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«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»

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Secondary care comprises in-patient care in hospitals and in day care. Hospitals are private or public non-profit organisations, classified into acute, psychiatric, geriatric and specialised hospitals. Specialist health care is provided by professionals, generally organised as self-employed professionals (except nurses and midwives). The majority (60%) of hospitals are non-profit private, mostly owned by religious orders or, to a lesser extent (5%), by sickness funds (Van Gyes, 2009); most of the public hospitals are owned by municipalities, provinces, a community or an inter-municipal association.10 The pharmaceutical sector is regulated at the federal level. Pharmaceuticals are exclusively distributed through community or hospital pharmacies and prescribed by physicians or, limited to their professional services, dentists and midwives.

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Finance and health care expenditure 11 Health care expenditure is mainly publicly funded (71.3% in 2006), main sources being social security contributions and taxation at the federal, regional and local level. Federated and local government revenues (1.5% and 2.0% of the total health expenditure, respectively, in 2006) are mainly for prevention and health promotion activities.

HOPE online country profile – Belgium: latest information from 2007 Gerkens and Merkur, 2010 In 2006, the private share of total health care expenditure was 28.4%, out of which 23.3% came from upfront payments and 5.1% from voluntary health insurance.

References:

- Gerkens S., Merkur S. (2010), Belgium: Health system review. Health Systems in transition, 2010, 12(5):1–266. ISSN 1817–6127

- Segaert S. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care:

Belgium. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms

- Van Gyes G. (2009), Representativeness of the European social partner organisations:

Hospitals – Belgium. EIROonline.

BULGARIA Main characteristics of the Bulgarian health care system ►Partially decentralised, with some implementation and funding responsibilities delegated to local authorities (municipalities) ►Providing coverage to some 92% of the population through statutory insurance; Roma and permanently unemployed individuals are excluded from the scheme ►Mixed funding of health expenditure: through public revenues out of statutory health insurance contributions and taxation, and private sources through out-of-pocket payments ►Mixed service provision – public and private Structure of the system At the central level, the Ministry of Health is responsible for health policy development, drafting of legislation, sectoral planning and priority setting, organisation of emergency care and of public health activities. It is operational at the regional level through 28 centrally-funded regional health centres and 28 independently functioning emergency health care centres. The Ministry of Health also has direct control of several national hospitals and defines the ‘guaranteed medical services package’ to which each insured person has free access.

The National Health Insurance Fund (NHIF), under the Ministry of Health, is a public non-profit-making organisation administering the compulsory health insurance: it has branches at the regional level (28 regional health insurance funds - RHIFs) and offices at the municipal level. The NHIF is responsible for financing health care and for guaranteeing access to it by the insured; in particular, it finances all outpatient and in-patient care provided by those institutions with which it has a contract. Provision of services within the statutory system is, in fact, subject to the conclusion of contracts between physicians and institutions on the one hand and the NHIF/RHIFs on the other.

Contractual conditions are set within the National Framework Contract, agreed on an annual basis and also determine the benefits package.

Since 1992, municipalities have had ownership of local hospitals, outpatient clinics, and other health care facilities, a circumstance that also implies financing responsibilities.

Municipalities may also have a share in the ownership of interregional and regional hospitals, organised into joint-stock companies.

The health insurance system is based on compulsory insurance. It is regulated by the Health Insurance Act and is designed as a state monopoly: ‘The choice of one fund for social health insurance brings into balance the interrelations with the health service providers who are also associated and represented by the professional organizations of doctors and dentists. The Law does not provide for a re-distribution mechanism to level the risks, which would have been necessary in the process of functioning of more than one independent fund’ (NHIF website). Insurance is based on citizenship and residence; it guarantees insured persons free access to a benefits package, as well as free choice of any service provider who has concluded a contract with the RHIFs. Some services require co-payments or user charges. Certain categories of the population are exempted from the payment of contributions: that is covered by state and municipal budgets (for example, pensioners, individuals receiving unemployment benefit, high school students up to the age of 26, or individuals below the age of 18).





The undertaking of voluntary health insurance is possible.

Delivery of services Primary and outpatient health care has been mostly privatised and is provided through individual and group practices. General practitioners function as gatekeepers to specialised and secondary care.

In-patient care is provided by general and specialised health care facilities. Hospitals may be public (owned by the state or by municipalities) or private. In the latter case, if they do not have a contract with the NHIF, patients have to pay in full for the services or be covered by a voluntary insurance scheme. In 1991, private practice was legalised and since then privatisation of health care facilities has progressed significantly; in 2009, there were 103 privately owned hospitals (ASISP, 2010) compared to 40 in 2004.

The Pharmaceuticals and Human Medicine Pharmacies Act of 1995 regulates the licensing, manufacturing, marketing, wholesale and retailing of drugs. It set the basis for the restructuring and privatisation of the sector, according to which most pharmacies are now private.

Finance and health care expenditure Health care expenditure is characterised by a high level of private funding. In 2005, upfront payments for user charges and co-payments for medical services accounted for 41.6% of total health expenditure. Private revenues from voluntary health insurance play a minor role. Public funding accounted for 57.5% of total health expenditure, mostly out of compulsory health insurance contributions, which are payroll-based, and state and municipal budgets that provide cover for those unable to contribute.12 The central budget revenue comes from general taxation (VAT, income tax, corporate tax) while the municipal budget revenue comes from local levies such as waste charges and building tax (Georgieva et al., 2007).

