Health technology assessment in Switzerland

Switzerland has a mixed public and private healthcare system. All citizens are enrolled in compulsory basic health insurance. A 1996 law allows people to choose among different sickness funds and managed care plans. The federal government is empowered to act on important health issues, but the 26 cantons have prime responsibility in health care and social welfare. They have their own laws on health care, hygiene, hospitals, and social welfare. These laws are not harmonized. The system is complex, with a mix of public (mainly hospitals) and private (mainly doctors' offices) providers. The health services are decentralized. Ambulatory care was traditionally provided in doctors' offices, but the last decade has seen the development of centers for day surgery, group practices, and managed care plans. Decisions on placement, location, and extension of services are decentralized. The payment system is very complex. Current trends include global budgets, cost analyses, and prices related to patient categories. However, coverage policy is developed centrally and includes both traditionally established services and new technologies. New technologies are added to the list only after evaluation by the Federal Coverage Committee. The coverage process integrates health technology assessment (HTA). Coverage can be granted in stages, including limited coverage and temporary coverage. Technologies and coverage can be reevaluated on the basis of registries or assessment information. The structure of the Swiss healthcare system does not lend itself to the establishment of a national HTA program. However, recent moves include the development of a coordinating mechanism for HTA in Switzerland.     

Development of medical care technology. The case of Israel.

This article presents a survey of the public and private agencies and institutions providing health care in Israel and examines the degree and nature of the control that these bodies exercise over medical technology. The author demonstrates that while the Israeli government is highly centralized, the Ministry of Health is able to exercise only limited practical influence and is neutralized because of its circumscribed control of government funds. In addition, the Ministry of Health lacks standardized procedures for the assessment of prospective or existing technologies. The author notes that there has been a clear move toward a system to oversee the rational diffusion of technology and outlines several proposals for the future.     

Priorities in the Israeli health care system

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and to purchase medication; and, primary care is free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing.     

An integrated approach to health services and manpower development: the experience of Poland.

After World War II, a new socio-economic policy stimulated development of industry and the socio-economic reconstruction of Poland. One of the main objectives of the new social policy was to develop the national health service so that it was available to the whole population. The most important decisions made for the health services and health manpower development in Poland were the following: 1945 -- Ministry of Health appointed as superior body responsible for organization and administration of national health services; 1951 -- Medical and Pharmaceutical Faculties become Medical Academies under the administration of the Minister of Health. Medical schools for nurses, midwives, sanitary instructors, and allied health personnel placed under supervision of the Ministry of Health; 1954 -- Sanitary epidemiological services organized and State Sanitary Inspection Act passed; 1956 -- Industrial health service organized; 1960 -- Minister of Health and Social Welfare appointed and charged with the administration of social welfare as well as rehabilitation and employment of invalids; 1971 -- Medical care and medical aid made available free of charge for the entire population, including the rural population previously not covered by health insurance system. In the years 1946--1960, a tendency towards vertical centralization prevailed in the organization and administration of the health services. Subsequently, decentralization has dominated, with a tendency to integrate health services with the social services, especially at the provincial and county levels and, more recently, in the form of the Integrated Health Service Institutions at the local level.     

Public health manpower: an alternative model

The Bhore committee observed that "if nation's health is to be built, the health program should be developed on the foundation of preventive health work and that such activities should proceed side by side with the treatment of patients." The committee defined two categories of workforce: one for the personal care and the other for the public health namely, public health nurses and sanitary inspectors for public health and nurse, midwife, and pharmacist for personal care. Recommendations of successive health committees lead to amalgamation of personal care services and public health services. Single focus programs and amalgamation of different cadre of Grassroots staff lead to dilution of public health services and more focused on different program-based personal care services. To carry out public health services, we need a sufficiently knowledgeable, well-skilled and competent mid-level supervisory public health workforce who can support and strengthen the performance of the existing multipurpose workers. Increased understanding of the influence of different determinants on health and well-being and also scientific progress to combat the environmental and biological effects on health has widened the gap between the actual need of human resources and expanding public health services needs. Keeping in view of the above and meet the challenges, a 3-year course of Bachelor in Public Health is conceived by the Indian Academy of Public Health. Professional responsibilities expected from this new cadre of workforce are also discussed in this article.     

What health care services does the public want and who should decide? Ask them!

