To what extent does current health policy hinder or facilitate health system resilience?
Health policies are fully aligned with the goal of achieving a resilient health system.
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Health policies are largely aligned with the goal of achieving a resilient health system.
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Canada
Public healthcare is the most popular social program in Canada and occupies a significant portion of provincial government budgets. Health Canada’s regulatory system aims to ensure the stability of critical supply chains. Public health units coordinate disease surveillance, though fragmentation across provinces persists.
Yet, Canada’s health system is generally considered quite resilient compared to many other countries. Canada’s single-payer universal healthcare system covers necessary medical services for the entire population, providing a baseline of access and helping manage public health crises. Healthcare is largely provincially managed, allowing for regional flexibility and adaptation. The federal Canada Health Act provides broad national standards that are not always strictly enforced. There is well-developed public health technology, surveillance systems, and expertise at all levels of government. Canada has an above-average number of hospital beds and doctors per capita compared to OECD countries. This provides a buffer during surges.
There are problems, however. Universal coverage facilitates resilience, as was amply shown in the case of access to medical services and vaccines during the COVID period. Preventive health investments, however, lag behind curative spending despite potential health system savings.
Data systems and technology infrastructure remain antiquated, slowing real-time monitoring. Healthcare policy data sharing among provinces is also weak. Cost control measures, such as competitive procurement, are often underutilized, allowing price inflation.
Rural and Indigenous communities experienced acute healthcare gaps during COVID and, beyond the pandemic, people in remote areas sometimes struggle to access care because they live so far from hospitals.
Shortages of nurses and family doctors, along with an aging health workforce, are all significant issues. Additionally, waiting lists for elective surgeries can be excessively long.
Many hospitals and facilities are outdated, and the lack of isolation capacity became an issue during COVID-19.
While Canada’s public system provides a good foundation, targeted investments and policy changes could help strengthen its capacity to handle crises and unforeseen shocks. Ongoing reform and innovation are likely needed to maintain and improve resilience (Alin et al. 2022).
Yet, Canada’s health system is generally considered quite resilient compared to many other countries. Canada’s single-payer universal healthcare system covers necessary medical services for the entire population, providing a baseline of access and helping manage public health crises. Healthcare is largely provincially managed, allowing for regional flexibility and adaptation. The federal Canada Health Act provides broad national standards that are not always strictly enforced. There is well-developed public health technology, surveillance systems, and expertise at all levels of government. Canada has an above-average number of hospital beds and doctors per capita compared to OECD countries. This provides a buffer during surges.
There are problems, however. Universal coverage facilitates resilience, as was amply shown in the case of access to medical services and vaccines during the COVID period. Preventive health investments, however, lag behind curative spending despite potential health system savings.
Data systems and technology infrastructure remain antiquated, slowing real-time monitoring. Healthcare policy data sharing among provinces is also weak. Cost control measures, such as competitive procurement, are often underutilized, allowing price inflation.
Rural and Indigenous communities experienced acute healthcare gaps during COVID and, beyond the pandemic, people in remote areas sometimes struggle to access care because they live so far from hospitals.
Shortages of nurses and family doctors, along with an aging health workforce, are all significant issues. Additionally, waiting lists for elective surgeries can be excessively long.
Many hospitals and facilities are outdated, and the lack of isolation capacity became an issue during COVID-19.
While Canada’s public system provides a good foundation, targeted investments and policy changes could help strengthen its capacity to handle crises and unforeseen shocks. Ongoing reform and innovation are likely needed to maintain and improve resilience (Alin et al. 2022).
Citations:
Allin, Sara, Sierra Campbell, Margaret Jamieson, Fiona Miller, Monika Roerig, and John Sproule. 2022. Strengthening Primary Care Key to Rebuilding Canada’s Crumbling Healthcare System. Toronto: University of Toronto.
