failure to prevent financial ruin, as a consequence of excessive OOP payments, is evident in 0.7 per cent of elderly households utilizing health care and 0.5 per cent of elderly households utilizing LTC. Those particularly concerned are the poor, women and the very old.     

The growth of UK health expenditure

Over the past four decades, spending on health care in the United Kingdom has accounted for a rising share, both of total public spending and of the total output of the economy. Other industrial economies have had similar experiences, although the peculiar nature of the UK health service makes the general explanations offered for such expenditure growth inappropriate. Health spending growth in the UK, for the period 1949–89, is found to be strongly associated with output growth, and reasons to explain this relationship are advanced. The relationship's continued stability in the light of the 1989 health service reforms is questioned.     

Public Satisfaction with the Health System and Popular Support for State Involvement in an East Asian Welfare Regime: Health Policy Legitimacy of Hong Kong

The legitimacy of social policies has gained increasing attention in the past decade, against the backdrop of fiscal austerity and retrenchment in many nations. Policy legitimacy encompasses public preferences for the underlying principles of policies and the actual outcomes as perceived by citizens. Scholarly knowledge concerning the legitimacy of health policy – a major element of modern social policy architecture – is, unfortunately, limited. This article seeks to extend the scholarly debates on health policy legitimacy from the West to Hong Kong, a member of the East Asian welfare state cluster. A bi‐dimensional definition of health policy legitimacy – encompassing both public satisfaction with the health system and the normative expectation as to the extent of state involvement in health care – is adopted. Based on analysis of data collected from a telephone survey of adult Hong Kong citizens between late 2014 and early 2015, the findings of this study demonstrate a fairly high level of satisfaction with the territory's health system, but popular support for government responsibility presents a clear residual characteristic. The study also tests the self‐interest thesis and the ideology thesis – major theoretical frameworks for explaining social policy legitimacy – in the Hong Kong context. Egalitarian ideology and trust in government are closely related to both public satisfaction with the system and popular support for governmental provision of care. However, the self‐interest thesis receives partial support. The findings are interpreted in the context of Hong Kong's health system arrangements, while implications for the territory's ongoing health policy reform are discussed.     

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

The relationship between different social expenditure schemes and poverty,inequality and economic growth

In this article, we study how social expenditure is related to poverty, income inequality and GDP growth. Our main contribution is to disentangle these relationships by the following social expenditure schemes: 1) “old age and survivors”, 2) “incapacity”, 3) “health”, 4) “family”, 5) “unemployment and active labour market policies” and 6) “housing and others”. For this purpose, we employ OLS and 2SLS regression models using a panel data set for 22 Member States of the European Union from 1990 until 2015. We find total public social expenditure to be negatively related to poverty and inequality, but not related to GDP growth. The results vary substantially between the different social expenditure schemes, which makes more accurate targeting possible.     

National Health Insurance: An Alternate Medical Viewpoint

Increasing medical technology, expertise and community expectations of health care are leading to an alarming escalation of health costs throughout the world. Many health planners are expressing doubts as to whether quality of health care can be maintained in the present circumstances. It is maintained that the Australian Government's proposal of National Health Insurance is an interim measure, intended to grant hospital and medical expenditure assistance to the entire community, at minimum cost. There is little evidence that the scheme threatens the medical market place, as it is seen at the moment, and a plea is made for productive and constructive discussion of the scheme by the medical profession.     

挤出还是促进——地方财政分权、市场化与低保救助水平差异

利用2013年全国市级有关数据,采用回归方法构建两个递进实证计量模型,考察地方财政分权、市场化对城乡低保救助水平的影响.实证结果表明,地方财政自给度和市场化水平均对低保救助有非常显著的促进作用,农村低保救助相对城市对地方财政分权和市场化的敏感度更高,科教文卫支出对低保救助支出存在非常显著的良性互动关系.建议进一步完善事权与财政支出责任相匹配的机制,提高地方财政自给度,同时转变政府职能,厘清政府权责边界,提升地方市场化水平.     

How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.     

Health Care during Transition and Health Systems Reform: Evidence from the Poorest CIS Countries

The poorest seven countries of the former Soviet Union (CIS‐7) moved from a centralized system of health‐care funding and delivery to a range of institutional and financial arrangements. The different paths chosen have implied different results in terms of available resources, internal efficiency, health‐care inequality, and the corresponding incidence of public expenditures. This paper examines the level, composition and allocation of public spending on health, in light of the evolution of the health systems during the transition. The financial constraints experienced by CIS‐7 countries were reflected in the decrease of health‐care quality, the collapse of the already inefficient public health activities, and the increased incidence of out‐of‐pocket expenditures. These factors, alongside the increase in poverty, resulted in a decrease in health‐care utilization, suggesting that these countries may experience difficulties in achieving the health‐related Millennium Development Goals.     

