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This analysis of the Belarusian health system reviews the developments in organization and governance, health financing, healthcare provision, health reforms and health system performance since 2008. Despite considerable change since independence, Belarus retains a commitment to the principle of universal access to health care, provided free at the point of use through predominantly state-owned facilities, organized hierarchically on a territorial basis. Incremental change, rather than radical reform, has also been the hallmark of health-care policy, although capitation funding has been introduced in some areas and there have been consistent efforts to strengthen the role of primary care. Issues of high costs in the hospital sector and of weaknesses in public health demonstrate the necessity of moving forward with the reform programme. The focus for future reform is on strengthening preventive services and improving the quality and efficiency of specialist services. The key challenges in achieving this involve reducing excess hospital capacity, strengthening health-care management, use of evidence-based treatment and diagnostic procedures, and the development of more efficient financing mechanisms. Involving all stakeholders in the development of further reform planning and achieving consensus among them will be key to its success., (World Health Organization 2013 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

As health professionals in the United States consider how to focus health care and coverage to ensure better, more equitable patient and population health outcomes, the experience of Cuba's National Health System over the last 5 decades may provide useful insights. Although mutual awareness has been limited by long-term political hostilities between the United States and Cuban governments, the history and details of the Cuban health system indicate that their health system merits attention as an example of a national integrated approach resulting in improved health status. More extensive analysis of the principles, practices, and outcomes in Cuba is warranted to inform health system transformation in the United States, despite differences in political-social systems and available resources.

A brief overview of the Green Paper on the National Health Insurance (NHI) policy of South Africa is presented. It describes the intention of the NHI to ensure equity, address the inequalities presented by the current private and public health system and present an ambitious plan to change the face of the South African health care system over the next fourteen years. It provides the context of the currents system that provides the case for the change. It also provides some detail on the structure of the proposed new Re-engineered Primary Health Care system as well as the future financing of this bold new health care system for South Africa. The challenge will be in its implementation.

In August 2010 the Vaccine European New Integrated Collaboration Effort (VENICE) project conducted a survey to collect information on influenza A(H1N1)pdm09 vaccination policies and vaccination coverage in the European Union (EU), Norway and Iceland. Of 29 responding countries, 26 organised national pandemic influenza vaccination and one country had recommendations for vaccination but did not have a specific programme. Of the 27 countries with vaccine recommendations, all recommended it for healthcare workers and pregnant women. Twelve countries recommended vaccine for all ages. Six and three countries had recommendations for specific age groups in children and in adults, countries for specific adult age groups. Most countries recommended vaccine for those in new risk groups identified early in the pandemic such as morbid obese and people with neurologic diseases. Two thirds of countries started their vaccination campaigns within a four week period after week 40/2009. The reported vaccination coverage varied between countries from 0.4% to 59% for the entire population (22 countries); 3% to 68% for healthcare workers (13 countries); 0% to 58% for pregnant women (12 countries); 0.2% to 74% for children (12 countries). Most countries identified similar target groups for pandemic vaccine, but substantial variability in vaccination coverage was seen. The recommendations were in accordance with policy advice from the EU Health Security Committee and the World Health Organization.

Background: The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage., Methods: Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services., Results: The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care., Conclusions: The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.

Background: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage., Objective: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage., Design and Participants: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings., Main Measures: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator., Key Results: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047)., Conclusions: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Background: Massachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities., Objective: Since racial/ethnic minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities., Design: Cross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006-2008., Participants: Adults from Massachusetts (n = 36,505) and other New England states (n = 63,263)., Main Measures: Self-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities., Key Results: Overall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor., Conclusions: Achieving equity in health and health care may require additional focused intervention beyond health reform.

Objectives: Based on a recent patient survey from Taiwan, where there is universal health insurance coverage and unrestricted physician choice, this study examined the relationship between physician specialty and the quality of primary medical care experiences., Methods: We assessed ambulatory patients' experiences with medical care using the Primary Care Assessment Tool, representing 7 primary care domains: first contact (ie, accessibility and utilization); longitudinality (ie, ongoing care); coordination (ie, referrals and information systems); comprehensiveness (ie, services available and provided); family centeredness; community orientation; and cultural competence., Results: Having a primary care physician was significantly associated with patients reporting higher quality of primary care experiences. Specifically, relative to specialty care physicians, primary care physicians enhanced accessibility, achieved better community orientation and cultural competence, and provided more comprehensive services., Conclusions: In an area with universal health insurance and unrestricted physician choice, ambulatory patients of primary care physicians rated their medical care experiences as superior to those of patients of specialists. In addition to providing health insurance coverage, promoting primary care should be included as a health policy to improve patients' quality of ambulatory medical care experiences.