Allin, Sara, Sierra Campbell, Margaret Jamieson, Fiona Miller, Monika Roerig, and John Sproule. 2022. Strengthening Primary Care Key to Rebuilding Canada’s Crumbling Healthcare System. Toronto: University of Toronto.
Denmark
There is a universal entitlement to healthcare for all citizens, regardless of economic circumstance. Services are offered “free of charge,” and elected regional councils have governed the sector since 2007.
The establishment of large centralized hospitals, as opposed to those administered regionally, has faced considerable contention. Issues such as unresolved problems with electronic patient records persist. The debate about bringing basic healthcare activities closer to the population through local healthcare centers is ongoing, and the government has taken steps in this direction.
Recently, there has been considerable public debate about the quality of hospital services. Rising medicine prices are putting pressure on the financing of healthcare. One recent priority has been cancer treatment, an area in which Denmark has been lagging behind comparable countries. The Commission on the Healthcare System in Denmark argues that the healthcare system faces three major challenges.
First, the system is confronting an aging population at the same time that the labor force is shrinking. This is expected to lead to a shortage of personnel at all levels in healthcare provision. Second, the commission argues there is insufficient communication across administrative levels responsible for care. When a patient leaves specialized treatment in a hospital, which is under the responsibility of the regions, information and care are lost in the handover to the municipalities. This is partly due to incompatible IT systems. Thus, the commission recommends that the system should be unified. Third, the commission finds significant differences in healthcare provision across regions, linked to the pattern that doctors are unwilling to settle in areas outside the bigger cities and towns (Commission of the Healthcare System in Denmark 2023).
The establishment of large centralized hospitals, as opposed to those administered regionally, has faced considerable contention. Issues such as unresolved problems with electronic patient records persist. The debate about bringing basic healthcare activities closer to the population through local healthcare centers is ongoing, and the government has taken steps in this direction.
Recently, there has been considerable public debate about the quality of hospital services. Rising medicine prices are putting pressure on the financing of healthcare. One recent priority has been cancer treatment, an area in which Denmark has been lagging behind comparable countries. The Commission on the Healthcare System in Denmark argues that the healthcare system faces three major challenges.
First, the system is confronting an aging population at the same time that the labor force is shrinking. This is expected to lead to a shortage of personnel at all levels in healthcare provision. Second, the commission argues there is insufficient communication across administrative levels responsible for care. When a patient leaves specialized treatment in a hospital, which is under the responsibility of the regions, information and care are lost in the handover to the municipalities. This is partly due to incompatible IT systems. Thus, the commission recommends that the system should be unified. Third, the commission finds significant differences in healthcare provision across regions, linked to the pattern that doctors are unwilling to settle in areas outside the bigger cities and towns (Commission of the Healthcare System in Denmark 2023).
Citations:
Commission of the Healthcare System in Denmark. 2023. “Challenges to the Danish Health Care System.” https://sum.dk/Media/638375378820897110/Sundhedsv%C3%A6senets-udfordringer-STRUK.pdf
Commission of the Healthcare System in Denmark. 2023. “Challenges to the Danish Health Care System.” https://sum.dk/Media/638375378820897110/Sundhedsv%C3%A6senets-udfordringer-STRUK.pdf
Finland
Health policies in Finland have led to significant improvements in public health, such as a decrease in infant mortality rates and the development of an effective health insurance system. Finnish residents have access to extensive health services despite comparatively low per capita health costs.
The Finnish healthcare system is based on public healthcare services to which everyone residing in the country is entitled. According to the constitution, public authorities must guarantee adequate social, health and medical services and health promotion for all. In other words, it is the constitutional duty of public authorities to provide equal access to high-quality healthcare and disease protection (EU Healthcare, 2020).
In Finland, municipalities were responsible for organizing and financing healthcare until the end of 2022. The responsibility was transferred to the regional level beginning in 2023. Healthcare services are divided into primary healthcare and specialized medical care. Primary healthcare services are provided at regional healthcare centers, while specialized medical care is usually provided at hospitals.
