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.     

Health Policy in the Asian NIEs

This paper compares the health policies of Hong Kong, South Korea, Singapore and Taiwan with the purpose of drawing policy lessons. The study finds two distinct policy clusters: Hong Kong and Singapore on the one hand, and Korea and Taiwan on the other. With respect to provision of health care, the former rely largely on public hospitals for delivering inpatient care while the latter rely on private hospitals. In matters of financing, they are similar in that out‐of‐pocket is a major source of financing in all four countries. However, they are also different because Korea and Taiwan have universal health insurance while the city states do not. The study concludes that public provision of hospital care, as in Hong Kong and Singapore, yields more favourable outcomes than many mainstream economists would have us believe. Conversely, private provision in combination with social insurance, as found in Korea and Taiwan, severely undermines efforts to contain health care costs.     

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.     

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.     

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.     

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.     

Central versus Local Service Regulation: Accounting for Diverging Old-age Care Developments in Sweden and Denmark, 1980–2000

In Sweden and Denmark, the development of old‐age care has followed markedly divergent paths over the past 20 years. In both countries, the level of old‐age care universalism was exceptionally high in the early 1980s. Since then it has dropped sharply in Sweden, while remaining constantly high in Denmark. These divergent trends are clearly irreconcilable with the common image of a coherent Scandinavian welfare state model, and they seem hard to explain with reference to traditional approaches of comparative social policy. This article attempts to account for the divergent developments by focusing on the balance of old‐age care regulation between central and local government. The main finding is that only in Sweden has the central regulation of old‐age care been weak and unspecific. As a consequence, Swedish municipalities have enjoyed sufficient autonomous, regulatory competence to exercise certain local retrenchment measures in times of austerity, thereby eventually causing a nationwide weakening of old‐age care universalism. By contrast, municipalities in Denmark have been much more tightly bound by central state regulations which have prevented them from imposing similar retrenchment measures in the old‐age care sector; consequently, Denmark's level of old‐age care universalism has remained comparatively high.     

Class, Attitudes and the Welfare State: Sweden in Comparative Perspective

One of the most important arenas for contemporary class politics is the welfare state. In this article, attitudes towards welfare policies among different classes in Sweden are compared with other Western countries and over time. In the first part of the article, attitudes towards state intervention among different classes are compared across four Western countries: Sweden, Germany, Britain and the USA. The data come from the 1996 survey on “The Role of Government” conducted within the International Social Survey Programme. In the second part of the article, more detailed national data sets are used in order to track developments within Sweden from the early 1980s until 2002. Attitudes towards welfare spending, financing of welfare policies and service delivery are used to track developments of class differences in attitudes over time. It is concluded (a) that class differences are particularly large in Sweden, and (b) that changes over time indicate stability in overall class differences, combined with changes in attitudes among non‐manual employees. The implications of the results for recent arguments about the restructuring of class relations and the impact of welfare policies on stratification are discussed.     

Health Care in Asia and the Pacific: Increasing the focus on social health insurance

This paper focuses on health insurance reform within the broader frameworks of both social security and health services system development. In most countries in Asia and the Pacific, it is indeed the reform of the health services system, through policy changes in health care financing, that has led to an increased focus on health insurance. The underlying issue in this reform is the shift in responsibility that has taken place in most countries in the region over recent years. In the past, governments were responsible for financing health care for their populations. This shifted to defining, legislating and implementing an appropriate health care financing mechanism, presenting several challenges: to reach universal health insurance coverage through new initiatives for new populations, mainly the informal sector accounting for the majority of the population in almost all these countries; to apply provider payment systems that enable control over costs and the volume of utilization; and to strengthen primary health care as a foundation for rational utilization and more resources for prevention, including prevention of chronic diseases among the ageing population. This approach will require an active partnership between health insurance schemes and government that should reflect the new division of responsibilities to guarantee access to high-quality health care for all.     

Denmark: Universal or Not So Universal Welfare State

This article questions whether or not Denmark is still a universal welfare state. It does so by first offering a comparative‐based analysis of the Nordic countries on central welfare state parameters. Second, the article utilizes a case‐based analysis in respect of three core areas of the Danish welfare state—pensions, unemployment and early retirement benefit—to assess the distinctiveness of the Danish model. The article concludes that, notwithstanding the Danish model is more mixed today than it used to be, it continues to be distinct in areas such as equality, full employment, a high level of spending on social security and an active labour market policy.     

‘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.     

Mortality analysis of persons with disabilities in Argentina by age,sex and duration of benefit, 2015–16

This article describes the differential mortality of Argentina’s disability pension beneficiaries during the 2015–16 period, based on National Social Security Administration (Administración Nacional de la Seguridad Social – ANSES) payment records. It compares data for those with an assessed disability with overall population data, as well as with available international data (from Canada, Chile, Mexico, and the United States of America). In addition to breaking down mortality rates for people with disabilities by age and sex, it also factors in duration of benefit, establishing an inverse correlation between benefit duration and mortality.     

Marketisation policies in different contexts: Consequences for home‐care workers in Germany,Japan and Sweden

Market‐oriented restructurings of long‐term care policies contribute significantly to the aggravation of care workers’ situations. This article focuses on the effects of broader long‐term care policy developments on market‐oriented reforms. Germany, Japan and Sweden are three countries that have introduced market‐oriented reforms into home‐based care provision embedded in distinct long‐term care policy developments. Conceptually, this article draws on comparative research on care to define the institutional dimensions of long‐term care policies. Empirically, the research is based on policy analyses, as well as on national statistics and a comparative research project on home‐care workers in the aforementioned countries. The findings reveal the mediating impact of the extension and decline of long‐term public care support and the corresponding development of the care infrastructure on both the restructuring of care work and the assessments of the care workers themselves.     

