Financing health services for pensioners in Argentina: a salutary tale

The article examines the problems facing a programme to finance health care for pensioners in Argentina, known as PAMI. The programme is accumulating large deficits and many of its services are of doubtful quality. PAMI's problems and its resistance to reforms are put in the wider context of Argentina's liberalised health-care system, neo-liberal adjustment and flawed governance. The Argentine experience has relevance for other developing countries with weak state regulatory capacity, and points to the dangers of delegating health financing of older people to the private sector.     

Japan's Radical Reform of Long-term Care

Japan's mandatory long‐term care social insurance system started in 2000. Many important choices about the basic shape and size of the system, as well as a host of details, were necessary when the program was being planned. It represents a reversal from earlier steps toward a tax‐based direct‐service system, and is based on consumer choice of services and providers. The benefits are in the form of institutional or community‐based services, not cash, and are aimed at covering all caregiving costs (less a 10 percent co‐payment) at six levels of need, as measured by objective test. Revenues are from insurance contributions and taxes. The program costs about $40 billion, and is expected to rise to about $70 billion annually by 2010 as applications for services go up. There are about 2.2 million beneficiaries, about 10 percent of the 65+ population. The program has operated within its budget and without major problems for two years and is broadly accepted as an appropriate and effective social program.     

Development of Social Health Insurance in Mongolia: Successes, Challenges and Lessons

This paper examines the process of developing social health insurance in Mongolia, and its successes, challenges and lessons. The government of Mongolia introduced social health insurance in 1994, which is compulsory for all public and private sector employees and low-income and vulnerable population groups. The scheme also provided voluntary insurance for unemployed people of working age. About 95 per cent of the population was covered by health insurance within the first two years thanks to a high level of government subsidy for vulnerable population groups. The insurance benefit initially covered nearly all inpatient services except the treatment of some specified chronic and infectious diseases, which were directly funded by the government. The scheme not only had many successes but also faced challenges in maintaining universal coverage. The new financing arrangement has provided little financial incentive for healthcare providers to contain health expenditure, contributing to rapid health cost inflation. In addition to reforming the payment system for providers, there has been an increasing need to expand benefits into ambulatory care. The development of compulsory health insurance in Mongolia shows that a prepaid health insurance mechanism based on risk sharing and fund pooling is feasible in low-income countries given political commitment and government financial support for vulnerable population groups.     

The Senior Outreach Program of Park Ridge Mental Health

Abstract

Availability and accessibility of mental health services for the elderly is woefully inadequate, failing to recognize the diversity of needs in the older adult population. Stigma, confusing and exclusionary insurance regulations and restrictive mental health center policies have both limited and discouraged treatment interventions. Through innovative case finding, programming and funding arrangements, the Senior Outreach program of Park Ridge Mental Health in Rochester, New York, has proven effective in identifying and providing outreach mental health services to elderly individuals. The program utilizes a human services agency model, yet operates within a large heath care system as part of a continuum of psycho-geriatric services.     

Charging and Quasi-Markets in Community Care: Implications for Elderly People with Dementia

Social services authorities in the UK are increasingly involved in charging and fee collection activities with clients in receipt of community care services. This article explores the implications of these developments for elderly people with dementia. The starting point of the article is a critique of existing legal and administrative options for handling other people's money, including the difficulties and dilemmas raised for both paid and unpaid carers by the existing arrangements. This is then related to the failure of charging and fee collection systems which have developed as a result of the community care reforms to address the particular needs of elderly people with dementia. A case study of policies in one local authority is outlined and this is followed by the presentation of the view of 37 fieldlevel professionals who were interviewed in focus groups. The concerns of these respondents included the complexity of the assessment task, conflicts between care managers and finance/revenue staff, the difficulty of defining and responding to financial abuse, and dilemmas over the extent to which relatives and carers should be trusted. The final section of the article considers the implications of a move to quasi-markets in social care for elderly people with dementia, particularly in terms of their vulnerability to financial exploitation.     

Why Ugandan rural households are opting to pay community health insurance rather than use the free healthcare services

Twikirize JM, O'Brien C. Why Ugandan rural households are opting to pay community health insurance rather than use the free healthcare services Uganda reintroduced free healthcare in 2001, but today, nine years later, less than 30 per cent of the population are using these services. This study investigated why rural households were under‐utilising the government's free health services and turning to community health insurance instead. A survey carried out on 260 randomly selected households was triangulated with qualitative data gained from 3 focus groups and 12 in‐depth interviews. The findings showed that 21 per cent of the households always accessed the government's free health services, while 79 per cent used private health services. The reasons given were poor quality services, including frequent drug stock‐outs, unmotivated and insufficiently trained health personnel, and overcrowding. Factors influencing enrolment in community health insurance included easier access to healthcare, financial protection against the cost of care, better quality care and benefits related to mutual assistance. This has both practical and policy implications, which are discussed in this article.     

