1. Health Care Systems in the World Assoc. Prof. JP van Dijk MD PhD Dept. of Community and Occupational Medicine University Medical Centre Groningen University of Groningen The Netherlands

2. Health Care Systems in the World Assoc. Prof. Jitse P van Dijk MD PhD Senior Lecturer ‘Social Determinants of Health’ Olomouc University Society & Health Institute Palacky University Olomouc Czech Republic

3. Health Care Systems in the World Assoc. Prof. Jitse P. van Dijk MD PhD Scientific Director Graduate School Kosice Institute for Society and Health Medical Faculty Safarik University, Košice Slovak Republic

4. Outline 1Types of Health Care Systems 2Financing Health Care Systems 3Financing Elements of the System 4Access to the System 5Public vs Private 6Transition

5. Organisation / Complete Chaos?

6. As many systems as countries? In the world some 180 countries exist Do also 180 health care systems exist? Or can some main types be distinguished?

7. Organisational types - simple Take home message: international: rather simple; just a few choices national: within the borders of the typology financial- economical compromises determine its appearance

8. Types of Health Care Systems: 1 1Shemashko systems: (Shemasko the first MoH in the first Lenin government) eg: Russia, former Central-Europe (1948-1990) Central Government - most important planner HC, had a monopolist position regarding - financing HC and - implementing HC

9. Types of Health Care Systems: 2 2Beveridge systems: (Beveridge the MoH in the Labour govt after 1945 in the UK) eg the UK, Sweden, Finland, Spain Decentral government very important role in - planning HC - financing local / regional HC; Collecting finances via the central government

10. Types of Health Care Systems: 3 3Bismarck systems: (Bismarck was the German Chancellor about 1870) eg The Netherlands, Czech Republic, Slovakia, Belgium, Germany, France Health Insurance Companies [subtypes: public / private] have a major role in - financing health care provides - reimbursing costs patients made - collecting premiums [- planning HC] Decision height premiums: central government / HIC

11. Types of Health Care Systems: 4 4Free market ‘system’: USA (not fully: Medicare (old), Medicaid (low income); recently Obamacare), developmental countries (also mixed systems: not / not good functioning public system + in cities a well functioning free market system for those who can afford)

12. Types of Health Care Systems: 5 In all countries in the meantime is urgent: * the necessity for cost containment and * system reorganisation. NB: the more unplanned, the more expensive (too many HC provisions) the more planned, the more client unfriendly (monopolies)

13. Financing Health Care - 1 Taxes government aimed for all government expenditures competition with other expenditures Premium non-govt org: insurance company aimed for certain expenditures no competion with other expenditures ‘Free’ government competition with other expenditures

14. Financing Health Care - 2

15. Financing Health Care - 3 Co-payments Combination possible with taxes, premiums and ‘free’ health care Under-the-table payments Where professionals earn too little (not only money, also goods or labour) or where HC provisions (like hospitals) are very poor

16. Financing the System’s Elements Individual HC providers Fee for service (amount per service) Capitation fee (amount per patient) Salary

17. Financing the System’s Elements Institutional HC providers Expenditures / Bed days, afterwards (NL hospitals before 1982; SK<2014) Budget (NL hospitals till 2005) Diagnosis Related Group (USA, Hungary, NL DBC >2005; SK >2014 ‘budget per diagnosis’)

18. Systems: pro’s & cons Cons: (fee for service; expenditures afterwards) - Quantity instead of Quality -Production (Capitation fee) - Referrals to Hospital Pro’s: (Capitation fee, salary) - simple, predictable (fee for service) - Performance is directly rewarded

19. Optimal payment system? Aim optimal payment system: - optimal care for patients - optimal cost containment In practice: * not too many and not too few services * not too many and not too few referrals * optimal quality of services provided Does such a ‘Holy Grail’ exist?

20. Optimal payment system? Optimal payment could be a combination of: - fixed amount per patient (capitation fee) - fee for service

21. Access to the System Lay referral system * enter after own decision the system everywhere Gatekeeper system * enter the system only after referral

22. Access to the System Lay referral system * The patient can enter the system anywhere, even when he is not ill * may lead to unnecessary use of health care services * loss of time when patient goes to the wrong specialist * nobody has a complete overview of the patients history

23. Access to the System Gatekeeper system * patient can enter the system in one place, mostly via the General Practitioner * the GP decides whether the patient has to go to the hospital, and to which specialist * loss of time when General Practitioner makes a wrong decision * the General Practitioner has a complete overview of the complete patients history

24. Public vs Private Health Care Provider PublicPrivate Source Of Money PublicAB PrivateCD

25. Public vs Private - NL Health Care Provider PublicPrivate Source Of Money PublicNL (prevention: eg standard vaccinations) GB (NHS) NL (most) Insurance based systems PrivateNL (prevention for trips to tropical countries) NL (Plastic surgery)

26. Public-Private – CZ, SK<1990 Health Care Provider PublicPrivate Source Of Money PublicCZ, SK (most of the HC system) Private

27. Public-Private – CZ, SK > 1990 Health Care Provider PublicPrivate Source Of Money PublicCZ, SK (part of the HC system) CZ, SK (part of the HC system) Private

28. * Central Europe: Replace the state organised / state financed system by an insurance based system. (‘Back to Bismarck’ as before 1950). * Western Europe: More cost containment. Some countries (like NL) by using market incentives in the public system; some other countries (like D) by introducing more government into their system. Transition

29. Aspects of Accessibility After transition, accessibility to the system changes. Criteria: * Equality * Equity * Accessibility: Physical / Geographical / Financial * Health Gain: Lower morbity & mortality / Better QoL * Solidarity

30. Organisational types - simple Take home message: international: rather simple; just a very few choices national: within the borders of the typology financial- economical compromises determine its appearance

31. Thank you for your attention!

32. QUESTIONS??