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

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

IRELAND Main characteristics of the Irish health care system ►Centralised, with main responsibilities held by the Health Service Executive ►Providing universal coverage for the ‘ordinarily resident’ ►Mainly public financing of health care – out of general taxation ►Mixed service provision – public and private Structure of the system and responsibilities Overall responsibility for the health care system lies with the Government, exercised through the Department of Health and Children (DoHC) under the direction of the Minister of Health and Children (MoHC). The MoHC is responsible for the strategic development and overall organisation of the health service, including legislation and regulation; it also approves annual National Health Service plans where priorities and activities as well as the governance structures needed for delivery are specified.

These plans are prepared by the Health Service Executive (HSE), accountable directly to the Minister of Health, established in 2005 to take responsibility for budgetary and management functions related to health services, along with a centralisation process that saw the abolition of Regional Health Boards and of a series of statutory agencies.

The HSE deals with health and personal social services through three divisions responsible for (i) population health, (ii) hospitals, and (iii) primary, community and continuing care. The Population Health Directorate is mainly responsible for the strategic planning; a National Hospitals Office is responsible for the organisation, planning and coordination of acute services in 51 hospitals; and the Primary, Community and Continuing Care (PCCC) Directorate is responsible for general practice services, community-based health and personal social services, services for older people and children, disability services, mental health services and social inclusion. The PCCC consists of 32 Local Health Offices (LHOs), representing the first point of access to services and the place

where dialogue and involvement with local stakeholders is expected to takeplace.

The HSE is divided into four administrative areas: West, South, Dublin NorthEast, and Dublin Mid-Leinster. Four administrative offices, one for each area, directly accountable to the HSE chief executive officer (CEO), assist in the coordination of services delivered through the LHOs. Each of the administrative areas has a Regional Health Forum made up of representatives of the city and county councils within that area: ‘The Fora make representations to the HSE on the range and operation of health and personal social services in their area, and the HSE in turn provides administrative services to the Forum’ (HSE, 2011).

A range of other statutory and non-statutory agencies have a role in the regulation and provision of health and social services, in particular voluntary NGOs in conjunction with, or on behalf of, the HSE; further, some social actors such as trade unions, employers, farming organisations and representatives of the community and voluntary sectors may formally have a role in the broad direction of health policy.

Delivery of services Local governments (county, city and town councils) have a limited role in health care; the HSE provides many health care services directly while the voluntary sector, including religious organisations, plays an important role.

Primary care is usually provided through general practitioners. GPs are the gatekeepers to secondary care as they provide referral to specialist physicians or publicly-funded acute hospitals. However, secondary care may be accessed directly upon the payment of a standard fee. GPs are self-employed and most of them treat both private and public patients, but recently, integrated multidisciplinary teams have been developed to facilitate the provision of services at the community level and reduce the dependency of the system on secondary care services. Out of the 519 planned Primary Care Teams, including a range of health professionals from GPs to nurses, 348 teams were, in March 2011, at an advanced functioning stage (HSE, 2011).

The public hospital sector incorporates voluntary and HSE hospitals, further distinguished into regional, county and district hospitals. Beds within hospitals may be designated for either public or private use, with the latter usually accounting for 20% of all beds. HSE hospitals are funded directly by the government, via the HSE, according to the NSP. Public voluntary hospitals, of which there are about 29, mostly established by religious orders and philanthropic groups, are primarily financed by the government but may be owned and operated on a non-profit basis by other organisations. There are also some 20 private hospitals.

Those ‘ordinarily resident’ citizens with Medical Card/Category I status, granted according to income levels and representing about one third of the population, are entitled to most services free of charge. Those without such status make upfront payments for both hospital and primary care services, unless they have the right to benefit from other exemption schemes. Some of these upfront costs may be covered by private health insurance, currently taken out by about 50% of the population, mostly with the Voluntary Health Insurance Board that has a 75% share of the voluntary insurance market. All health insurance schemes provide open enrolment with lifetime cover, with a premium depending on the insurance package but not on age or health status.

Health inequalities are an issue. Among the instruments developed to tackle inequities is the National Treatment Purchase Fund which allows public patients who have waited for over two months for treatment to obtain, at public expense, treatment in the private sector either in Ireland or abroad.

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Finance and health care expenditure The health care system is predominantly tax-funded (78.3% in 2006), the remaining components of total health expenditure being from private sources such as upfront payments for services (approximately 13% of all health care costs) and payments to private health insurance providers (8%). Taxation is nonearmarked, collected at the national level and includes VAT, income tax, corporation tax, and excise duty, overall accounting for 86% of total net tax receipts; ‘the remainder is made up of customs, agricultural levies, capital gains and acquisitions, and stamp duty on property sales’ (WHO, 2009).

The hospital sector accounts for approximately 50% of health expenditure.


- DoHC website

- HSE (2011), Fact Sheet on Primary Care Teams, March 2011

- McDaid D. et al. (2009), Ireland: Health system review. Health Systems in Transition, 2009; 11(4): 1 – 268. European Observatory on Health Systems and Policies.