How Much Internalization of Nuclear Risk Through Liability Insurance?

An important source of conflict surrounding nuclear energy is that with a very small probability, a large-scale nuclear accident may occur. One way to internalize the associated financial risks is through mandating nuclear operators to have liability insurance. This paper presents estimates of consumers' willingness to pay for increased financial security provided by an extension of coverage, based on the 'stated choice' approach. A Swiss citizen with median characteristics may be willing to pay 0.14 US cents per kwh to increase coverage beyond the current CHF 0.7 billion (bn.) (US$ 0.47 bn.). Marginal willingness to pay declines with higher coverage but exceeds marginal cost at least up to CHF 4 bn.(US$ 2.7 bn.). An extension of nuclear liability insurance coverage therefore may be efficiency-enhancing.     

Health and welfare of immigrants and access to services in Australia

The main issues in relation to the provision of health and social welfare services for migrants in Australia are: (a) to ensure access and equity; (b) concern about the relatively high proportions of some groups from specific birthplaces requiring support; and (c) the complexity and costs of ethnically specific services. This article focuses on the major pensions and benefits paid by the Department of Social Security, particularly the age pension and unemployment benefit. It also examines the interrelationship between mortality, morbidity, private health insurance, use of health services and the proportions on health-related pensions. Linked with these issues is the debate about an appropriate level of immigration when the unemployment rate is high, as in the current recession, and when new arrivals have little prospect of finding a job. A second major concern is the cost of caring for elderly immigrant parents who have come to Australia under the family reunion program.     

Lloyd's Financial Distress and Contagion within the US Property and Liability Insurance Industry

The intra-industry effect of Lloyd's financial distress on publicly traded US insurance companies is examined. Given Lloyd's prominence in the international insurance industry, large losses raised questions about the industry's capacity for certain types of risks and the financial solvency of other insurers. The market value of US property-liability insurers fell significantly at the announcement. This decline is related to the firm's revenues from insurance and reinsurance exposure. Results support contagion between Lloyd's distress and the US insurance industry. The study raises concerns about the potential for a systematic disruption of the supply of reinsurance in the international marketplace.     

老年休闲与居家养老——以上海市某社区老年人休闲为例

截至2008年底,中国60岁以上老年人口近1,6亿,占总人口的12％。迅速到来的老龄化让整个社会聚焦养老问题,通过多年的摸索、试验、论证,各界大多认为社区居家养老是应对人口老龄化挑战的重要方式。老人退休后基本处于休闲状态,那么老年人的休闲活动与居家养老有无内在关系,是否会影响居家养老模式的推行呢？鉴于此,作者通过对老年人日常休闲的调查研究,试图揭示它与社区养老的内在逻辑,并就如何提高老年人的生活质量和顺利推进居家养老模式提出相应的对策。     

Reforming health insurance: A question of principles?

Most industrialized countries have financed health services through health insurance. Two systems prevail: private, or public (social) health insurance. The theoretical differences between them are reviewed. It is argued that most health systems are, however, hybrids and that health insurance reform in Europe and the United States has accentuated this trend because the principles distinguishing the two systems have often been ignored. This is illustrated through the evolution of voluntary vs. compulsory affiliation, coping with moral hazard, and provider regulation.     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

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.     

Taiwan's path to national health insurance (1950–1995)

This study explores the evolution of statutory health insurance in the Republic of China on Taiwan from its inception in 1950 through to the inauguration of the National Health Insurance Programme in 1995. The main focus of the study is the timings of the adoption of the different statutory health insurance schemes targeted to the various segments of the population. It is argued that Taiwan's adoption of Labour Insurance for workers in 1950 could be best explained by the country's specific historical circumstance. The then-ruling Nationalist government was keen to build up Taiwan as a showcase for the whole of China. The inauguration of the National Health Insurance Programme in 1995 was predominantly subjected to the Nationalist government's adjustment to its changing political position.     

