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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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Voluntary actors also deliver health-related services; public-private partnerships are encouraged primarily in the establishment, operations and management of community homes for the elderly. It is in the care of the elderly that local authorities (local councils) may play a role.

Finance and health care expenditure The public health care system in Malta is funded through general taxation and national insurance paid by workers and employees, although the latter is not earmarked for health but goes to welfare services in general. The central government is both purchaser and provider of services. Public funding represented 78.1% of total health expenditure in 2005.

Care in private facilities is funded by private insurance, purchased on a voluntary basis, or upfront (direct) payments. Those joining a private scheme are, nevertheless, not allowed to exit the public system. Private health spending in Malta accounted for 21.3% of total health expenditure in 2005 (2.1% from private insurance and 19.2% from upfront payments).


- The Ministry of Health, the Elderly and Community Care website

- Greene N. (2010), Annual National Report 2010 - Pensions, Health and Long-term Care, Malta 2010

- WHO Europe (2009), Environment and health performance review – Malta

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


Main characteristics of the Dutch health care system ►Market-based, with an important role played locally by the municipal health services (GGDs) ►Nearly universal (99%) coverage through compulsory health insurance ►Mainly funded through compulsory income-related contributions and premiums paid to insurers ►Service provision is private, on the basis of a regulated competitive market Since 2006, with the entering into force of the Health Insurance Act, the introduction of a compulsory health insurance scheme has changed the role of the government in terms of health care. Its main task is now to ensure the functioning of a regulated competitive insurance market. Thus, responsibilities have been passed to insurers, providers and patients, while the government controls quality, accessibility and affordability of health care. Supervision and management of the system has been delegated to independent bodies. Insurance is compulsory (even though not all citizens are insured and some default, i.e. citizens do not pay their premium). Private health insurers compete for clients; they can negotiate with health care providers on cost, volume and quality of care; and they can make a profit. They are obliged to accept new applicants and cannot charge applicants differently based on different risk factors. The reform process, however, is still ongoing as stakeholders get used to the new roles. Within the reform, some responsibilities for home care have been delegated to municipalities.

The Ministry of Health, Welfare and Sport defines health policies; jointly with local authorities, it bears responsibility for public health services. To meet this responsibility, municipalities have established 29 municipal health services (GGDs - Gemeentelijk Gezondheidsdiensten), regionally organised, that are involved in the prevention, promotion, and implementation of youth health care;

additionally, since 2007, according to the Social Support Act, they are also partly responsible for the provision of long-term care, through home care services and the management of nursing homes. Municipalities set their own policies for the provision of care; accountability for implementation is only at the local level, a circumstance that may lead to inequalities in access to care depending on the municipality.

Delivery of services Patients are free to select their health insurer and providers, unless some restrictions are applied by the insurance package. There are two main types of arrangement between the insurer and the applicant: the ‘in-kind arrangement’, where services are paid in full but the choice of providers is restricted; and the ‘restitution arrangement’, where there is a free choice of providers but if the cost of services is above a certain maximum level of reimbursement, the difference is paid by the patient. Insurers are obliged to provide a basic health insurance package defined by the government; citizens may decide to complement this package with voluntary health insurance schemes.

Preventive care and in particular disease prevention, health promotion and health protection are delivered through municipal public health services (GGDs). GGDs’ tasks, as specified in the Public Health Act include: youth health care; environmental health; socio-medical advice; periodic sanitary inspections; public health for asylum seekers; medical screening; epidemiology; health education and community mental health.

With regard to primary care, all citizens are registered with a general practitioner practice. A very high percentage (96%) of contacts is handled within the general practice that is part of the basic health package provided by insurers.

Other primary care providers include physiotherapists, dentists, midwives, pharmacists, and psychologists. A gate-keeping system through the GPs is in place for accessing specialist and hospital care (with the exception of emergencies). Secondary care is provided in hospitals and in different types of ‘centres’ (independent treatment centres, top clinical centres and trauma centres). Hospitals are differentiated into general, academic and categorical hospitals, the latter focussing on specific forms of care or illness. In most cases, hospitals are non-profit corporations: ‘The public hospitals belong to the State’.16 Emergency care is provided through GPs, emergency wards and trauma centres. Finally, long-term care, also under the responsibility of municipalities, is provided by nursing homes, residential homes and home care organisations.

Pharmacies are public, hospital or general practice dispensers. Public pharmacies cover 92% of the population; general practice dispensers cover the remaining 8% and are important in rural areas. Pharmacies are going through an aggregation process; several are currently retail and chemist chains and pharmaceutical wholesalers.

HOPE online country profile – The Netherlands: latest information from 2007

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Finance and health care expenditure The Health Insurance Act refers to a basic health insurance scheme covering primary and secondary outpatient care, in-patient care and, up to the age of 18, dental care. The Exceptional Medical Expenses Act provides for long-term and mental care insurance. These two statutory insurances are funded through a combination of income-related contributions (levied from salary and/or social security payments and/or profit for entrepreneurs, and transferred to the Health Insurance Fund for further re-distribution to health insurers according to a riskadjustment system) and premiums (paid directly to the insurers).

