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.     

An Enhanced Macroeconomic Approach to Long-Range Projections of Health Care and Social Security Expenditures as a Share of GDP

An enhanced two-sector economic growth model is created to project health care and Social Security expenditures as a share of GDP in the United States. Parameters used in the economic simulation model are based largely on consensus views in the literature. The main advantages of an economic model over the more commonly used actuarial models are: (1) explicit specification of underlying fundamental structures, (2) ability to investigate relationships in the entire economy, and (3) a fuller scope provided for policy analysis. Under the base model assumptions, that is, a continuation of current conditions for the production of, demand for, and financing of health care services, the economic model projects that the health care sector consumes 15.8 percent of national output by the year 2000 and 27.1 percent by the year 2040. The annual rate of increase in per capita consumption (less health spending) (“adjusted consumption”) falls from 1 percent in 2000 to 0.6 percent in 2025, and then increases to 0.8 percent in 2040, as the rate of increase in spending on health care for the elderly, and the capital investment required to support such spending, flow and ebb with the passing of the baby boom generation. Over the whole projection horizon, government spending on the health care of the elderly increases from a projected 3.8 percent of GDP in 2000 to 9.2 percent in 2040. Social Security expenditures for the elderly are projected to increase from 3.9 percent to 6.3 percent over the same period. More widespread HMO coverage is shown to lead to some small improvements in adjusted consumption. Over the long horizon, improved efficiency and productivity in the health sector and lower Social Security benefits assumed to cause an increased rate of savings and investment, however, actually cause the rate of growth in health spending to increase and adjusted consumption to decline, ceteris paribus. By contrast, an increase in sensitivity to health care prices leads to dramatically improved results, both in higher adjusted consumption and better finances for government programs of health care for the elderly.     

国家汲取能力、政策导向和中国城镇卫生保健的筹资与服务不公平

改革以后,中国政府在承担卫生保健职能方面的意愿和能力发生了变化,本文考察了这些变化对城镇卫生保健筹资和服务公平性的影响。文章着重分析了两个相关问题：在多大程度上,卫生保健的筹资具有累进性？在多大程度上,医疗服务的利用是公平的？第一节解释为什么在改革开放期间中国政府承担卫生保健的意愿与能力都有所下降,并探讨这些变化对卫生总费用的结构产生了什么样的影响。接下来的两节分别对中国城市卫生保健筹资和服务利用的不平等程度进行了实证分析。第四节进一步指出,筹资与服务方面的不平等将本来就处于弱势的社会群体置于更加不利的地位。总之,以市场为导向的卫生体制改革不但没有解决医疗费用上涨问题,反而加剧了这一问题;它因此损害了卫生保健筹资的公平性,降低了弱势人群对卫生服务的获取,增加了因病致贫的几率。     

Public Opinion On Taxes And Government Spending

This article analyses egalitarian attitudes as well as opinions concerning taxation and government spending. Australians would prefer to have their taxes reduced than to increase government spending on social services, if faced with such an alternative. Typical welfare programs have a low priority, but the public would like to see increased spending on education and science, health services, roads improvements, military defence, and fighting against drug addiction. An individual's opinions about government spending are influenced by his or her socio-economic characteristics, with unemployed people and urban dwellers being more supportive of government spending on social programs.     

The Impact of Structural Reform on County Government Service Provision*

Objective. This study examines the effect that county government structure has on county spending in an environment of rapid population growth. In particular, it looks at the consequence of changing from a traditional commission noncharter form to an appointed administrator/elected executive commission type with a home rule charter. Methods. This study uses a pooled time‐series design to analyze the spending behavior of seven rapid‐growth counties in Florida that adopted a modernized structure between 1980 and 1990. Results. The findings indicate that changing the form of county government leads to a statistically significant increase in total spending as well as for spending for traditional and regional services. Conclusions. In addition to the theoretical implications for studying government structural impacts, there are practical implications for county officials in rapidly growing areas who view the adoption of modernized structures as a means to facilitate the expansion of current services and/or the addition of new services.     

The political economy of changes in family and old‐age welfare policy spending: Analysis of OECD countries, 1998–2011

This study investigated whether in times of budget constraints and in countries with relatively large family policy spending, family policy has an advantage in the budget competition with old‐age expenditures, compared with countries with a lower level of family policy spending. We employed pooled time‐series cross‐sectional analysis of 24 OECD countries from 1998 to 2011. Our findings suggest that the initial level of family spending tends to moderate the crowding‐out effect of old‐age spending, indicating that the more mature a family spending policy is, the more it resists budget competition from old‐age policy. Furthermore, the size of government debt was found to have an insignificant effect on welfare budgeting. Our findings indicate that retrenchment in welfare spending for old age cannot be fully explained by budget constraints. Politics among interest groups associated with different welfare programmes can be an important determinant in explaining changes in spending on each welfare programme.     