Unheard voices,unmapped terrain: Care work in long‐term residential care for older people in Canada and Sweden

Daly T, Szebehely M. Unheard voices, unmapped terrain: care work in long‐term residential care for older people in Canada and Sweden This article aims to contribute to comparative welfare state research by analysing the everyday work life of long‐term care facility workers in Canada and Sweden. The study's empirical base was a survey of fixed and open‐ended questions. The article presents results from a subset of respondents (care aides and assistant nurses) working in facilities in three Canadian provinces (n= 557) and across Sweden (n= 292). The workers' experiences were linked to the broader economic and organisational contexts of residential care in the two jurisdictions. We found a high degree of country‐specific differentiation of work organisation: Canada follows a model of highly differentiated task‐oriented work, whereas Sweden represents an integrated relational care work model. Reflecting differences in the vertical division of labour, the Canadian care aides had more demanding working conditions than their Swedish colleagues. The consequences of these models for care workers, for older people and for their families are discussed.     

Design limitations of long-term care insurance schemes: A comparative study of the situation in Spain

Social and demographic changes are gradually transforming the way Western societies cope with old‐age dependency, in particular the provision of long‐term care (LTC). In response to the need for formal care services and financing instruments, this study examines a range of both private and public insurance tools. As a general rule, LTC insurance is markedly underdeveloped. Furthermore, in southern European countries, the role of the public sector in LTC is unclear compared with its role in other, related welfare areas such as healthcare. The study examines the financing alternatives for LTC insurance, taking as its benchmark the Spanish LTC financing reform. It briefly examines some existing, publicly funded LTC financing tools and explores the potential role of private LTC insurance, arguing that it has an active part to play alongside compulsory mainstream insurance schemes and self‐insurance alternatives. As in other European countries, Spanish social attitudes show a preference for some kind of general entitlement to publicly funded schemes, although this preference is subject to significant regional heterogeneity.     

Why spouses depress each other: A cross‐national study to test the shared resource hypothesis in depressive symptom concordance within older adult couples

The shared resource hypothesis suggests that married couples share the same environmental resources, which shape their health concordance. This study tests its cross‐national applicability. Cross‐sectional 2012–2013 Health and Retirement Study data from China, England, Mexico, and the United States were analyzed. Heterosexual couples (age ≥60) who were married or partnered were studied (N = 20,565 pairs). Dyadic data were analyzed by multilevel models to examine the effect of self and spousal social and physical health statuses on depressive symptoms. Regression models were used to test the relationship between couples' shared resources and depressive symptom concordance. Results indicated both husbands and wives' depressive symptoms were associated with their own and spouses' social and health statuses. Most couple‐level resources were insignificant predictors for Chinese and Mexican couples' concordance, but having more social and financial resources was associated with higher concordance among British and American couples. Self‐reported health was the most consistent predictor in all countries. The shared resource hypothesis was more applicable to depressive symptom concordance within couples in the United States and England, but not in China and Mexico. Couple‐centered intervention is suggested for clinical practice, and the spousal effect should be considered in policymaking.     

From walls to homes: Child care reform and deinstitutionalisation in Ghana

In 2006, the Ghanaian government, in partnership with the United Nations Children's Fund (UNICEF), began to reform the child welfare system. The main aim of this reform was to provide a sustainable and culturally appropriate system of care for children without parental care by shifting from an institutional‐based model to a family and community‐based one. Drawing on existing peer‐reviewed and grey literature, this article provides an overview of the major components of the reform, including reintegration with the extended family, foster care and adoption. In addition, the article discusses the prospects and challenges involved in achieving the reform's intended component. Key Practitioner Message: ● Use community development techniques to raise the resources needed to provide family support services for vulnerable families; ● Social work practitioners partner with non‐governmental organisations to train community members as para‐social workers; ● Social workers, especially in developing countries, understand the challenges they face when embarking on deinstitutionalisation.     

A critical review of mental health and mental health‐related policies in China: More actions required

In China, there are over 170 million people suffering from mental illness. However, there is a lack of a critical review of the policies governing the provision of mental health services. Drawing on the framework of mental health policy developed by the WHO, this article critically examines mental health policies regarding legislation, financing, model of care and delivery, as well as manpower and the training of mental health professionals in China. This analysis raises a number of policy‐related questions concerning the lack of community‐based psychiatric services, inadequate coverage of mental health services in the rural areas, poor standard of education and an insufficient number of trained mental health professionals, and insufficient protection of the human rights of people with mental illness. The article ends by urging the various levels of governments to make a firm commitment to improve mental health care for people with mental illness in China.     

Access to Childcare in Europe: Parents' Logistical Challenges in Cross‐national Perspective

A burgeoning comparative literature has identified the centrality of childcare policy and provision in promoting parental, and specifically maternal, participation in paid employment across countries. This literature has focused on the importance of macro‐level institutional arrangements, with a special emphasis on variation in availability of, and access to, formal early childhood education and care services. However, there has been limited comparative exploration of what this means in practice at the micro‐level: the everyday challenges parents face when attempting to navigate the childcare system and the labour market simultaneously. Taking inspiration from human geography literature on the concept of ‘space–time fixity’, we present cross‐national findings on the logistical challenges of arranging childcare. Evidence is drawn from interviews with parent‐ and childcare‐related organizations in six European countries: Germany, Hungary, Italy, Slovenia, Sweden and the UK. Our research provides a richer understanding of childcare availability than would a sole focus on formal childcare services, by elucidating the difficulties parents face in organizing access to these services, which can be a challenge to some extent even in contexts where childcare services are comprehensive and affordable.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.