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References:

- European Commission (2008): The socio-economic impact of the Hospital Information System in National Heart Hospital-Sofia, Bulgaria

- Georgieva L. et al. (2007), Health Systems in Transition, Vol.9 No.1, Bulgaria: Health system review, European Observatory on Health Systems and Policies

- NHIF website CYPRUS Main characteristics of the Cypriot health care system ►Currently highly centralised, although an ongoing reform process is expected to move towards decentralisation ► Not yet providing universal coverage ► Public health care financing is through general taxation ► There is a high share of private expenditure ► Mixed service provision – public and private Structure of the system Cyprus is in the midst of a reform process of its national health system that has been planned since 2001 but that remains unimplemented. Factors currently slowing down the reform process include,, the downturn caused by the financial crisis with consequent budgetary constraints, and a debate on the need to restructure public hospitals as independent units. The reform is considered necessary to address major deficiencies and inequalities that characterise the existing system. Established by Law 89(I)/2001, the Health Insurance Organisation (HIO) is the public legal entity in charge of implementing the new National Health System (NHS).

Overall responsibility for social protection and health care lies with the Council of Ministers. The provision of care is regulated by the Government Medical Institutions and Services General Regulations of 2000 and 2007. The Ministry of Health, through the Department of Medical and Public Health Services, governs the Government Medical Institutions and is responsible for the organisation and the provision of health care services.

Services are provided by the Government Medical Services, made available through Government Medical Institutions, or by the private sector. Private health facilities are, in fact, flourishing, although there is a lack of effective control and coordination with public care. Some 70% of the population is covered by public health care.

Delivery of the services Delivery of public services is via a network of hospitals, health centres, subcentres and dispensaries. Namely, public primary health care is provided ‘at 4 hospital outpatient departments, 7 suburban outpatient departments, 5 urban and 23 rural health centres and 274 sub-centres’ (WHO, 2004). Lower administrative levels cooperate in implementation and promotion activities but the organisation, administration and regulation functions remain at the central level. Secondary and tertiary health care is provided through four main district hospitals and specialist centres, in addition to three small rural hospitals. The private provision of services is through practising physicians, and supporting structures such as surgeries, pharmacies, laboratories and polyclinics. Limited to urban areas, there are 105 small private clinics for in-patient care, some of which offer highly specialised services. Patients are free to choose the service provider; there is no gate-keeping system in place.

The forthcoming reform is expected to unify service provision by both private and public suppliers on a competitive basis, thus the need to make hospitals independently managed units. Once implemented, the reform is expected to generate a certain degree of decentralisation.

Pharmaceutical care is provided according to an approved list of pharmaceuticals; medicines are dispensed through community pharmacies (430 private and 35 public in 2006) and public hospital pharmacies (8 in 2006).

Finance and health care expenditure Public health services are financed by general taxation through the budget. The contribution of charges imposed on some services is limited.

Some categories of patients are exempted from the payment of public care service provision : state officials and civil servants (active or retired) and their dependants, families with four or more children, university students, and people belonging to vulnerable categories because of illness (chronic disease, for example) or income. However, co-payments may also be requested from some of the above categories for the delivery of certain services.

Those persons deciding to refer to the private sector pay upfront fees; they may be fully or partially covered by medical funds operated by trade unions or employers. There is a high level of private expenditure for health (about 60% of total expenditure).

As a result of the reform process, the public health system will be funded through compulsory health insurance contributions.

References:

- Ministry of Health of the Republic of Cyprus website

- Cyprus Health Insurance Organisation website

- Golna C. et al. (2004), Health care systems in transition: Cyprus. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies

- Petmesidou M. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Cyprus. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms

CZECH REPUBLIC

Main characteristics of the Czech health care system ►Decentralised, with responsibilities held by regional authorities (selfgoverning regions) ►Providing universal coverage through a mandatory health insurance system ►Mainly public financing of health care – contributions from the insurance system ►Mixed service provision – public and private Structure of the system At the central level, the Ministry of Health is responsible for health policy and legislation. It has also a supervisory role and the direct administration of some care institutions and bodies, the latter including the Regional Public Health Authorities, the National Institute of Public Health and the Regional Institutes of Public Health, responsible for science, research, epidemiological and immunisation activities. Together with the Ministry of Finance, the Ministry of Health supervises the health insurance funds.

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Other key actors in the system include the health insurance funds, quasi-public, self-governing bodies in charge of contracting health care providers. The purchasing process and related negotiations are supervised by the Ministry of Health. The health system is based on mandatory social health insurance through membership in one of the 10 (as at 2009) health insurance funds. The funds function as payer and purchaser of care services; they are obliged to accept all applicants, regardless of the risk, and therefore a risk-adjustment scheme applies when funds pooled by the social health insurance are redistributed among them;

additionally, these funds are not allowed to make profit, any surplus they may have is used for health care funding. Responsibility for the regulation of primary care is shared between the central level, the regions, and the health insurance funds, since regions, as members of dedicated committees, contribute to the issuing of recommendations on the contracting of providers. Although these recommendations are not binding, they are usually followed by the health insurance funds.



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