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.     

The ratification of ILO Conventions and the provision of unemployment benefits: An empirical analysis

This article tests the relationship between the ratification of International Labour Organization (ILO) Conventions and the provision of unemployment benefits. Statistical tests focus on two related issues: why countries ratify ILO Conventions on unemployment benefits, and whether ratification influences government spending on unemployment benefits. The main findings are that democracy, region, income, and globalization are the main factors influencing why countries ratify ILO Conventions on unemployment benefits. In turn, the ratification of ILO Conventions is systematically associated with higher spending if countries have ratified more than two Conventions.     

Strategic Government Spending in South Korea and Taiwan: Lessons for Emergent Democracies*

Objectives. How is government spending used strategically in South Korea and Taiwan? As nations generally considered to have weathered democratization, government allocations in South Korea and Taiwan are instructive on how spending may be used strategically without undermining democratization. Methods. The similar sociocultural, historical, political, and economic experiences of the two nations underlie a most‐similar‐systems approach to study how their differences influence diversity in strategic spending and, correspondingly, political outcomes such as size of the government party in the legislature. This article evaluates defense and civilian expenditures for South Korea and Taiwan from 1975 to 2006. Results. Three results are interesting. First, different elections—legislative elections in South Korea, presidential elections in Taiwan—lead to increases in spending. Second, in both nations, defense spending increases in election years but not social spending; however, defense spending benefits the government‐party in the legislature in South Korea but not in Taiwan. Third, when the strategic uses of spending are accounted for, democratization does not directly affect allocations. Conclusions. These results explicate that government spending is a viable resource for party building in new democracies; however, the results also underscore that governing parties in new democracies benefit from spending only insofar as it is used to build the nation's or party's strengths—not undermine the opposition—under competitive elections.     

Partnerships, Power and the "New" Politics of Community Participation in British Health Care

Multi–sectoral approaches to health improvement in its broadest sense have entailed an emphasis by the British government upon partnership working in and around community involvement in planning processes. New service planning and delivery organizations in the health service—primary care groups and primary care trusts—thus have to ensure that public and patient involvement strategies reflect a coordinated, if not integrated, multi–sectoral approach to such involvement. But how are these enforced partnership arrangements shaping the approach taken by primary care groups and trusts to the issue of public and patient involvement? More particularly, is the traditional dominance of health service managers and the medical profession in decision–making processes under challenge? This article draws on a study of primary care groups and trusts in three districts in order to gauge perceptions and calculations with regard to partnerships for involvement. Results appear to suggest that health service managers and practitioners continue to exercise considerable influence in comparison to that of patients and citizens. But, if the findings are viewed in the broader contexts of government managerialist strategies of surveillance and accountability and the growth of service–user and advocacy organizations, partnerships may offer significant scope for “lay” challenges to managerial and medical power.     

The government spending multiplier: Evidence from county level data

The passage of the American Recovery and Reinvestment Act (ARRA) of 2009 has brought fiscal policy to the forefront once again. The size of the “multiplier” of government spending becomes of critical importance for determining the effect of stimulus programs. Yet there is considerable controversy about this issue. This study adds to the discussion on the size of the multiplier by using earnings data by county. This allows the creation of a panel data that includes 3141 counties for the time period 2001–2012. We estimate the federal government spending multiplier to be approximate 1.5. Our estimate for state and local spending multipliers are considerably smaller. Our results have implication for policy in that federal programs will be more effective for stabilization county economies than state or local spending.     

Social investment effects of public education,health care,and welfare service expenditures on economic growth

The purpose of this study is to theoretically and empirically examine whether public spending in education, health care, and welfare service operates as a fruitful investment in welfare states, which has been implied in the literature of social investment arguments. Based on comprehensive review of existing literature, this study suggested a tripartite mechanism of social investment effect of such spending, that is “enhancement of human capital,” “support for labor force participation,” and “job creation.” To find the empirical evidence, a pooled time‐series cross‐section analysis was conducted with the data of 15 advanced welfare states from 1980 to 2015 using estimation technique of fixed‐effect model. The results confirmed that public spending in education, health care, and welfare service had a positive medium‐term as well as long‐term effect on economic performance, while cash‐type welfare spending had an obscure or no visible effect on economy. Government consumption that is a proxy and control variable of size of the welfare state showed a positive effect on real GDP in the medium term but a negative effect in the long run. In conclusion, this study suggests that reinforcing social services should be recognized and dealt with as essence of social investment strategy.     