Most of the parties involved in healthcare decisions – governments, politicians, healthcare professionals, pharmaceutical companies, special interest groups – actively work to make their desires known. In Israel the public is part of the decision committee; in Germany health care decision are made more or less without the public being involved. In a recently published IJHPR article, Giora Kaplan and Orna Baron-Epel raise the question of how well acquainted senior decision makers in the Israeli health system are with the public’s priorities regarding the services being considered for inclusion in the public funding list. This commentary speculates about the reasons for the discrepancies found in that article between the decision makers’ and the public’s view. Furthermore, it reports on survey results from Germany about who should be part of the decision making committee and briefly touches upon the situation in other OECD countries. While public opinion may not be the determining factor, all authors advocate a strengthening of the public’s contribution to the health care decision making process, including steps to make decision makers aware of public priorities on an ongoing basis.     

The National Mental Health Plan in Chile: 10 years of experience]

Dealing with mental health problems is undoubtedly an increasingly important public health responsibility around the world. In Chile, because of the changes in the epidemiological profile of the population, the lifetime prevalence of mental and behavioral disorders has reached 36%. In response, the Ministry of Health of Chile, through its Mental Health Unit, prepared the National Plan for Mental Health and Psychiatry. The Plan establishes objectives, strategies, and steps to improve the well-being and mental health of Chileans. This piece describes the model of care for mental health and psychiatry used in Chile's public health care system, analyzes the main difficulties encountered and the achievements made in the 10 years that the Plan has been in place, and makes recommendations for improving the Plan. Over the 10-year period, the new model for mental health and psychiatry has managed to make a place for itself in the public health care system. Indicators show that the beneficiaries of the public health care system in Chile now have greater access to mental health services than before the new model of community care was established, have broader health care coverage, and receive better quality services.     

中国城市医疗卫生体系的去商品化研究:以北京市贫困人口为例

以社会福利制度的商品化和去商品化理论为依托,在对北京市四类贫困人群25个案及其所在社区居委会相关工作人员进行深度访谈的基础上,对北京市城市医疗救助制度、"一老一小"大病医疗保险、劳动年龄内无业居民大病医疗保险以及灵活就业人员医疗保险制度的去商品化效果进行了评估,并对城市贫困人口医疗保障制度的改善提出了合理性建议。     

Definition of the “Health Benefit Basket” in Poland

The subject of “health benefit basket” has been hotly debated for years among the Polish public, but until recently the debate has tended to be largely theoretical and abstract and therefore has lacked an effect on public policy. The situation changed in 2004, for two reasons: first the verdict of the Constitutional Tribunal invalidating the existing health insurance law and, second, Poland’s accession to the European Union. The first problem was solved in part by defining a list of specific exclusions in the law and a promise to establish an institution for health technology assessment. The second issue remains open, although to some extend it is being dealt with legally by regulations issued from the Ministry of Health on acceptable waiting times for health services.     

Public health expenditures: developing estimates for improved policy making.

The Public Health Foundation (PHF), under contract to the U.S. Department of Health and Human Services, Public Health Service (PHS), worked with federal, state, and local public health, mental health, substance abuse, and environmental agencies in nine states to develop and successfully test a methodology for estimating investments in essential public health services. Estimates from the nine-state sample revealed the predominance of personal health expenditures in the public health system. Of total state health care dollars, only 1 percent was spent on population-based health services by participating agencies. This pilot provides a rational starting point toward a uniform methodology for highlighting public health expenditures that may be critical in revealing the effects of a changing health care environment on the nation's health. In combination with other data, results are expected to lead to a more informed policy-making process.     

Health technology assessment in Ireland

Ireland's health system is primarily funded from general taxation and is publicly provided, although private health care retains a considerable role. It is a unique structure, a mixture of universal health service free at the point of consumption and a fee-based private system where individuals subscribe to private health insurance that covers some of their medical expenses. The recent history of the Irish health services saw consolidation of existing services and an expansion into new areas to adapt to changing practices and needs. There has also been a drive to extract maximum efficiency so as to maintain the volume and quality of patient services at a time of very tight financial constraints. Introduction of new health technologies continued to accelerate. New technologies tended to spread rapidly before systematic appraisal of their costs and benefits. When the state is involved in funding the public hospital system, acceptance of new technology is a matter for discussion between agencies and the Department of Health and Children. Decisions about spending annual "development funding" have generally not been based on careful assessment of proposals for new technology. In 1995, a healthcare reform put new Public Health Departments in Health Boards in a prime position in Ireland's health services organization. These departments now emphasize evidence-based medicine. While Ireland does not have a national health technology assessment (HTA) program, there are plans to form an advisory group on HTA in 1998. HTA is seen as a significant element of future health policy in Ireland.     

