Pendanaan pelayanan

kesehatan: Sebuah
perspektif internasional
Who Pays? Who Benefits?
What values are reflected?

Umum pengalaman negara-negara

industri untuk lebih dari satu abad
lalu

Biaya penyakit adalah hasil dari gaji

yang hilang dari pekerjaan, bukan biaya
perawatan medis
Peningkatan kompetensi medis
Semakin tingginya ekspektasi konsumen
Peningkatan pemanfaatan pelayanan
medis
meningkatnya biaya

Common developments
a. Hampir semua negara-negara industri
menjamin sebagian besar biaya rawat inap
untuk sebagian besar warganya
b. Universalisme berkurang saat Anda
bergerak menjauh dari rumah sakit untuk
perawatan rawat jalan, barang medis, dll
c. Belanja publik mendominasi strategi
pendanaan
Sumber daya terkonsentrasi pada rumah
saki

Health systems main source of

financing

Taxes
Australia
France
Germany
Japan
U.K.
U.S.

Social
insurance
contributions

Private
insurance
premiums

Very different proposals for

government action
For example:
Bismarcks Germany: started with
health insurance for industrial workers
(1880s)
England: started with health insurance
for low income workers
In most cases, broader expansion part
of government action

More on government action

By 1940, no Western European country
was without a compulsory government
health insurance program
U.S. was late in the game (1965) with
Medicare
Australia was even later (1972) with
Medibank
Medicare

National Health Services

Access to health care is a right of citizenship or residence
Generally, characterized by/associated with:

General taxation funding

Universal coverage
Public ownership of health care facilities
Salaried medical professionals
Waiting lists
Some NHS include U.K., Australia, Denmark, Sweden, Italy,
Greece, Spain, Portugal

Small role for private health insurance

cover uncovered services, elective surgery, cost sharing

Nationalization always remains

incomplete!
Outside public hospitals, physicians in NHS
still mostly private contractors
Private hospital beds supplement public
Australia 25% private; U.K. 5% private

Some services not covered--prescriptions

drugs, dental, eyeglasses

Social insurance schemes

Social reflects public, collective,
compulsory aspects
Insurance reflects private,
individualistic and voluntary
Together, Social insurance means
publicly-mandated, though paid for and
provided by independent institutions

Social insurance schemes are

characterized by
Funding through payroll contributions
(mandated insurance premiums), usually
split between employer and employee
Entitlement language, direct linkage between
contributions and benefits
Limits to state intervention, preserves a
private sector
Some social insurance examples are
Germany, France, Japan, the Netherlands

Example: Germany
Archetypal social insurance system1st
in the world (Bismarck 1880s)
Compulsory health insurance--paid 1/2
employer, 1/2 employee
750 sickness funds
each is independent, self-governing unit
Sponsorship range from: local, company,
occupation

More on Germany
Benefits include income maintenance
Sickness funds contract directly with
providers
Hospital capital investment regionally
planned

Australia
Universal entitlement based on
citizenship/residency
General tax funding
Delivery system is public/private hybrid
Private insurance encouraged

U.S. hybrid system

How insurance schemes (private,
Medicare, Medicaid) pay providers is
beyond scope of talk, but it varies
significantly
On delivery side,
About of hospital beds are publicly
owned

What social values are

reflected through funding?

Access
Equity
Cost control (global)
Income protection (individual)
Efficiency (at macro and micro levels)
Including target efficiency (benefits flow to the
most financially or medically needy)

Freedom of choice
Innovation

Adequacy of access:
the right to health care
Access to health care as necessary to
general welfare of country
Along with education, police/fire protection

General welfare as necessary to individual

freedom and self sufficiency
General welfare as supporting economic
growth
As health spending makes up greater % of GDP,
this notion is less strong

Solidarity
In contrast to the individualistic (market)
notions of a right to health care and
individual freedoms and self-sufficient
Solidarityvery important notion in
European health care schemes
The mutual responsibility of citizens for the
health care of each other

Income protection
Without universal coverage, some
must bear the cost of care entirely
out of pocket
Remember: average per capita
spending ranges from $2249 - 6102, the
range is great

This is devastating to all but the

highest income and impacts the
unhealthy disproportionately

Equity
The ways in which health care is paid
for have a significant bearing on
questions of equity or fairness
Equity issues reflected in whether
payment is progressive, regressive,
proportional

Cost control
2 ideas here:
First, controlling total HC spending
public funding = public control
Second, controlling HC spending
relative to other national spending
priorities (education, safety)
General tax funding makes this
explicit

Choice
The essence of economic and social
freedom!
Made up of all of the following
The choice of doctor
The choice by a doctor about how she
wants to practice medicine
The choice of a health care system
The personal choice of how much to pay
for health care

More about choice

Competition is supposed to lead to
more satisfaction because there is more
choice
Consumers role in choosing between
providers is questionable in many areas
of the health system
Information on which to compare

Innovation
The market has been potent force
behind innovation and medical progress
Commercial creation of medical goods of
all kinds---drugs and devices
(medical progress has increased peoples
expectations and costs)

Resources
Medicine and the Market: Equity v.
Choice by Daniel Callahan and Angela
Wasunna (2006)
The Politics of Health in Europe by
Richard Freedman (2000)
www.oecd.org