The impact of ethnicity on attitudes toward health care reform in New Mexico

Latinos tend to have significantly lower levels of access to general and top quality medical care than do non-Latino whites, and although disparities in access to health care have diminished for all other minority groups over time, they have widened for Latinos. Given these trends, current attempts to provide universal health care at both the national and state levels across the United States have large implications for the health status of Latinos. The objective of this analysis is to determine whether Latinos have different attitudes regarding health reform than non-Latino whites. Our data are from a statewide random digit dialing telephone survey of New Mexico residents, age 18 and older, conducted in the Fall of 2007. With a Latino population of 44% and ongoing health care reform efforts by the state legislature, New Mexico is an ideal location for this analysis. After controlling for a host of individual level factors, our findings suggest that while Latinos are less likely to identify health care as a salient state issue relative to the economy and crime, they are more likely than non-Latino whites to believe affordable health care programs are important. Finally, Latinos view employers, more than government or individuals, to be responsible for expanding health care coverage.     

Integrating Health and Social Care at the Micro Level: Health Care Professionals as Care Managers for Older People

A common problem in the provision of coordinated long‐term care is the separation of health and social care. The present government has been increasingly concerned with promoting convenient, user‐centred services and improving integration of health and social care. One arrangement that could contribute to this for some older service users is for health care staff to act as care managers, coordinating the provision of both health and social care. This paper presents the findings of a survey of arrangements in place in local authorities for health staff to work as care managers for older people. This was designed to provide details about the range and scope of care management activities undertaken by health care professionals. Key areas of enquiry included: which kinds of health care staff undertook care management and in what settings; how long the arrangements had been in place and how widely available they were; whether there was a distinction between the types of cases and care management processes undertaken by health care staff compared with their social service department counterparts; and what management and training arrangements were in place for the health care staff.     

A note on the determinants of sexually transmitted disease rates

This paper addresses the impact of several factors on rates of sexually transmitted disease (STD) in the United States. Similar to existing studies, which proxy health outcomes by mortality rates or life expectancy, we find that health care spending improves health outcome. That is, using annual data over the 1960–1997 period, rates of syphilis, gonorrhea, and chancroid fall with increases in per capita health care expenditure. Furthermore, per capita income, per pupil education expenditure, as well as a host of socio-demographic variables, also affect STD rates.     

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.     

Macroeconomic and financing determinants of out of pocket payments in health care: Evidence from selected OECD countries

In this paper, we examine the impact of macroeconomic, as well public and private health insurance financing (PHI) factors on out of pocket (OOP) healthcare expenditures, by using fixed/random effects and dynamic panel data methodology to a dataset of 26 EU and OECD countries for a period lasting from 1995 to 2013. The existing empirical literature has focused on testing the hypothesis that several macroeconomic and health financing determinants have an effect on OOP healthcare expenditures. Nevertheless, the related articles have not well tested the hypothesis concerning the potential impact of PHI financing on OOP spending. We find that public and PHI financing have a significant countervailing effect on OOP spending. Moreover, we show that unemployment rate has a significant positive impact on OOP expenditures. Sensitivity tests with variation of specifications and samples show that our findings are robust. We argue that policy-makers should give serious consideration to PHI institution; our results indicate that there is an inverse effect on OOP spending. We suggest that our examined countries have to provide financial risk protection to their citizens against OOP payments, rather than only attending health budgetary retrenchments in order to adjust public finances.     

The Economic and Gender Consequences of South Africa's Home‐based Care Policy

South Africa's approach to care provision in the era of HIV/AIDS is home‐ and community‐based care, but in reality care for ill people in the home is provided on an unpaid basis, predominantly by women. But how much do they spend on this care work, in time and money? And what economic consequences does this policy have, particularly for poorer women? This article is based on findings from a study that focuses on unpaid care provision within the home for those in late‐stage HIV/AIDS in KwaZulu‐Natal, South Africa, and specifically on the costs of such provision. The findings show that female caregivers are bearing the bulk of the costs of care provision for ill people within the home on an unpaid basis. Home‐based care is cost‐effective for the provincial government but not for unpaid caregivers who are subsidizing the provincial economy. While hospital care for people with HIV/AIDS has been capped, home‐based care services have not been increased to a commensurate level. Unpaid caregivers and ill people within the home are largely disconnected from the health system. The analysis clearly shows that the home‐based care policy is not resulting in appropriate or sufficient support for these individuals in need and needs to be revised.     

TAXES AND SOCIAL SPENDING: THE SHIFTING DEMANDS OF THE AUSTRALIAN PUBLIC

This paper uses data from the Australian Election Studies (1987–2001) to investigate the preference for lower taxes or higher social spending among Australian voters. We offer some explanations for the increased support for higher social spending, especially after the election of the Howard Government in 1996. Regression models allow us to distinguish various factors that predict support for higher social spending. The main conclusions of the paper are that support for social spending is higher among voters with ‘social‐democratic’ attitudes and voting preferences but significantly, is also higher among voters who think health and Medicare services have declined since 1998. These findings are discussed in the context of various possible explanations for declining support for tax cuts.     

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.