Strong government influence over the Israeli health care system has led to low rates of spending growth

Israel reformed its health care system in 1995. In contrast to many other developed nations, it has since experienced relatively low rates of growth in health spending, even as health outcomes have continued to improve. This paper describes characteristics of the Israeli system that have helped control rising costs. We describe how the national government exerts direct operational control over a large proportion of total health care expenditures (39.1 percent in 2007) through a range of mechanisms, including caps on hospital revenue and national contracts with salaried physicians. The Ministry of Finance has been able to persuade the national government to agree to relatively small increases in the health care budget because the system has performed well, with a very high level of public satisfaction. It is unclear whether this success in health expenditure control can be sustained because of growing signs of strain within the system, the rapid increase in nongovernment financing for health care services, and the growing prosperity of Israeli society.     

The political economy of health system reform in Israel

On June 15, 1994, the Israeli Parliament voted to enact the National Health Insurance bill (NHI). The bill marks the end of a process that lasted for virtually as long as Israel's almost 50 year history. Israel's attempts at health reform began long before the current spate of reforms in many Western countries. Faced with many of the same problems of access, equity and cost control common to many of its counterparts, Israel initiated a reform process based on the recommendations of a prominent State Commission of Inquiry into the Israeli Health System (the Netanyahu Commission) which reported to the Government in 1990.² The Commission's proposals were based on a diagnosis indicating that the major problems of the system stem from the lack of clarity regarding the rights of citizens to health care, the lack of a clear allocation of responsibility and accountability among government, insurance or sick funds, and providers in the system, and undue centralization of system operations. This diagnosis led to three major planks for reform: (1) enactment of national health insurance legislation granting a basic package of care to each citizen and hence bringing most of the system's finance under public auspices; (2) divesting the Government from the organization, management and provision of care; hence integrating the management of preventive and psychiatric services provided by the government with the primary and other services provided by sick funds, and granting financial and operational independence to at least government hospitals; and (3) restructuring the Ministry of Health. As is often the case in public policy, more consensus surrounds the diagnosis than the solutions. As a result, nearly four years of implementation efforts have only recently resulted in a major breakthrough. In this paper we make an effort to outline the inherent weaknesses of the Israeli health care system that have led to the crisis in the mid 1980s, summarize the recommendations of the State Commission for structural change in the system, and review the politics of implementing the recommended reforms.     

Utilization of pediatric health services in Jerusalem

The high rate of utilization of health services and rising health care costs in Israel, have prompted the need for reform of the health care system. Preventive and curative aspects of mother and child health care in Israel have traditionally been addressed by independent but parallel health systems. Prior to the pilot integration of these services, current patterns of utilization of health services by children during their first year of life, and determinants of use, were analyzed. Mothers of 651 children from five neighborhoods, representing the middle-low, middle and upper social class Jewish population were interviewed. Overall, a high degree of compliance with recommended visits to the preventive family health centers was found, with an average of eleven visits to the public health physician or nurse. The children also made an average of 12 visits to curative practitioners. Combined with all other health care consultations, these children averaged 26 health care visits in the first year of life. This pattern of frequent visitations, and its determinants, is discussed in context of the current framework of parallel health care systems. Multivariate analysis revealed that the birth order of the child was the key factor in determining the number of preventive visits, while the mother's perception of her child's health status held the major influence on the number of curative visits. No association between utilization of services and social class was discovered. Comparison of utilization patterns arising from this study with subsequent investigation of the planned integrated services allows for the assessment of the effects of a major change in the structure and delivery of pediatric services.H. Palti is Associate Professor, Head of Maternal and Child Health Unit, Department of Social Medicine, Hadassah Medical Organization, and Director, School of Public Health and Community Medicine, Hebrew University-Hadassah; Y. Neumark is instructor at the School of Public Health and Community Medicine, Hebrew University-Hadassah; M. Donchin is a member of the Department of Social Medicine, Hadassah Medical Organization; A.Y. Ellencweig is a member of the Department of Medical Ecology, Hebrew University-Hadassah.Acknowledgement: The research on Utilisation of health services was supported by Hadassah Medical Organisation, The Jerusalem Municipality, the Ministry of Health and the Labour Sick Fund. It is the first in a series of papers on the utilisation of health services. Part of this publication is based on the MPH thesis of Y. Neumark tutored by H. Palti.     

Access policies and utilization patterns in prenatal and child delivery care in Mexico

