Dating back to 1992, healthcare in Colombia is characterized by a managed competition model, where citizens may choose between one of the health insurance companies. Insurers are financed by premiums and tax revenues. Healthcare services are largely provided by private care providers, but there are also public hospitals. Access to secondary care is dependent on a GP referral and the insurer’s authorization. Remuneration of services (emergency care excepted) depends on a contract between provider and insurer. Services are usually contracted on a fee-for-services basis, in some areas a fee per capita is used. The Colombian healthcare system recently has made significant advances, for example regarding universal coverage (covering more than 95.6 per cent of the population). Some serious challenges remain, notably regarding a clearer delineation of the coverage, an increase of insurer’s financial sustainability and actual or potential anticompetitive behaviour.
The English National Health Service (NHS) is a taxpayer funded healthcare system established in 1948 and provides healthcare services to everyone who lives in the UK and remains free of charge at the point of use. Funding is largely allocated to 195 local Clinical Commissioning Groups (CCGs), clinically led statutory NHS bodies. At the time of referral, patients have a legal right to choose the provider. NHS-funded hospital care is provided by (135) acute trusts that are responsible for ensuring that high-quality care is provided. The private healthcare sector (with private healthcare insurance held by around 11 per cent of the population) is increasingly offering an equivalent range of services, including primary care. The NHS continues to perform well in international comparisons. However, recent developments – such as the increase of waiting lists, staff shortages and loss of efficiency – put the system’s original principles seriously to the test.
Isabelle Durand-Zaleski and Johan van Manen
The general goals of the French healthcare system are: full coverage, access without waiting lists and patient choice and satisfaction. Recent reforms have aimed to improve governance and increase transparency in the system, to contain expenditure without diminishing equity in access, and to improve geographical equity in access to care. The central government plays an important role in defining policy and has been increasingly involved in containing expenditure. Although the system was originally based on the Bismarck model of social insurance, France has moved towards a more centrally organized single-payer model. France has universal and compulsory coverage of healthcare costs for all residents. Coverage is provided by non-competitive social health insurance. Voluntary complementary insurance is available, offered mainly by not-for-profit mutual associations or provident institutions. 95 per cent of residents are covered through employers or vouchers. Private for-profit insurers offer complementary coverage for a limited list of services.
Katherine Polin, Wilm Quentin, Victor Stephani and Alexander Geissler
The German social health care system is the oldest in the world and coined the name of the Bismarck system of social health insurance. Germany’s healthcare system provides universal health coverage for a wide range of benefits, and health insurance has been mandatory for all citizens and permanent residents since 2009 through either statutory of private health insurance (SHI or PHI). In international terms Germany has a generous basket of benefits, one of the highest levels of capacity, and relatively low cost-sharing. In 2017, 89 per cent of the population were covered by one of the SHI’s sickness funds, while 11 per cent were covered by PHI. The introduction of quality improvement measures has started to address issues relating to the quality of care. The division between SHI and PHI remains a challenge for the German healthcare system, leading to inequalities, redundancies and obstacles to coordination.
John Lombard and Gerald O’Nolan
The Irish healthcare system is a tax payer system providing access to hospital services free of charge. However means tested charges may apply resulting in 30 per cent of the population having free access. All public hospitals – 48 in total, organized into seven different groups – are principally funded by the state. Since 2016, the traditional block grant – based payments has been partially replaced by activity-based funding. Payment in the private sector is exclusively by way of ‘fee-per-item’. Hospital consultants are entitled to carry out private practice in the public hospital up to a limit of 20–30 per cent of their total work. Around 46 per cent of the population have private health insurance, facilitating earlier access to services. Current proposals for systemic reforms aim to reduce access inequalities and envisage a shift from hospital-centric to primary and social care settings.
Johan van Manen
The general objectives of healthcare policy in the Netherlands can be summarized as accessibility, affordability and quality improvements. Set against the background of these three objectives, the Netherlands’ system of healthcare has undergone thorough-going reform over the past decade, in the areas of both long-term care and curative care. The aim of the Health Insurance Act was to introduce health insurance for all residents and it accords an important role to healthcare insurers. The insurers are responsible for ensuring efficiency and quality, rather than the government. Despite the reforms, affordability continues to require attention. We have seen an increase in waiting times which may indicate a capacity shortage, but also a lack of coordination across the sector and between the hospital sector and primary care services. As in many countries, the rising cost of (new) drugs is a problem.
Karl Harald Søvig and Harald Platou
In Norway, patients are entitled to emergency specialist healthcare and to necessary specialist healthcare, facilitated by (four) regional health enterprises. These are separate state-owned legal entities. Patients have a free choice between public providers and private – if contracted – providers. The regional health enterprises are partly funded through basic state funding and partly by services using Diagnosis Related Groups (DRG). Norwegian healthcare is, in general, provided by public entities. However, in recent years there has been an increase in private health insurance to more than 500,000 people (of a population of 5.2 million). New developments involve the application of public procurement rules for healthcare services which may lead to tensions regarding trust in new providers and with existing services; the collection and storage of health data creating dilemmas between privacy and monitoring of outcomes; and an increased emphasis on measures and financing aimed at prevention.
Alex van den Heever
The South African public health system is universally free at point-of-service for the entire population except for access to the hospital system, which is subject to a means test. Apart from significant regional differences, healthcare is marked by a division into public and private health insurance, the latter used by 15.6 per cent of the population. Doctors working in public hospitals are virtually all state employed, those working in private hospitals work are usually self-employed. Public hospitals are reimbursed on the basis of annual budgets, private hospitals are largely funded by fee-for-service payments. Proposals by the Competition Authority to address the private sector’s high levels of concentration have been developed, yet implementation is uncertain. Leaving aside the intrusion of racial segregation into South Africa's public policy, different population groups are increasingly being catered for and currently have a high degree of access to healthcare.