«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»
Since 2009, health insurance has been mandatory. Individuals are covered by Statutory Health Insurance (SHI) on the basis of their income (some 88% of the population being covered by SHI). High earners may choose to be covered by Private Health Insurance (PHI), which also applies to civil servants and the selfemployed (some 10% of the population being covered by PHI). Special regimes apply to other categories, such as soldiers and policemen. As at March 2010, insurance was provided by some 169 quasi-public sickness funds for SHI and 46 private insurance companies for PHI, though these numbers continuously change, the market being competitive.
Delivery of services The SHI provides for a comprehensive benefits package including, among other things, preventive services, in-patient and outpatient hospital care, dental care, rehabilitation and prescribed drugs. Long-term care is covered by a separate mandatory insurance scheme.
Ambulatory care (primary and secondary) is provided through individual private practice or polyclinic-type ambulatory care centres and includes both generalist and specialist care. There is no referral system and patients can choose the doctor they prefer. In-patient care is provided in public and private hospitals. The number of for-profit hospitals is increasing, mainly through the takeover of public hospitals, as policies aim at securing or attracting new capital investments in the sector and reducing health expenditure. There are also numerous non-profit organisations involved in the provision of health care. Public hospitals may belong to the Länder, local authorities or their associations.13 Medicines are dispensed by hospital, institutional and, in particular, by public pharmacies, the latter often being privately owned and operated by selfemployed pharmacists.
Finance and health care expenditure In 2006, public contributions accounted for 77% of total health expenditure, the rest coming from private sources.
Public sources of the health system include: statutory health insurance contributions (occupation-based contributions for employers and employees, unemployment entitlements for the unemployed and government flat rate per capita for long-term unemployed people) and federal grants derived from taxation. Private sources include private health insurance contributions and upfront payments, as some of the services provided for by the benefits package imply cost-sharing by patients.
More than a quarter of total health care expenditure is allocated to the hospital sector; within hospitals, operating costs are financed by payments from sickness funds and private insurers (calculated on a daily basis), while capital expenditure is financed by state budget funds.
- Schmähl W. et al. (2010), Annual National Report 2010 – Pensions, Health and Longterm Care: Germany. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms
- Busse R. and Riesberg A. (2004), Health Systems in Transition, Germany, European Observatory on Health Systems and Policies.
GREECE Main characteristics of the Greek health care system ►Highly regulated at the central level, although structured at the territorial (regional) level ►Theoretically universal but in practice the system is not yet fully-fledged as such ►Health care financing is public – through social insurance and taxation and private ►Mixed service provision – public and private Structure of the system Both funding and delivery of services are provided through a mixed system including a national health service (NHS), occupation-based health insurance and private providers. The existence of many different players and the lack of an effective coordination mechanism imply inequalities in both service provision and funding.
At the central level, the Ministry of Health and Social Solidarity is responsible for the regulation, planning and management of the NHS, including allocation of resources and funds to the priorities set at the national level, and regulation of the private sector, while the Ministry of Employment and Social Protection is responsible for the social insurance system. The latter encompasses several funds and a variety of schemes, with some 30 social insurance organisations, many of which are administered as public entities but operate within different regulatory frameworks and based on different levels of contribution, coverage, benefits and criteria for accessing these benefits. The social insurance system comprises a large number of funds. Membership of one of the social insurance funds is compulsory for the employed population (employers and employees), the fund being determined by the type of occupation.
Under the Ministry of Health and Social Solidarity are several organisations and institutions, the health administrations at the regional level (Health Region Administrations) and the National Centre for Emergency Care that has also regional branches. Centrally, there are other bodies that participate in the governance and regulation of the sector, among which is the Central Council of Health Regions that plays a coordination role with regard to the policies of the regional health administrations and ensures their cooperation with the Ministry of Health. The Ministry of Health and Social Solidarity is structured around five directorates, two of which are responsible for public health and for social solidarity and oversee regional directorates and prefectural directorates. The directorate on health services oversees the Health Region Administrations that, in turn, are responsible for health centres and public hospitals. Regional directorates for public health are responsible for the delivery of health services at the regional and local level, in the latter case through public health departments. Administratively, the regional directorates belong to the Health Region Administration.
There are seven Administrations in the country, each responsible, in its catchment area, for: coordinating and implementing health policies; preparing business plans; organising health facilities and deciding on assets; managing health personnel; and preparing, approving and monitoring budgets and their implementation. Several of these functions, though, are made on a proposition basis only and are for the approval of the central level. Devolution is thus within a controlled and centralised framework, although Law 3852/2010, enacted in June 2010, provides for the competence of the Health Region Administrations to be transferred to municipalities within the so called ‘Kallikratis Plan’.
Responsibilities of regional and local (prefectural) authorities in the field of health are currently limited to: distribution of financial resources to hospitals, as determined centrally; endorsement of health personnel; licensing and monitoring of the operation of the private sector; and tasks related to environmental and public health. Municipalities run public centres for children and the elderly. In the region of Attica, exceptionally, large municipalities run a few health care centres.
Delivery of services Delivery of primary health care is through public and private health service providers. The NHS provides both primary and secondary care; in rural areas it is still the main provider, but the role played by the private sector is growing in importance.