In Mexico, people utilize public, private and traditional health providers interchangeably and in contrast to official access policies. Access policies for prenatal and child delivery services are evaluated using data from the National Health Survey of 1988. The study documents significant coverage gaps on the part of public providers with respect to their potential coverage, and especially, large cross-utilization of social security, Ministry of Health and private providers by beneficiaries. Child deliveries in Mexico are attended by a physician in only 66% of cases. The percentages are 85% for social security affiliates, 53% for women within reach of IMSS-Solidarity services (a relief programme for the rural poor) and only 31% for women with official access to private or Ministry of Health care, or beyond the reach of services. Seventy-eight per cent of medical deliveries by women affiliated to social security occur at their pre-paid facilities, while 14% deliver at extra cost with private physicians, contributing to 32% of deliveries so offered. Even though only 7% of insured women deliver at Ministry of Health facilities, this amounts to 20% of the Ministry's relief offer. In all, only 66% of affiliates use social security delivery services. On the other hand, 36% of deliveries by non-insured women are cared for by Ministry of Health providers, and 39% by the private sector; 22% of such deliveries occur in social security institutions, amounting to 18% of these institutions' care offer. These results indicate a wide departure between policy and fact, and the working of distributive and redistributive forces that impinge on the quality and efficiency of health care. Open access to the reproductive health services of all public institutions, with coordination among them and private providers, is suggested as a possible solution.     

The integrating role of the Chair of Social Hygiene and Public Health Administration in working with public health authorities and institutions

An integrating role of the Chair of Social Hygiene and Public Health Administration in its work with public health bodies and institutions is described. The system of training of senior health staff is being analyzed. It is specified by direct needs of the applied health care system and professional and official instructions for public health administrators. This system of training assists in the intensification of the learning process due to the application of such methods as expert assessment, business games, etc. There are presented new forms of the joint work of the Chair with base curative and preventive institutions, city departments of public health and the Ministry of Public Health of the Kazakh SSR.     

The influence of health sector reform and external assistance in Burkina Faso

Despite health reform and increasing public investment in the health sector, utilization of curative health services, immunization coverage and patient satisfaction with the public health care system are steadily decreasing in Burkina Faso. It seems that the health care system itself is "ill". This paper examines the major symptoms associated with this illness. The central thesis suggests that any further improvement of health care performance in Burkina Faso will be subject to profound central reform in the area of human resources and financial management of the sector. Such a broad reform package cannot be achieved through the current project approach, but a sector-wide approach (SWAp) does not seem to be realistic at the present time. Policy discussions at a level higher than the Ministry of Health could be beneficial for achieving better donor coordination and increasing the commitment of the Ministry of Health to a sector-wide approach. Health sector reform issues and priorities and the role of international cooperation are reviewed and discussed.     

南京市基本公共卫生服务现状及均等化政策建议

新医改明确提出努力实现人人享有基本公共卫生服务均等化,从2009年起,逐步向城乡居民统一提供疾病预防控制、妇幼保健和健康教育等基本公共卫生服务。南京市基本公共卫生服务工作起步早,相关制度健全、管理规范,社区卫生服务的南京模式被国家卫生部推广。但南京市基本公共卫生服务城乡差距明显,与均等化目标差距较大。在审计实践的基础上,描述了南京市基本公共卫生服务现状,提出了实现均等化政策建议,旨在促进南京市基本公共卫生服务健康、持续发展。     

A reform proposal from 2019 aims to improve coordination of health services in Poland by strengthening the role of the counties

Numerous attempts have been undertaken over the past two decades to improve the coordination of health services in Poland. These have usually focused on specific groups of patients or conditions, usually encompassing various types of specialist care, with only a few initiatives including a wider range of health services or sectors. These efforts have not been helped by the fragmentation of responsibilities between the various levels of territorial self-government, which are the founding bodies for different types of public providers. In 2019, a new policy initiative of the Ministry of Health proposed the establishment of County Health Centres that would improve integration of primary health care with specialist outpatient care, inpatient care in the county hospitals (hospitals of the 1st reference level), and other services at the level of the county. This would constitute the so-called “core system of health security” and support reorientation of health services towards PHC and the community and away from specialist hospitals. With its focus on health promotion and disease prevention and tailoring provision to the needs of the local populations, the proposal resembles examples of population health models introduced in several other countries, and offers a chance to improve the allocation of resources and to reduce the persisting health disparities across the country.     

Wasteful use of financial resources in public hospitals in Turkey: a trend analysis

The Turkish health system is mainly financed by public sources such as taxes and premiums collected from workers. According to 2003 data, total health expenditures were 4.5% of the country's Gross Domestic Product. Currently, 56% of the system is financed by the Ministry of Health, and services are also provided by the Ministry. The main sources of finance among the Ministry of Health hospitals are general budget contributions made by the Ministry and revolving funds. The purpose of this study is to evaluate the financial conditions of those Ministry of Health hospitals that have revolving funds. The financial trends of 2514 hospitals were followed from 1996 to 2000, and financial statement analyses were conducted. The results of the study show that the Ministry of Health hospitals are not professionally administered for their financial situation and also that their financial resources are not used effectively. The hospitals had difficulty in collecting debts and had problems in cash returns. At the end of the study, policy suggestions are made for health care managers toward improving financial conditions in these public hospitals.