Complementary private health insurance is purchased on a voluntary basis. The basic health insurance makes some 59% of the contribution-financed health care, the remaining 49% being attributed to long-term care insurance (2008 data).

Funding of the health system is mainly through compulsory contributions and premiums (66%), followed by private expenditure (14%, of which 10% comprised upfront payments and 4% voluntary insurance schemes) and state contribution (14%).

The Municipality Fund is contributed to by the central government. The fund is to allow municipalities to provide social care. Municipalities purchase care from organisations by means of public procurement, or provide those in need with a personal budget for their individual organisation of care. Municipal health care expenditure in 2007 was only 1.9% of total health care expenditure.


- Schäfer W. et al. (2010), The Netherlands: Health system review. Health Systems in Transition, 2010; 12(1):1–229. European Observatory on Health Systems and Policies

- Donders P. and van Riel S. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: The Netherlands. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.

POLAND Main characteristics of the Polish health care system ►Partially decentralised, with some competencies delegated to regional and local authorities ►Providing universal coverage through mandatory health insurance ►Mostly public funding - out of health insurance contributions and taxation ►Mixed service provision – public and private Structure of the system With the Health Care Institutions Act of 1991, the Ministry of Health became responsible for health policy, education and research; regional authorities became responsible for organising and financing tertiary care; and local authorities became responsible for primary and secondary care, the latter through county-level hospitals. The Ministry of Health also supervises the National Health Fund, directly accountable to the government, and shares responsibility for approving the Fund’s financial plan with the Ministry of Finance. The National Health Fund (NHF) is the institution responsible for the pooling of resources raised through the insurance scheme, for the provision of health care services to citizens, and for the funding of services and the reimbursement of medicines. The Fund has branches in all 16 regions, and offices at the local level.

The health insurance scheme is mandatory by law and universal. Farmers have also been included under the scheme’s coverage. Contributions are pooled into the NHF and represent the major part of revenue for health care expenditure.

Delivery of services The health insurance provides access to a range of services including prevention, diagnosis, medical treatment and outpatient care. Benefits not covered by the insurance are included in the so-called ‘negative basket’. There is free choice of doctors and of health care facility, as far as providers have contractual arrangements with the regional branches of the Fund; however, a referral from a physician is needed to access both specialist care and in-patient care.

Health care providers are contracted by the NHF and may be public or private. Providers include physicians, public and non-public health care facilities (hospitals and surgeries). Primary care is through a general practitioner.

Secondary care is delivered in facilities that may be owned by the State, regional or local authorities or private actors; ‘Healthcare institutions are autonomous in terms of the planning, regulation and management of their own services.’17

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Finance and health care expenditure The health care system is funded mainly from health insurance contributions and, to a lesser extent, from state and self-government budgets, used for paying the contributions of specific categories of people and for investments in public health care facilities. In 2005, social insurance contributions accounted for almost 57% of total health care expenditure, some 13% being still public contribution in the form of taxation. Private revenue was about 30% of the total health expenditure in 2005, mainly from upfront payments. Upfront payments still amounted to 24.3% in 2007.


- Ministry of Health website

- eHealth strategy and implementation activities in Poland. Report in the framework of the eHealth ERA project

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

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

PORTUGAL Main characteristics of the Portuguese health care system ► Regulated, planned and managed at the central level although the delivery of health care services has been structured at the regional level ►Guaranteeing universal coverage mostly free of charge at the point of service ►Mainly public financing of health care – out of general taxation ►Mixed service provision – public and private; various public and private ‘sub-systems’ complement the national system Structure of the system At the central level, the Ministry of Health is responsible for defining health policy and for the regulation, planning and management of the NHS. It also regulates and controls private health service providers.

Under the Ministry’s direct or indirect administration are several institutions and Regional Health Administrations (RHA): for the North, the Centre, Alentejo, Algarve, and Lisbon/Vale do Tejo. Each RHA is governed by a board that is accountable to the Minister of Health. These five administrations are responsible for managing the health system at the regional level, within their catchment area they: coordinate, guide and evaluate the implementation of the national health policy, taking into account the principles and directives contained in regional plans; coordinate health care provision; supervise the management of primary health care and of hospitals; interact with the private sector and other non-profit organisations and municipal councils. Municipal councils are involved in specific actions or project-based initiatives. Under the RHAs are health centres and hospitals. Further to Decree-law nº 28/2008, health care centres have been grouped into local organisations called ACES (Agrupamentos de Centros de Saúde) with functional units for the provision of family health care (USF Unidades de Saúde Familiares), community health care (UCC- Unidades de Cuidados na Comunidade), personalised health care (UCSP - Unidades de Cuidados de Saúde Personalizados), and public health coverage (USP Unidades de Saúde pública). Through these ACES, the management of health care provision is decentralised, although the role played by local authorities is minimal.

The National Health System is complemented by other public or private schemes or health ‘sub-systems’ through which health care is also provided.

These include ‘civil servants and other state employees’ health subsystems, health insurance and other private occupational subsystems, financed by employers and users contributions’ (ASISP, 2010).

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