Friday 28 October 2016

How other health systems operate

The Irish healthcare system is unusual in that the State owns most hospitals here, writes Thomas Molloy

Published 27/10/2013 | 01:55

PATIENT CARE: The costs can vary greatly from country to country
PATIENT CARE: The costs can vary greatly from country to country

COMPARING healthcare systems is difficult. Some countries such as Britain and the Netherlands use one common system for the entire country. Others, such as Germany and the United States, rely more heavily on their federal structure and there are often large differences from region to region.

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Still, it is fair to say that the Irish system is unusual. Here, the State owns and operates almost all hospitals while also employing the vast majority of staff. Most other countries act as regulator and operate some sort of insurance scheme with varying degrees of success. Hospitals tend to be privately owned.

In a recent World Health Organisation health-care ranking, France came in first, while the Netherlands came 17th, the UK came 18th and Ireland 19th. Germany came in 25th while the US, scored 37th. Here's how they do it.


THE 65-year-old NHS is mostly free to everybody although it is no longer entirely free at the point of use. There are small prescription charges and quite a lot of dentistry is private, along with most spectacles and contact lenses . Long-stay hospital wards for the elderly have been replaced by means-tested social care.

The tax-funded NHS also remains relatively cheap at £120bn with public spending as a share of national income well below that of Ireland, France, Germany, the Netherlands, Canada, New Zealand or the US. Not everything is rosy, however. The UK's record for cancer survival rates is poor.


GERMANY'S system offers near-universal care by forcing everybody to have private, not-for-profit insurance. The state does not own or operate hospitals but does regulate them to ensure standards are high and costs are low. The system is financed by a payroll tax amounting to 14.9 per cent. Employees pay 7.9 per cent while employers pay the rest. Unemployment insurance pays the fees for those out of a job and the government pays to cover children, maternity benefits and home help.

The state keeps prices down by setting fixed payment rates for hospitals and bargaining collectively with drug companies. Wages are also much lower. German GPs earn around €65,000 a year. A GP typically gets €45 per patient per quarter, no matter how many visits they make. GPs are given fixed budgets for medicines. Hospitals spend far less on expensive machinery and invest heavily in rehabilitation programmes for stroke and accident patients.

There is a very limited private system, with around 25,000 people a year, out of Germany's 80 million, signing up. Anybody over 55 in the private system is barred from switching to the public system.


FRANCE spends more on healthcare than any other large country in the western world bar the US but usually comes close to the top in surveys of healthcare systems.

The financial crisis has forced cuts. Patients may no longer see any doctor they want for free and must now register with a single GP.

The French system is a complex mix of private and public financing. Everyone has access to the same basic coverage through national insurance funds, to which every employer and employee contributes. The government picks up the tab for the unemployed. Almost all French also buy supplemental insurance which reduces their out-of-pocket costs and covers extra expenses such as private hospital rooms, glasses, and dental care.

In France, the sicker you get, the less you pay. Chronic diseases, such as diabetes, and critical surgeries are reimbursed at 100 per cent. Cancer patients are treated free.

France excels in prenatal and early childhood care, with a network of health-care facilities, called Protection Maternelle et Infantile, to ensure that every mother and child receives basic preventive care. Children are evaluated by a team of private-practice paediatricians, nurses, midwives, psychologists, and social workers. When parents fail to bring their children in for regular checkups, social workers are sent to the home.


The DUTCH system is supposedly the model for Fine Gael's election promises of total reform here in Ireland.

The Dutch system was probably picked because it is a concrete attempt to solve previous problems including a two-tier private and public system along with an inefficient and complex bureaucracy and long waiting lists. The good news is that Dutch are happy with their new system and it was voted as the best health service in Europe in the 2008 and 2009 Euro Health Consumer Index .

Like many other European countries, the system offers universal medical care but the State avoids owning hospitals or employing staff. Instead, the government monitors quality and access. Unlike Germany, it does not control prices or capacity.

The system can seem strange to Irish eyes, however. Everybody is insured for "exceptional" or "catastrophic" medical expenses and the system covers the entire population for long-term care and mental health issues. The cost is paid by the employer. Patients make some co-payments for certain services such as psychotherapy, nursing home care and home care.

There is also a second compulsory sickness fund for everybody earning less than around €36,500 a year. Anybody earning more than this, about a third of the population, can take out private insurance and most do. Patients pay charges if they buy expensive drugs but the state will pay almost the entire cost of the cheapest drug that is clinically effective.


THE US system is in flux since the introduction of Obamacare and still varies greatly from state to state. Generalisations are difficult but perhaps the most extraordinary aspect is the cost; around 20 per cent of gross domestic product. After years of political wrangling, the complex law has extended insurance to about 30 million citizens who had previously had no insurance. Another striking aspect is the poor return on all this spending; Americans don't live particularly long even allowing for the large number of immigrants.

The central government does not levy any special taxes to pay for healthcare and provision is the responsibility of individuals in most cases. There is no equivalent of the HSE or a basic system open to all as a right but some states do offer basic healthcare to all. This means that pretty much everybody needs some sort of insurance. Until President Obama's reforms, many people without jobs were also without healthcare.

Most people have healthcare insurance which is linked to their jobs. Those in good jobs or those with good employers pay reasonable insurance and get good healthcare in return although many Americans live in dread because the small print of many health insurers can exclude all sorts of treatments.

Since the introduction of Obamacare in 2010, the US has a new system to help the poorest 10 per cent of the population which relies a complicated combination of taxes on the healthcare industry, subsidies to help people pay for coverage, and penalties for those who remain uninsured. The new system gives a basic free healthcare to any adult making less than $15,401 (€11,150) a year or families making less than $31,809 €23,000). Everybody else needs to pay into some sort of insurance pot.

Thomas Molly is Group Business Editor, Independent Newspapers

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