«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»
Hospital country profiles by HOPE are available at: http://www.hope.be Hope & Dexia (2009) In a number of cases, reference was directly to the website of relevant ministries dealing with health within individual countries and to the information made publicly available there. Finally, another significant literature source was the OECD Health Working Paper reporting on the results of a survey launched in 2008 to collect information from 29 countries on their health systems.6 The survey, based on 81 questions, also gathered information on governance and decentralisation in decision-making with regard to resource allocation and financing responsibilities; replies related to the latter aspects have been included in the profile of those EU Member States that are also OECD member countries, as a complementary element to the narrative description of their health system.7 A number of health systems are undergoing reform, especially with regard to funding mechanisms and revision of purchaser/provider relationship. This is a direct consequence of increasing health expenditure driven, among other things, by the economic downturn and related occupational crisis (several systems have an occupation-based mechanism for contributing to statutory health insurance) and important demographic changes (ageing population). Whenever possible, the occurrence of these changes was noted.
The inventory is by nature a descriptive text but efforts have been made to provide visually immediate information to the reader on important features such as prevalence of a decentralised or centralised management structure, types of health facilities owned by LRAs, and types of power/responsibility exercised by LRAs. Table 1 provides the ‘legend’ of such visual information.
Paris, V., M. Devaux and L. Wei (2010) Reference is to Table 30 in Paris, Devaux, Wei (2010), pages 69-70.
The information gathered in this inventory supports the outlining of a typology of health care systems in terms of decentralisation of tasks and responsibilities from the central to the local and/or regional level. Aggregated conclusions and synthesis of the information included in chapter 2 are presented in chapter 3 where the cluster analysis is also supported by other relevant statistics and indicators.
The main findings of the inventory in terms of functions are summarised in Table 2.
Table 2 – Overview of functions delegated to local or regional authorities, by country
2.2 Country profiles AUSTRIA Main characteristics of the Austrian health care system ►Decentralised, with several competencies delegated to provincial and local authorities or social security institutions ►Providing almost universal coverage (98.8%) through statutory insurance ►Health expenditure is mostly funded through public funds – out of social insurance contributions and taxation - and complemented by private payments ►Mixed service provision – public and private Structure of the system The Federal Government is responsible for health policy and legislation.
Overall, it plays a supervisory and facilitating role among the numerous actors involved in health care, with several functions being shared with, or delegated to, the nine States/Provinces (Bundesländer) and/or social security institutions. In general, cooperation within the health sector is regulated by law. The Federal government bears responsibility for: regulations regarding pharmaceuticals, pharmacies and medical devices; health professions (for example education of physicians) and structural policy; and legislation for outpatient care (physicians in individual practices). Main institutional actors include: (i) at the federal level, the Federal Health Agency and its executive body (the Federal Health Commission), managed by the Federal Ministry of Health and composed of representatives from all government levels, as well as from social security institutions, the Austrian Medical Chamber, church-owned hospitals, and patient representatives; (ii) at the provincial level, the Regional Health Funds and their executive bodies (the Regional Health Platforms) that include representatives of the respective provinces, of the Federal Government, of the Main Association of Austrian Social Security Institutions8, of the Austrian Medical Chamber, of local governments and hospital organisations. The Regional Health Funds are the implementation branches of the Federal Health Agency and distribute funds to public, private and non-profit hospitals.
As self-governing bodies, the social security institutions have regulatory functions with respect to outpatient health services. The social insurance system is based on statutory insurance that is thus compulsory and regulated by law.
There is no insurance market, as people may not choose their social security institution. Affiliation to an insurance fund depends on the profession of the insured person, on the place of work, or on the place of residence.
Planning of resources across all levels is through a national Health Care Structure Plan (ÖSG) and Regional Health Care Structure Plans (RSG).
All levels of government, from the federal to the local, are jointly involved in the provision of public health services and administration. The responsibility for in-patient care (provided in hospitals) is shared between the federal and the provincial authorities, with the former laying down the legislative framework and the latter preparing enforcement legislation.
The Main Association of Austrian Social Security Institutions (HVB) is the umbrella organisation of 22 social security institutions, covering pension, health and accident insurance.
Delivery of services Insurance provides free access to a package of services; services not included in this package may require upfront payments by patients, or copayments. Direct payments are also made when using benefits that are not covered by the package or that are delivered through physicians not employed by the respective social health insurance fund. Exemptions from co-payment exist for specific categories of patients (chronically ill, below a certain income level, etc.) Provincial authorities are specifically responsible for the implementation of hospital care, the maintenance of hospital infrastructure, health promotion and prevention services; social welfare benefits and services are the responsibility of local governments (districts, statutory cities and municipalities).
Access to health services is not regulated, in that patients are not obliged to enrol with one specific physician and physicians do not play a gate-keeping role.
Patients may thus also access outpatient departments of hospitals without referral. Outpatient care is provided through physicians (some self-employed), outpatient clinics, privately owned or belonging to the social health insurance funds, other specialists and outpatient departments of hospitals. Physicians usually have a contract with the social health insurance funds.