Mental Health Policy in Northern Ireland

Mental health policy in Northern Ireland has moved through a number of phases during the past seventy years. This article examines some of the developments during each of these phases in the context of political factors which had an effect on policy formation and implementation. The services which existed in 1921 were deeply rooted in the lunacy legislation and provision of nineteenth century Ireland. The political uncertainty and financial stringency, which characterized the following two decades, resulted in a situation of almost complete stagnation in those services. The contribution of Northern Ireland during the Second World War guaranteed a financial commitment by Britain to the building of a comprehensive health service in the post-war era. The expansion in mental health services was unprecedented. The relative stability of this era was shattered by the political “troubles” of the 1970s and the imposition of “direct rule” from Westminster. Though advantageous to health service development at first, this has now led to tighter central controls and the further loss of local autonomy. In policies dictated from Westminster, Area Boards moved towards a reduction in psychiatric beds to 1,500—the level of provision in 1870. History tells us that the needs of mentally ill people have not had a significant impact on services in the past. Will the future be any different?     

A Comparative Case Study of Care Systems for Frail Elderly People: Germany, Spain, France, Italy, United Kingdom and Sweden

Comparative studies of European social policies towards frail elderly people typically focus on the systems and their implementation. The study presented in this article, conducted in 2001 in six European countries (Germany, Spain, Italy, France, the United Kingdom and Sweden) aims at comparing the rights of the individuals within the different care systems. The methodology used is a case study approach, which draws on a series of situations of dependent elderly people. Therefore, the analysis focuses on the public authorities’ responses – the care packages, which determine the type of care required and the financial contribution of the user – in each of the six countries, in relation to the concrete situations of frail elderly people. As local variations are important, in all the countries studied, local authorities have been chosen in each of the countries. This approach gives us interesting concrete elements on the services and financial help which can be given to frail elderly people, but it also enables us to understand precisely the national care systems organized in the different countries and the main difficulties encountered by public authorities in facing this problem of frail elderly people.     

When Social Health Insurance Goes Wrong: Lessons from Argentina and Mexico

Social health insurance (SHI) has gained popularity in recent years as a health‐care funding mechanism for developing countries in Latin America and beyond. This is reflected in a number of high‐profile conferences sponsored by international agencies, and a profusion of externally funded reform projects. This article assesses the potential of SHI to provide a sound model of health‐care financing, drawing on the experiences of Argentina and Mexico. It uses four criteria to assess the performance of SHI: coverage, equity, effectiveness and sustainability. The article begins by outlining key principles of SHI and comparing it to other models of health‐care financing. It then gives a comparative overview of four SHI programmes in Argentina and Mexico, before analysing their performance in greater detail. The article finishes by extracting lessons from this comparative analysis, both for the countries studied and for global debates on SHI.     

Older Adults Navigating Medicare: When Benefits Are Denied

Guided by Bourdieu's theory of practice and symbolic violence, this qualitative study explored experiences and perceptions of elderly beneficiaries who had been denied rehabilitation services by Medicare. In semistructured interviews, 12 beneficiaries or family members told of the physical, psychological, and financial consequences of service denial/termination. The resulting perception of Medicare was as a cumbersome, difficult to negotiate system. Findings have implications for future research on service denial and indicate the need for better communication with, and support of, consumers by health care professionals when this occurs.     

A Functional Classification of Services for Older People

A deductively derived classification scheme is proposed which categorizes the health and social services of a community according to the levels of competence (behavioral functioningj and the levels of independence of the older people they address. Five levels of individual behavioral functioning ranging from simple to complex are specified: life-maintenance and health; perception-cognition: self-maintenance; effectance: and sociol role performance. Three levels of independence (of living arrangements) are specified ranging from the independent to the dependent subgroups of older people: the comparatively well elderly; elderly who require alternatives to prevent premature institutionalization; and elderly whose needs may confer institutional care or its equivalents. The services of a sample community are classified within this two dimensional scheme. The applications of the classification scheme to both community planning and individual treatment plan formulation are discussed.     

Informal workers and Kenya’s National Hospital Insurance Fund: Identifying barriers to voluntary participation

This article investigates the barriers to informal workers’ voluntary participation in Kenya’s national health insurance scheme – the National Hospital Insurance Fund. Based on primary data from both qualitative and quantitative methods, we find that the key determinants of enrolment include social factors, such as marital status, which create demand for insurance, and the role of informal workers’ associations that promote the voluntary uptake of health insurance and prevent default through contribution support. Participation barriers and reasons for inactiveness stem from the nature of informal work characterized by irregular earnings, which combine with apprehension about having to pay penalty charges for the late payment of premiums, inadequate levels of knowledge about health insurance schemes, institutional constraints such as complex registration procedures, as well as premium costs and poor-quality services, all of which discourage enrolment or the reactivation of lapsed membership. There is thus a need for health insurance schemes, such as Kenya’s National Hospital Insurance Fund, to educate informal workers on insurance services and protocols and to improve services to encourage uptake and reduce default behaviour.