The aim of the social and healthcare reform of 2023 was to foster investment in digital infrastructure and utilize health data to monitor emerging threats and accurately assess public health matters. This progress is still hindered by the absence of a centralized patient register system used by all regions. The Social Insurance Institution maintains a database holding some patient information, but it is not comprehensively utilized by the regions.
The policies and regulations aim to ensure the availability of health products and services when and where they are needed, even in times of crisis, but many regions still fall short of this objective. This is reflected, for example, in the often-protracted waiting times for services.
Another significant goal of the health and social care reform was to implement measures to counteract the rising costs caused by an aging population and advancements in medical technology. These objectives will not be achieved soon. Instead, costs are expected to increase more than anticipated when the reform was planned.
The Finnish healthcare system is based on public healthcare services to which everyone residing in the country is entitled. According to the constitution, public authorities must guarantee adequate social, health and medical services and health promotion for all. In other words, it is the constitutional duty of public authorities to provide equal access to high-quality healthcare and disease protection (EU Healthcare, 2020).
In Finland, municipalities were responsible for organizing and financing healthcare until the end of 2022. The responsibility was transferred to the regional level beginning in 2023. Healthcare services are divided into primary healthcare and specialized medical care. Primary healthcare services are provided at regional healthcare centers, while specialized medical care is usually provided at hospitals.
The aim of the social and healthcare reform of 2023 was to foster investment in digital infrastructure and utilize health data to monitor emerging threats and accurately assess public health matters. This progress is still hindered by the absence of a centralized patient register system used by all regions. The Social Insurance Institution maintains a database holding some patient information, but it is not comprehensively utilized by the regions.
The policies and regulations aim to ensure the availability of health products and services when and where they are needed, even in times of crisis, but many regions still fall short of this objective. This is reflected, for example, in the often-protracted waiting times for services.
Another significant goal of the health and social care reform was to implement measures to counteract the rising costs caused by an aging population and advancements in medical technology. These objectives will not be achieved soon. Instead, costs are expected to increase more than anticipated when the reform was planned.
Citations:
Ministry of Social Affairs and Health. 2014. “Socially Sustainable Finland 2020. Strategy for Social and Health Policy.” http://alueuudistus.fi/en/social-welfare-and-health-care-reform
EU Healthcare. 2020. “Healthcare system in Finland.” https://www.eu-healthcare.fi/healthcare-in-finland/healthcare-system-in-finland/
Ministry of Social Affairs and Health. 2014. “Socially Sustainable Finland 2020. Strategy for Social and Health Policy.” http://alueuudistus.fi/en/social-welfare-and-health-care-reform
EU Healthcare. 2020. “Healthcare system in Finland.” https://www.eu-healthcare.fi/healthcare-in-finland/healthcare-system-in-finland/
Germany
Germany is investing in the digitalization of its health system. Sixteen percent of the €25.4 billion German Recovery and Resilience Plan is dedicated to healthcare investments. The funds are planned to be invested in the digital strengthening of public healthcare, hospital modernization, and more (OECD/European Observatory on Health Systems and Policies, 2023, p. 17ff.). Additionally, a public research data center for health (Forschungsdatenzentrum Gesundheit) is currently under construction. It will collect data from the statutory health insurances and use it for research, prevention, and better control of the health system. It will use artificial intelligence to collect and analyze data, optimize processes, and deliver data-supported diagnoses and therapy recommendations (Bundesministerium für Gesundheit, 2023a).
In Germany, it is mandatory to be insured in health insurance, either statutory or private. As a result, only 0.1% of Germany’s population is not part of health insurance. Additionally, Germany had the highest per-capita healthcare spending in the European Union, with more than €5,000 per person in 2021. Citizens’ direct payments for health services not covered by insurance were among the lowest in the EU at 12%, compared to an EU average of 15%. Furthermore, Germany has one of the lowest percentage rates of unmet needs for medical care in the European Union, with a rate lower than 1%. The share of medical consultations by phone increased during the COVID-19 pandemic but remains low compared to other EU countries (OECD/European Observatory on Health Systems and Policies, 2023).