The World Health Organization Joint Report of 2007 (WHO/UNAIDS/UNICEF) estimated that in developing world economies, 2 million people with HIV/AIDS were being treated with antiretroviral drugs (ARVs) out of the 7 million needing treatment. The ongoing political and humanistic movement in Brazil highly relates to health care provision, especially to treatment of the HIV/AIDS epidemic. "Compulsory licensing" (patent breaking) was used by Brazil to manufacture and import HIV/AIDS drugs. The Brazilian government provided top-of-the-line antiretroviral drugs in the form of HAART (highly active antiretroviral therapy) to all needing treatment for HIV/AIDS. Subsequently, the international community found Brazil as an eager "poster child" in the universal access movement for HIV/AIDS drugs. However, can this program of justice and humanity in Brazil be feasible when applied to the HIV/AIDS epidemic in other developing world countries? It is worth exploring.

In this paper, we simulate several scenarios of the potential premium range for voluntary (supplementary) health insurance, covering benefits which might be excluded from mandatory health insurance (MI). Our findings show that, by adding risk-factors, the minimum premium decreases and the maximum increases. The magnitude of the premium range is especially substantial for benefits such as medical devices and drugs. When removing benefits from MI policymakers should be aware of the implications for the potential reduction of affordability of voluntary health insurance coverage in a competitive market.

America's health care system is characterized by rising costs, increasing numbers of Americans who lack health insurance coverage, and poor quality of health care delivery. The convergence of these factors is adversely affecting not only the health of Americans but also the ability of businesses to compete successfully in a global marketplace. AARP and other nonprofit organizations are collaborating with the private sector to have more people covered by health insurance and to educate them to make behavioral choices that prevent chronic disease and ultimately lower costs.

The collapse of the World Trade Organization's (WTO) Doha Round of talks without achieving new health services liberalization presents an important opportunity to evaluate the wisdom of granting further concessions to international investors in the health sector. The continuing deterioration of the U.S. health system and the primacy of reform as an issue in the 2008 presidential campaign make clear the need for a full range of policy options for addressing the national health crisis. Yet few commentators or policymakers realize that existing WTO health care commitments may already significantly constrain domestic policy options. This article illustrates these constraints through an evaluation of the potential effects of current WTO law and jurisprudence on the implementation of a single-payer national health insurance system in the United States, proposed incremental national and state health system reforms, the privatization of Medicare, and other prominent health system issues. The author concludes with some recommendations to the U.S. Trade Representative to suspend existing liberalization commitments in the health sector and to interpret current and future international trade treaties in a manner consistent with civilized notions of health care as a universal human right.

The 2006 Enthoven-inspired Dutch health insurance reform, based on regulated competition with a mandate for individuals to purchase insurance, will interest U.S. policy makers who seek universal coverage. This ongoing experiment includes guaranteed issue, price competition for a standardized basic benefits package, community rating, sliding-scale income-based subsidies for patients, and risk equalization for insurers. Our assessment of the first two years is based on Dutch Central Bank statistics, national opinion polls, consumer surveys, and qualitative interviews with policy makers. The first lesson for the United States is that the new Dutch health insurance model may not control costs. To date, consumer premiums are increasing, and insurance companies report large losses on the basic policies. Second, regulated competition is unlikely to make voters/citizens happy; public satisfaction is not high, and perceived quality is down. Third, consumers may not behave as economic models predict, remaining responsive to price incentives. Finally, policy makers should not underestimate the opposition from health care providers who define their profession as more than simply a job. If regulated competition with individual mandates performs poorly in auspicious circumstances such as the Netherlands, how will this model fare in the United States, where access, quality, and cost challenges are even greater? Might the assumptions of economic theory not apply in the health sector?

This study discusses basic health services in China. In this study common sense and international experience in establishing a high-performing health system were introduced. Five components are identified: basic qualified human resources for health; basic infrastructure; essential medicines; essential technology and procedures; and basic service pathways. Recommendations were presented based upon the Chinese situation. They are: increase public financing and lower private out-of-pocket payment for services; revitalize the functions of public facilities; merge different health financing schemes; co-ordinate public fiscal and pricing policies; prioritize public financing to preventive and primary healthcare; establish and strengthen the partnership between public and private facilities and insurance schemes; and re-organize the administrative system in health-based upon the rules of simplicity, unity, and efficiency., (© 2008 Blackwell Publishing Asia Pty Ltd and Chinese Cochrane Center, West China Hospital of Sichuan University.)

