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Health Care System
Health care systems are designed to meet the health care needs of target populations. There are a wide variety of health care systems around the world. In some countries, the health care system has evolved and has not been planned, whereas in others a concerted effort has been made by governments, trade unions, charities, religious, or other co-ordinated bodies to deliver planned health care services targeted to the populations they serve. However, health care planning has often been evolutionary rather than revolutionary.
Goals
The goals for health systems, according to the World Health Report 2000 – Health systems: improving performance (WHO, 2000), are good health, responsiveness to the expectations of the population, and fair financial contribution. Duckett (2004) proposed a two dimensional approach to evaluation of health care systems: quality, efficiency and acceptability on one dimension and equity on another.
Providers
Health care providers are trained professional people working self-employed or as an employee in an organization, whether a for-profit company, a not-for profit company, a government entity, or a charity. Organisations employing people providing health care are also known as health care providers. Examples are doctors and nurses, dentists, medical laboratory staff, specialist therapists, psychologists, pharmacists, chiropractors, and optometrists.
Financing
There are generally five primary methods of funding health care systems:
- direct or out-of-pocket payments,
- general taxation,
- social health insurance,
- voluntary or private health insurance, and
- donations or community health insurance.
Most countries systems feature a mix of all five models. One study [5] based on data from the OECD concluded that all types of health care finance “are compatible with” an efficient health care system. The study also found no relationship between financing and cost control.
The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected health care expenses. Similar benefits paying for medical expenses may also be provided through schemes organized by the government and funded through contributions from users.
By estimating the overall cost of health care expenses, a routine finance structure (such as a monthly premium or annual tax) can be developed, ensuring that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, most often either a government agency or a private or not-for-profit entity operating a health plan.
Many forms of commercial health insurance control their costs by restricting the benefits that are paid by through deductibles co-payments coinsurance, policy exclusions, and total coverage limits and will severely restrict or refuse coverage of pre-existing conditions. Many government schemes also have co-payment schemes but exclusions are rare because of political pressure. The larger insurance schemes may also negotiate fees with providers.
Many forms of government insurance schemes control their costs by using the bargaining power of government to control costs in the health care delivery system. For example by negotiating drug prices directly with pharmaceutical countries, or negotiating standard fees with the medical profession. Government schemes sometimes features contributions related to earnings as part of a scheme to deliver universal health care, which may or may not also involved the use of commercial and non-commercial insurers. Essentially the more wealthy pay a little more into the scheme and to cover the needs of the relatively poor who therefore contribute a little less. There are usually caps on the contributions of the wealthy and minimum payments that must be made by the insured (often in the form of a minimum contribution, similar to a deductible in commercial insurance models).