Compared to other European OECD countries, the German health insurance system has one of the best coverage rates for medical treatments. Additionally, 76% of patients were able to secure a doctor appointment the same day or the next day the last time they needed medical care. This is the highest rate among all European OECD countries (Finkenstädt, 2017, p. 69ff.).
The number of surgeries conducted in Germany dropped during the Covid-19 pandemic; however, the decline was less severe than in other EU countries. This indicates that the health system was able to maintain its usual services during the crisis more effectively than the systems in other countries (OECD/European Observatory on Health System and Policies, 2023).
Hospitals face significant challenges due to labor shortages of nurses, caretakers, and doctors, as well as limited capacities, leading to inadequate patient care (Tagesspiegel, 2022). To address these issues, a reform of hospitals and their funding is planned. The reform aims to change the funding structure to ensure hospitals are economically sustainable, even with fewer patients than expected. Previously, funding was calculated based on the number of patients treated, which sometimes forced hospitals to discharge patients early. The reform seeks to ensure that decisions about patient treatment are based on medical rather than economic considerations (Bundesministerium für Gesundheit, 2023b).
As in other industrial countries, high demand and supply chain problems have caused temporary shortages in pharmaceuticals in recent years, prompting discussions on the need to reshore production to Europe and Germany. However, in typical years, the supply of drugs remains stable. In Europe, Germany leads in the rapid deployment of innovative pharmaceuticals (Pharma Fakten, 2023).
Between 1992 and 2020, spending on healthcare in Germany increased by an average of 3.6% per year, and the share of healthcare spending compared to the gross domestic product also increased (Bundeszentrale für politische Bildung, 2022). The insurance contributions are not sufficient to cover total healthcare expenses. In 2019, expenses exceeding €50 billion had to be financed by governmental grants (Statistisches Bundesamt, 2019).
In Germany, it is mandatory to be insured in health insurance, either statutory or private. As a result, only 0.1% of Germany’s population is not part of health insurance. Additionally, Germany had the highest per-capita healthcare spending in the European Union, with more than €5,000 per person in 2021. Citizens’ direct payments for health services not covered by insurance were among the lowest in the EU at 12%, compared to an EU average of 15%. Furthermore, Germany has one of the lowest percentage rates of unmet needs for medical care in the European Union, with a rate lower than 1%. The share of medical consultations by phone increased during the COVID-19 pandemic but remains low compared to other EU countries (OECD/European Observatory on Health Systems and Policies, 2023).
Compared to other European OECD countries, the German health insurance system has one of the best coverage rates for medical treatments. Additionally, 76% of patients were able to secure a doctor appointment the same day or the next day the last time they needed medical care. This is the highest rate among all European OECD countries (Finkenstädt, 2017, p. 69ff.).
The number of surgeries conducted in Germany dropped during the Covid-19 pandemic; however, the decline was less severe than in other EU countries. This indicates that the health system was able to maintain its usual services during the crisis more effectively than the systems in other countries (OECD/European Observatory on Health System and Policies, 2023).
Hospitals face significant challenges due to labor shortages of nurses, caretakers, and doctors, as well as limited capacities, leading to inadequate patient care (Tagesspiegel, 2022). To address these issues, a reform of hospitals and their funding is planned. The reform aims to change the funding structure to ensure hospitals are economically sustainable, even with fewer patients than expected. Previously, funding was calculated based on the number of patients treated, which sometimes forced hospitals to discharge patients early. The reform seeks to ensure that decisions about patient treatment are based on medical rather than economic considerations (Bundesministerium für Gesundheit, 2023b).
