Social insurance for health service.

Implementation of social insurance for financing health services has yielded different patterns depending on a country's economic level and its government's political ideology. By the late 19th century, thousands of small sickness funds operated in Europe, and in 1883 Germany's Chancellor Bismarck led the enactment of a law mandating enrollment by low-income workers. Other countries followed, with France completing Western European coverage in 1928. The Russian Revolution in 1917 led to a National Health Service covering everyone from general revenues by 1937. New Zealand legislated universal population coverage in 1939. After World War II, Scandinavian countries extended coverage to everyone and Britain introduced its National Health Service covering everyone with comprehensive care and financed by general revenues in 1948. Outside of Europe Japan adopted health insurance in 1922, covering everyone in 1946. Chile was the first developing country to enact statutory health insurance in 1924 for industrial workers, with extension to all low-income people with its "Servicio Nacional de Salud" in 1952. India covered 3.5 percent of its large population with the Employees' State Insurance Corporation in 1948, and China after its 1949 revolution developed four types of health insurance for designated groups of workers and dependents. Sub-Saharan African countries took limited health insurance actions in the late 1960s and 1970s. By 1980, some 85 countries had enacted social security programs to finance or deliver health services or both.

Recent health system development in Poland and Hungary.

Before 1989, the health systems of both Poland and Hungary were fully socialist, with all resources being governmental. The total populations of these countries were entitled to comprehensive health services from regionalized networks of hospitals, polyclinics, and primary health stations. Preventive environmental and epidemiological services were provided through special small facilities. Since the termination of socialism in 1989, the Polish system has been largely unchanged, except for greater emphasis on primary health care. About 5 percent of polyclinics have been privatized. In Hungary, financing has been transferred to a Social Security Fund. Polyclinics have been absorbed by hospital outpatient departments, and patients may use them only on referral by a family doctor. Public health officers have a wider scope of responsibilities in their districts. Both health systems still stress equitable distribution of services to everyone.

The meanings of social medicine and public health.

The term "social medicine" has been marked by a great deal of confusion in the medical literature, in medical education, and in discussion of systems of health care. It has occupied diverse relationships to the term "public health", which this article will explore.

Public health principles and methods.

Author presents his views on the past and present problems of public health. Special attention is given to the differences in public health goals of industrialized and developing countries.

Higher education for public health leadership.

The primary health care approach to public health stresses recognition of economic, political, and social determinants of health. In practice, briefly trained community health workers provide people with education and health care, but they require sound supervision. Such tasks of leadership require higher education. This demands more schools of public health of independent status, as well as stronger departments of community medicine within schools of medicine. Independent schools of public health throughout the world are much stronger than preventive medicine departments in medical schools, as measured by full-time faculty, scope of teaching and research, and candidates enrolled. To train properly for leadership, such independent schools in the developing world should be multiplied by 12 times to meet the needs. Leadership requires basic preparation in the full scope of public health knowledge, along with skills of effective management.

Health care costs and financing in world perspective.

Expenditures for health services, as a percentage of national wealth (gross national product, or GNP), have been rising throughout the world. Data to quantify this trend are available for many industrialized countries. The share of health spending derived from governmental sources has also been increasing. Mandatory or social insurance has developed to support health services in 70 nations. While widely used for paying doctors on a fee basis or by capitation, in Latin America doctors are organized in polyclinics and paid by salaries. General revenues are used to support Ministry of Health programs. Among health expenditures, the largest share goes to hospitalization. Cost sharing by patients is widely used to control rising costs. World trends have promoted equity in health care delivery.

Prudence in international comparisons: insights for the United States from the Canadian health insurance experience.

Canadian social insurance for medical care started in the province of Saskatchewan in 1946, when conditions were very different from those in the United States today. The Cooperative Commonwealth Federation political party has no counterpart in the United States today. Voluntary insurance was weak in the Canadian priaries, but currently strong in the United States. The U.S. Medicare and Medicaid programs help elderly and poor people, but Saskatchewan lacked such programs. Separation of executive and legislative powers in the United States differs from unified powers in Canada. However, there are several similarities between the U.S. federation of states, and the Canadian provinces. The U.S. Democratic Party has a progressive wing. Voluntary insurance in the United States grew weaker in the 1980s. The U.S. health care crisis on costs today is equivalent to post-Depression conditions in Canada. Both countries are dominated by private fee-for-service medical care, but access to that care has been promoted by compulsory insurance laws in several U.S. states. Therefore, the United States could well emulate Canada by action of the states, which would lead eventually to federal action. Coverage should be universal, with limited benefits initially; gradually, benefits would be broadened.

Global health, national development, and the role of government.

In spite of extreme differences in health status between the more developed and less developed countries, trends of infant mortality and life expectancy show substantial improvements in both types of country between 1950 and 1980. These improvements may be attributed to three types of change: 1) socio-economic development with decolonization, increased industrialization, growth of gross domestic product, urbanization, the gains of women, and enhanced education; 2) cross-national influences due to greater international trade, the spread of technology, and widespread affirmation of human rights; and 3) national health system development through expanded governmental health programs. Further improvements will depend on greater strength in public sector health services rather than private sector services which aggravate inequities.

[A world perspective on social security systems]. / Perspectiva mundial de los sistemas de seguridad social.

A brief account of the main events in the history of National Health Insurance systems is presented, from its beginnings in the late 18th and early 19th centuries, with the creation of "sickness insurance" funds, to the patterns of its development in today's world.

National health systems as market interventions.

National health systems have developed in all countries; their features have been shaped largely by organized interventions in the free market of health service. Any health system can be characterized through analysis of five major components: (1) its production of resources, (2) organization of programs (including a residual private market), (3) sources of economic support, (4) modes of management, and (5) patterns of providing services. The diverse types of health systems in the world may be categorized in a matrix derived from two dimensions: (a) the economic level (four steps), and (b) the political ideology of the health system, scaled (also four steps) from highly entrepreneurial (minor market intervention) to socialist (nearly complete market intervention). Every national health system would fit into one of the 16 cells of this matrix, although positions change as a result of economic and political dynamics.