Delivery of public health services is through 114 outpatient departments of public hospitals and some 201 rural health centres that, administratively, are attached to the hospitals and funded through hospital budgets. However, primary care is also provided by: health centres and special units owned and operated by social insurance funds; clinics and welfare services run by municipalities; and physicians working in private practice.
Health centres are staffed with general practitioners and specialists that deliver primary care free of charge; 1,458 health surgeries with public medical staff are administratively dependent on the health centres. However, there is no gatekeeping mechanism and patients may refer themselves directly to secondary care.
Secondary and tertiary care is provided through public and private hospitals.
There are about 155 public hospitals, 23 of which operate outside the national health system; there are 218 private profit-making hospitals, equivalent to 26% of total bed capacity; and social insurance fund hospitals mainly funded by social security revenues.
Emergency care is provided by the National Centre for Emergency Care in Athens, with branches across the whole country. Pharmaceutical care is universal and prescribed medicines are reimbursed by social insurance, although 25% of the cost is co-paid by patients. Exemptions from, or reduction of, copayments are granted depending on the health status (chronic diseases) and income level. Planning and implementation of pharmaceutical policy is at the central level.
Finance and health care expenditure Health care is funded through public and private resources. Public resources come from social insurance (contribution of employers and employees) and taxation (direct and indirect tax revenues). Private funding is mainly in the form of: upfront payments for services not covered by social insurance or covered but not reimbursed because they were purchased outside the formal system; copayments; and private expenses. Upfront payments account for a high share of total health expenditure (almost 38%), one third being then contributed to the total health expenditure through taxation and social insurance. The role of private health insurance is still minor with only some 12% of the population having taken out private coverage with just a 2.1% contribution to total health expenditure.
- Economou C. (2010), Greece Health System Review. Health Systems in Transition, 2010, 12(7):1–180, European Observatory on Health Systems and Policies
- Petmesidou M. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Greece. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.
HUNGARY Main characteristics of the Hungarian health care system ►Centrally regulated but with an executive role played by county and municipalities as owners of health care facilities ►Providing nearly universal coverage through statutory social health insurance system based on citizenship ►Mainly public financing of health care – out of contribution and state and local budgets ►Mixed service provision – public and private, the latter especially at primary care level Structure of the system and responsibilities At the central level, the Ministry of Health is responsible for health policy development and health sector regulation, as well as for the planning and operation of the health care system. Under the Ministry of Health are the National Public Health and Medical Officer Service, responsible, among other things, for the supervision of health care delivery; and the National Health Insurance Fund Administration (NHIFA), responsible for administering insurance contributions to the mandatory national health insurance as well as for sourcing and paying for health care services and medicines. Since 2009, the NHIFA has been structured into seven regional institutions.
County (or regional) and local authorities own and manage health care facilities; thus, they are directly involved in the delivery of health care services and in the funding of investment costs for care facilities through local budgets. Responsibility for the delivery of health care services on a territorial basis is defined within the 1997 Act CLIV on Health.
The social health insurance scheme is compulsory for all citizens and provides nearly universal coverage. Employers and employees pay contributions to the Health Insurance Fund through a payroll tax; some categories, such as dependants, pensioners and people with very low income, are exempted from payment. The level of contribution and the modalities for taxation, however, change according to the administration in charge, as new fiscal policies were put in place in July 2009 and then again in April 2010. In practice, health policy is currently under review as the new administration has prepared and is discussing a reform plan, the ‘Semmelweis Plan’, that is expected to restructure, among other things, also the health care delivery system.
Delivery of services The insurance provides access to a package of benefits. Primary care is delivered through general practitioners working in private practice; outpatient care is mostly delivered in polyclinics that are owned by municipalities. There is a free choice of the general practitioner by patients. A referral is needed for accessing specialist care and secondary care in hospitals.
Secondary care is delivered through so called ‘territorial hospitals’, the majority of which are also owned by the municipalities, while tertiary care is delivered through ‘high priority hospitals’. Almost all hospitals are publicly owned or belong to foundations or universities. Specifically: 66% of the hospitals are owned by local governments; 16% by the church or foundations; 9% are owned by the state or by universities; and 7% by the private sector. With regard to management, publicly owned hospitals may be run directly by public owners as budgetary institutions or for-profit or non-profit companies (about 30% of the facilities are run as companies), or are handed over to private management (ESKI, 2009; ESKI, 2011).
New rules for the establishment and ownership of pharmacies are being developed in 2011 by the new administration.
Finance and health care expenditure Total health expenditure is mainly funded through public sources (70.6% in 2007), the rest being private expenditure, most of which is represented by upfront payments (accounting for approximately 25% of total private expenditure) and cost-sharing for services delivered through the insurance system. Public expenditure is mainly financed by contributions through the NHIF, and by funding from the central budget. While recurrent and operational costs of hospitals are financed through the NHIF, capital costs are funded through capital grants from the central governments or the local budgets of the owning municipalities.
- National Institute for Strategic Health Research (ESKI) website, Health System Scan newsletters January 2011 and December 2009 & Hungarian Health Care System 2009