Why Health Care Reform Now? Strategic Framing and the Passage of Obamacare

Economic reform and health care reform were both focal points outlined in President Obama's policy agenda, with increasing pressure to address economic and social insecurity given that President Obama entered office during the Great Recession (2007–09). The Patient Protection and Affordable Care Act (commonly known as ‘Obamacare’) successfully passed in March 2010 in the context of the economic crisis. We argue that the strategic framing of the economic crisis, through reasoning and arguments linking health care reform with economic downfall, is important in understanding the successful passage of Obamacare, and that this is reflected through strategic frames in speeches delivered by the President on health care reform. Health care reform has been successful not in spite of but rather because of the economic crisis of 2008, that allowed President Obama to use a strategic frame focusing on costs and economic problems. The two main frames identified are the ‘market’ and ‘rights’ frames. President Obama's strategic frames specifically surrounding the economic and cost‐containment priority of health care reform are categorized as a ‘market’ frame in this article. He used this frame until the passage of the law in 2010, when the frame shifted to ‘rights’ frames, largely portrayed through anecdotes and focused on the concept of ‘access’ to care rather than the ‘cost’ of care. This is observable through tracking speeches and statements made in support of health care reform between 2009 and 2013.     

源于身份的隔阂:人口多样性、社会信任与犯罪

本文以2014年中国劳动力动态调查（CLDS）数据为基础，构建了一个人口多样性指数，并将其与288个城市的数据相匹配，检验了人口多样性与犯罪率之间的关系。实证结果表明，人口多样性是导致城市犯罪率上升的原因之一，且这一发现是稳健的。作用机制检验结果表明，社会信任是一个重要的中介变量，即人口多样性通过削弱社会信任水平导致犯罪率的上升。进一步，从地区制度环境和民生支出水平两个角度展开的实证检验发现，产权保护越完善、民众对法庭越有信心，政府在公共教育和社会保障上的财政支出越高，人口多样性对犯罪率的影响越弱，说明良好的制度和较高的社会福利支出具有显著的犯罪治理效应。本文的发现为城市化进程中我国各级政府的犯罪治理政策选择提供了经验证据，有助于科学把握犯罪治理的着力点。     

Supplemental home care and topping‐up: A shift from service universalism towards a new and privatised public service model?

How does a public service model based on service universalism react to the introduction of market principles of topping up? In a recent so‐called Free Municipality Scheme (an experimental scheme that allowed for greater operational autonomy locally in an effort to reduce state bureaucracy), a number of Danish municipalities were for the first time ever allowed to compete with for‐profit providers of home care in selling supplemental home care services paid entirely by the user. The take‐home message from this experience is that the introduction of supplemental home care entails challenges and eventually wider implications for the public service model, on an economic, organisational and cultural level. Supplemental services represent a new and potentially powerful combination of market and state logics that eventually redirects away from the universalist welfare state and towards a new and increasingly privatised public service model – a model where the service level is determined by the user's capacity to purchase and pay for services. The introduction of such services therefore implies a change of the potential of the Nordic welfare state to ensure equal access regardless of class and income.     

Empirical Analysis of Fiscal Soundness and Public Social Expenditure: A Lesson for the Future Direction of the Korean Welfare State

The aim of this paper is to investigate the relations between fiscal soundness and public social expenditure in advanced welfare states so as to reconsider the conventional wisdom that welfare expenditure aggravates national finances. Through this, I propose the clues of building the sustainable Korean welfare state. I focus on the interdependent relationship between fiscal soundness and public social expenditure based on fiscal sociology. Considering this interaction, I form two sets of simultaneous equations models and employ a special statistical method, three‐stage least squares (3SLS). The results regarding the causal relationship between fiscal soundness and public social spending indicate that, if public welfare spending is increased, fiscal health is damaged. However, as many comparative social policy researchers have pointed out, outcomes of welfare states differ from country to country according to the composition of public welfare spending. Specifically, some welfare states with priority given to social services such as vocational training or childcare services have maintained the stability of public finance. By extension, we can say that public social expenditures have a positive influence on fiscal soundness based on the composition of social expenditures. Finally, it is possible to create financially sustainable welfare states.