Discussion of universal healthcare is nothing new for US politicians or among reform advocates, policy experts, or the general public. Physicians, however, have been minor voices in the discussion. Their relative silence has been detrimental both to the public and to physicians themselves. We pose 3 arguments as to why physicians should support universal access grounded in medicine's own self-interest, arguments that are largely ignored in the current debate. These are: (1) the need for paying patients, (2) the need for a sense of self-esteem rooted in professionalism rather than commercialism, and (3) the urgency to affirm a public purpose for medicine by promoting the nation's health through universal care. Who has a stake in universal healthcare? Some groups, such as those lacking insurance, are obviously at risk and have a keen interest. Others, such as insured workers, have a less obvious but demonstrable concern. Arguments that urge adoption of an inclusive system typically focus on "healthcare horror stories" designed to evoke sympathy for the unfortunate persons whose lives are forever changed by unmet health needs or unpaid health bills. Our focus is different. We ask, regarding universal healthcare, "What's in it for physicians?" While the active support of doctors may not be a sufficient force to change the US system, it is probably a necessary one. At a minimum, universal coverage will be far less likely if physicians are opposed to it. Our aim here is to explore and discuss some of the reasons that should motivate active physician involvement in a more just and equitable system. We will discuss 3 reasons in particular. They are: (1) the need for paying patients; (2) the need to take pride in what one does--that is, the need to be nurtured by recognition of skillful professional performance in medical work, and not just rewarded monetarily; and (3) the importance of embracing a public purpose for medicine and thus engaging the trust and esteem of the population. We will examine each of these in turn, but first we will discuss briefly the other constituencies for universal coverage, since their reasons for supporting an inclusive system are often shared by doctors.

Background: Many argue that "free" medical care leads to unnecessary use of health resources. Evidence suggests that user fees do discourage physician use, at least by those of low socioeconomic status. In this study, we compare health care utilization and health among socioeconomic groups to determine whether people of low socioeconomic status see physicians more than would be expected given their health status., Methods: We examined the use of health care services (physicians and hospitals) by residents of Winnipeg, Manitoba, in 1999. The cost of physician services was drawn directly from the claims filed, and the cost of hospital services was estimated using the Case Mix Group and Day Procedure Group methods linked to resource intensity weights and Manitoba hospital costs. We used neighbourhood indicators of socioeconomic status from the 1996 census and measured health status by examining rates of premature mortality, acute myocardial infarction, hip fracture (1995-1999) and diabetes (1999). Using these measures, we compared health status and health care use of residents living in areas with low average household incomes with those living in areas with high average household incomes. All rates were age- and sex-adjusted across the groups., Results: The province spent 44% more providing hospital and physician services to residents of Winnipeg neighbourhoods with the lowest household incomes (820 dollars/person annually v. 596 dollars/person for residents of the neighbourhoods with highest household incomes). However, expenditures were strongly related to health status. The 70% of the population on which the province spends 10% of its health care dollars scored well on all health indicators, and the 10% of the population on which 74% of the dollars are spent scored poorly. In each expenditure group, those with lower socioeconomic status had poorer health. In the highest expenditure group, those with lowest socioeconomic status had 82% higher premature mortality rates (23.0 v. 12.6 per 100,000 population) and 53% higher hip fracture rates (5.5 v. 3.6 per 100,000 population) than those with the highest socioeconomic status. Despite their poorer health, in each expenditure group, residents of the neighbourhoods with the lowest household incomes incurred physician expenditures that were similar to those of residents of wealthier neighbourhoods., Interpretation: Most people use little health care; high-cost users are a small group of very sick people drawn from all neighbourhoods and all income groups. People living in areas with low average household incomes use fewer physician services than might be expected, despite their poor health status.

The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care--the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least 200 billion dollars annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage.

Background: Despite enormous public sector expenditures, the effectiveness of universal coverage for health care in reducing socioeconomic disparities in health has received little attention., Study Objective: s: To evaluate whether universal coverage for health care reduces socioeconomic disparities in health., Design: Information on participants of the 1990 Nova Scotia Nutrition Survey was linked with eight years of administrative health services data and mortality. The authors first examined whether lower socioeconomic groups use more health services, as would be expected given their poorer health status. They then investigated to what extent differential use of health services modifies socioeconomic disparities in mortality. Finally, the authors evaluated health services use in the last years of life when health is poor regardless of a person's socioeconomic background., Setting: The Canadian province of Nova Scotia, which provides universal health care coverage to all residents., Participants: 1816 non-institutionalised adults, aged 18-75 years, from a two stage cluster sample stratified by age, gender, and region., Main Results: People with lower socioeconomic background used comparatively more family physician and hospital services, in such a way as to ameliorate the socioeconomic differences in mortality. In contrast, specialist services were comparatively underused by people in lower socioeconomic groups. In the last three years of life, use of specialist services was significantly higher in the highest income group., Conclusions: Universal coverage of family physician and hospital services ameliorate the socioeconomic differences in mortality. However, specialist services are underused in lower socioeconomic groups, bearing the potential to widen the socioeconomic gap in health.

Child health care financing must maximize access to and ensure quality comprehensive child and maternal care. This policy statement replaces the 1993 policy statement, "Principles of Child Health Care Financing." Changes reflect new state and federal legislation that affect child health care financing. The principles outlined in the policy statement will be used to evaluate the changing structure of health care financing.