ITALY Main characteristics of the Italian health care system ►Highly decentralised to regional authorities ►Providing nearly universal coverage mostly free of charge at the point of service ►Mainly public financing of health care – out of national and regional taxation ►Mixed service provision – public and private Structure of the system and responsibilities The National Health Service is organised into three levels: national, regional and local. At the national level, the Ministry of Health is responsible for ensuring the right to health by citizens as defined in article 32 of the Constitution. The Ministry of Health guarantees equity, quality and efficiency of the NHS and, along with a monitoring role, promotes improvement actions, innovation and change. The central Government is responsible for setting the ‘minimum level of health assistance’ (livelli essenziali di assistenza sanitaria – LEA), i.e. the services the NHS is obliged to deliver to all citizens for free or upon the payment of a contribution (‘ticket’).14 Additionally, it allocates health care resources to regional governments according to ‘Health Pacts’ agreed upon by the Government, the regions and the two autonomous Provinces of Trento and Bolzano. The Health Pact 2010-2012 provides for the contribution by the government of 104,614 million EUR for 2010, 106,934 million EUR for 2011 and an equivalent amount increased by 2.8% for 2012.

The 20 Regional Authorities and the two autonomous Provinces of Trento and Bolzano bear responsibility for the governance and organisation of all activities related to health care and health service delivery. The regional level has legislative, administrative, planning, financing and monitoring functions.

Executive functions are based on 3-year regional health plans. Regional Authorities are responsible, among other things, for: allocating resources to Local Health Enterprises (Aziende Sanitarie Locali - ASLs) and public hospital More than 5,700 assistance types and services are defined with regard to prevention, care and rehabilitation.

enterprises (AOs - Aziende Ospedaliere); defining criteria for accreditation of private and public health care entities; appointing general managers of ASLs and public hospitals; defining the regulatory framework of operation of ASLs and public hospitals; and defining the technical and management guidelines for the provision of services. Since regions set their health policy independently, their level of involvement in the direct management of health services varies greatly; for example, the hospital beds directly managed by the regional level may range from over 60% to less than 1%.

Delivery of services As of October 2009, delivery of services at the territorial level is through a network of some 184 Local Health Enterprises. ASLs are public entities with an autonomous entrepreneurship role for their organisation, administration, accountancy and management. Services are delivered through accredited public or private structures. Public structures include hospitals directly administered by the ASL (‘Presidi ospedalieri’) and public hospital enterprises (AOs), i.e. independent entities, usually with a regional or interregional catchment population, with autonomous management and purchasing power, including ‘research hospitals’.

General practitioners have a gate-keeping function within the NHS. Primary care is provided by GPs, paediatricians, and self-employed and independent physicians, who are paid a fee based on the number of people (adults or children) registered with them. Specialist care is provided either by ASLs or by accredited public and private facilities with which ASLs have agreements and contracts. Specialist care may be accessed through a referral by GPs or, for some services such as dental care, directly through a centralised booking system.

Hospital care is delivered through some 669 public facilities providing both outpatient and in-patient services, or through some 559 private hospitals contracted by ASLs.

Pharmaceutical care is regulated by the Italian Agency of Pharmacy (AIFA), which deals with licensing, monitoring, pricing, and drug reimbursement. Drugs can be delivered directly by ASLs or pharmacies spread all over the territory.

Pharmacies may be public or private, with revenues going to the pharmacy’s owner.

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Finance and health care expenditure Health care is mainly financed by earmarked taxes applied at the regional and national level. Direct taxes include (i) IRAP, a regional corporation tax levied nationally but mostly (90%) allocated back to the regions where it is levied, imposed on the value added of companies and on the salaries of public sector employees, and (ii) ‘additional IRPEF’, a regional tax imposed on top of the national personal income tax. Indirect taxes include a share on VAT and petrol excise. Additionally, ASLs rely on revenues from the purchase of services and over-the-counter drugs and from co-payments by patients for pharmaceuticals, diagnostic procedures and specialist visits.

Public funding accounts for about 70% of total health care expenditure and private insurance companies (non-public funding) account for about 11%.

Upfront payments and co-payments account for the remaining part of expenditure (approximately 19%). Voluntary health insurance does not play a significant role in funding.


- Italian Ministry of Health website

- Lo Scalzo A. et al. (2009), Italy: Health system review. Health Systems in Transition, 2009; 11(6)1-216. European Observatory on Health Systems and Policies

- Corte dei Conti, Sezione Regionale di Controllo per la Lombardia (2010), Relazione sulla Spesa Sanitaria Regionale.

LATVIA Main characteristics of the Latvian health care system ►Centralised, with an important role played by the newly established Health Payment Centre ►Coverage is based on residence and is often dependent on the payment of fees or contributions ►Mainly public and private financing of health care – out of general taxation and upfront payments ►Mixed service provision – public and private Structure of the system and responsibilities At the central level, the Ministry of Health (MoH) bears the main responsibility for the development of national health policies and regulations. Local governments, that were initially given broad responsibilities in both the financing and provision of health services, are now mainly responsible for ensuring access to health care services. Local governments own hospitals and clinics but in several cases these are rented out or have become self-managing health centres and institutions.

Subordinated to the Ministry of Health is the Health Payment Centre that, since late 2009, has replaced the functions of the Compulsory Health Insurance State Agency. The Centre is responsible for ‘realizing and implementing state policy for the availability of health care services, as well as for administering the state budgetary funds prescribed for health care’ (MoH website);, its functions include administration of the state budget, the purchase of services (selection, conclusion of agreements, maintenance of a registry of providers), making payments to service providers, and supervising expenditure. The centre has five territorial units : Riga, Kurzeme, Latgale, Zemgale, and Vidzeme.

Delivery of services Health care is provided on the basis of residence, regardless of citizenship, according to a list of benefits and through state, municipality and private inpatient and outpatient health care institutions.

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