RESUMO
The paper analyzes trends in contemporary health sector reforms in three European countries with Bismarckian and Beveridgean models of national health systems within the context of strong financial pressure resulting from the economic crisis (2008-date), and proceeds to discuss the implications for universal care. The authors examine recent health system reforms in Spain, Germany, and the United Kingdom. Health systems are described using a matrix to compare state intervention in financing, regulation, organization, and services delivery. The reforms’ impacts on universal care are examined in three dimensions: breadth of population coverage, depth of the services package, and height of coverage by public financing. Models of health protection, institutionality, stakeholder constellations, and differing positions in the European economy are factors that condition the repercussions of restrictive policies that have undermined universality to different degrees in the three dimensions specified above and have extended policies for regulated competition as well as commercialization in health care systems.
El artículo analiza las tendencias de reformas de salud contemporáneas -dentro del contexto de la crisis económica (2008)- en países europeos con sistemas universales de salud (modelos bismarckiano y beveridgiano) y discute las implicaciones para la universalidad. Se analizan las reformas de salud en España, Alemania y Reino Unido. Para la descripción de los sistemas de salud se utiliza una matriz comparativa de la intervención del Estado en la financiación, regulación, organización y prestación de servicios. Se examinan los efectos de las reformas sobre la universalidad en base a tres dimensiones: amplitud de la cobertura a la población; composición de la cesta de servicios; y nivel de cobertura con fondos públicos. La diversidad de modelos de protección en salud, instituciones implicadas, constelaciones de actores y la posición de esos países en la economía europea han condicionado el impacto de las políticas restrictivas en cada uno de ellos. Estas últimas afectaron a la universalidad en sus tres dimensiones, con diferente intensidad, y profundizaron políticas anteriores de competencia regulada y comercialización.
O artigo analisa tendências de reformas de saúde contemporâneas, em contexto de forte pressão financeira, resultante da crise econômica iniciada em 2008, em países europeus com sistemas nacionais de saúde (modelos bismarckiano e beveridgiano) e discute suas consequências para a universalidade. São analisadas reformas recentes na Espanha, Alemanha e Inglaterra. Para descrição dos sistemas de saúde, utiliza-se matriz comparativa da intervenção estatal no financiamento, regulação, organização e prestação de serviços. O exame das repercussões das reformas sobre a universalidade é realizado com base em três dimensões: amplitude da cobertura populacional; abrangência da cesta de serviços; nível de cobertura por financiamento público. Modelos de proteção em saúde, institucionalidade, constelação de atores e posição na economia europeia diferenciados condicionaram as repercussões das políticas restritivas. Elas afetaram a universalidade nas três dimensões, com distinta intensidade nos países, e aprofundaram políticas prévias de competição regulada e comercialização.
RESUMO
Since the mid 1970s the health policy in Germany has focused on cost containment - precisely reduction of employer's contribution for statutory health insurance (SHI). However political parties and the government have also changed their strategies to achieve this aim. The grown structures of SHI concerned with financing, provision and management remained unaltered till the early 90s. The 90s are marked by a broad transformation of the health sector. Regulatory instruments have been developed to create financial incentives for all stakeholders (sickness funds, health care providers, insured/patients) to reduce expenditure in health sector. The transformation process is marked by normative principle of taking stakeholders as economic subjects acting rationally. The article aims at evaluating the desired/undesired impacts of this paradigm shift, where solidarity is surpassed by competition, co-payment and privatisation. It shows where this paradigm change can be observed and which instruments have been used for its realisation. It is also given an analysis on the reaction of important stakeholders to this change. Finally, it is demonstrated ,by using examples of prevention and health promotion that the only focus on economic models doesnït allow health policy to adequately meet the challenges set upon it.