In 2008, a total of 267 hospitals were available for inpatient care, with some 130 hospitals (about 48,600 beds) funded by provincial health funds (Landesgesundheitsfonds) and some 44 hospitals (about 4,000 beds) by the private hospitalfinancing fund (Privat-krankenanstaltenFinanzierungsfonds). The ownership of hospitals is 58% public (States/Provinces, local authorities, or social insurance institutions, directly or through companies) and for the remaining share, private (religious orders, associations).9 Licensing and monitoring of medicines market is at the federal level by the Austrian Medicines Agency, AGES PharmMed. Drugs are delivered through privately owned pharmacies or, in rural areas, through family physicians.
Finance and health care expenditure In 2007, 76% of total health expenditure was from public sources and the remaining 24% from private sources; in particular, social insurance contributions covered about 50% of total health expenditure (ÖBIG, 2010a).
The health care system is thus primarily financed through public funds, the main sources of revenue for which are social insurance contributions (about 60%) and HOPE online country profile – Austria: latest information from 2007 taxation (40%). Public funds come from the Federal Government, the provincial and the local governments. Private payments are in the form of both direct and indirect co-payments.
‘The organisation and financing of the healthcare system are governed by intrastate agreements between the national and provincial governments in accordance with Article 15a B-VG (Austrian Constitutional Law)’…such funds ‘are distributed to the individual provinces and the provincial health funds in those provinces on the basis of set proportional allocations’ (ÖBIG, 2010b).
- Federal Ministry of Health website
- Österreichisches Bundesministerium für Gesundheit (2010a), The Austrian Health Care System – Key Facts
- Österreichisches Bundesministerium für Gesundheit (2010b), The Austrian DRG system
- Fink M. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care:
Austria. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms BELGIUM Main characteristics of the Belgian health care system ►Decentralised, with main responsibilities shared between the federal government and the federated authorities (communities, regions), reflecting the institutional setting and devolution of the country ►Providing nearly universal coverage (99.6% of the population) through compulsory insurance ► Health expenditure is mostly funded through public funds – out of social security contributions and taxation from the federal government and, to a lesser extent, from the local level ►Mixed service provision – public and private Structure of the system Health care is determined by three levels of government: the federal government, the federated authorities (three regions and three communities) and, to a minor extent, the local governments (provinces and municipalities). The division of responsibilities for health care reflects the structure of the country as, since the 1980s, some responsibilities have been devolved to the three communities (Flemish, French, and German).
The federal level, through the Ministry of Social Affairs and Public Health, is responsible for the regulation and financing of compulsory health insurance, pharmaceutical policy and hospital legislation. The health legislative framework and the drawing up of the annual budget of the health system are determined at the federal level. Both the federal level and the federated entities are responsible for health policy. The three communities define their own objectives for health promotion and preventive health care policies and their internal governance structures. Responsibilities of the federated authorities are mainly on ‘health promotion and prevention; maternity and child health care and social services;
different aspects of community care; coordination and collaboration in primary health care and palliative care; the implementation of accreditation standards and the determination of additional accreditation criteria; and the financing of hospital investment.’ (Gerkens and Merkur, 2010).
As an example of responsibility-sharing and of the level of interaction with regard to hospital planning, hospital capacity is planned at the federal level, along with the requirement for hospitals to obtain accreditation from the regional ministries of public health; the communities are responsible for authorising hospital construction; capital subsidies for hospital buildings are provided by both the communities and the federal government.
Cooperation between the different levels is through inter-ministerial conferences, composed of ministers responsible for health policy from the federal and federated governments. These conferences may produce protocol agreements on specific policy areas such as long-term and elderly care, vaccination programmes, and cancer screening, but decisions are not binding and, above all, are a consultation forum.
Provinces and municipalities have limited responsibilities in health care.
Provincial commissions deal with responses in cases of contagious diseases, the checking of professional qualifications and the supervision of the practice of medicine, nursing and paramedics. Municipalities are responsible for organising social support for those on lowincomes, as well as emergency care and public hospitals.
The health insurance scheme is compulsory. Membership is based on current or previous professional activity. There are two main schemes, one for all but the self-employed, and one for the self-employed (since 2008). Compulsory health insurance is managed by the National Institute for Health and Disability Insurance, a public institution accountable to the Minister for Social Affairs and Public Health. All individuals entitled to health insurance must register with one of the existing sickness funds that are private, non-profitmaking organisations. Voluntary health insurance accounts for a small share of the market.
Delivery of services Insurance coverage provides access to a range of some 8,000 services.
Outpatient care is usually delivered upon upfront payment by patients that will be later reimbursed through their sickness fund. For in-patient care and medicines, patients only pay user charges, as the sickness funds pay the providers directly (third party payer system).
General practitioners do not function as gate-keepers and generally operate from their premises as independent professionals. Patients thus have free choice and can directly access both specialists and hospitals. In general, emergencies are handled through 24-hour primary health care hospital emergency departments.