As in other industrial countries, high demand and supply chain problems have caused temporary shortages in pharmaceuticals in recent years, prompting discussions on the need to reshore production to Europe and Germany. However, in typical years, the supply of drugs remains stable. In Europe, Germany leads in the rapid deployment of innovative pharmaceuticals (Pharma Fakten, 2023).
Between 1992 and 2020, spending on healthcare in Germany increased by an average of 3.6% per year, and the share of healthcare spending compared to the gross domestic product also increased (Bundeszentrale für politische Bildung, 2022). The insurance contributions are not sufficient to cover total healthcare expenses. In 2019, expenses exceeding €50 billion had to be financed by governmental grants (Statistisches Bundesamt, 2019).
Citations:
Betanet. n.d. “Früherkennung von Krankheiten.” https://www.betanet.de/frueherkennung-von-krankheiten.html
Bundesministerium für Ernährung und Landwirtschaft. 2023. “Mehr Kinderschutz in der Werbung: Pläne für klare Regeln zu an Kindern gerichteter Lebensmittelwerbung.” https://www.bmel.de/DE/themen/ernaehrung/gesunde-ernaehrung/kita-und-schule/lebensmittelwerbung-kinder.html
Bundesministerium für Gesundheit. n.d. “Prävention.” https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/p/praevention
Finkenstädt. 2017. Zugangshürden in der Gesundheitsversorgung – Ein europäischer Überblick. https://www.wip-pkv.de/fileadmin/DATEN/Dokumente/Studien_in_Buchform/WIP_Zugangshuerden_in_der_Gesundheitsversorgung.pdf
OECD/European Observatory on Health Systems and Policies. 2023. Germany: Country Health Profile 2023, State of Health in the EU. Paris: OECD Publishing. https://doi.org/10.1787/21dd4679-en
Stiftung Gesundheitswesen. 2021. “Prävention: Der Mix macht’s.” https://stiftung-gesundheitswissen.de/gesundes-leben/kompetenz-gesundheit/praevention-der-mix-machts
Pharma Fakten. 2023. “Große Unterschiede in europäischer Arzneimittelversorgung: ‘Kein tragbarer Zustand’.” https://pharma-fakten.de/news/grosse-unterschiede-in-europaeischer-arzneimittelversorgung/
Betanet. n.d. “Früherkennung von Krankheiten.” https://www.betanet.de/frueherkennung-von-krankheiten.html
Bundesministerium für Ernährung und Landwirtschaft. 2023. “Mehr Kinderschutz in der Werbung: Pläne für klare Regeln zu an Kindern gerichteter Lebensmittelwerbung.” https://www.bmel.de/DE/themen/ernaehrung/gesunde-ernaehrung/kita-und-schule/lebensmittelwerbung-kinder.html
Bundesministerium für Gesundheit. n.d. “Prävention.” https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/p/praevention
Finkenstädt. 2017. Zugangshürden in der Gesundheitsversorgung – Ein europäischer Überblick. https://www.wip-pkv.de/fileadmin/DATEN/Dokumente/Studien_in_Buchform/WIP_Zugangshuerden_in_der_Gesundheitsversorgung.pdf
OECD/European Observatory on Health Systems and Policies. 2023. Germany: Country Health Profile 2023, State of Health in the EU. Paris: OECD Publishing. https://doi.org/10.1787/21dd4679-en
Stiftung Gesundheitswesen. 2021. “Prävention: Der Mix macht’s.” https://stiftung-gesundheitswissen.de/gesundes-leben/kompetenz-gesundheit/praevention-der-mix-machts
Pharma Fakten. 2023. “Große Unterschiede in europäischer Arzneimittelversorgung: ‘Kein tragbarer Zustand’.” https://pharma-fakten.de/news/grosse-unterschiede-in-europaeischer-arzneimittelversorgung/
Israel
Israel’s healthcare system is highly centralized and digitalized and operates mainly through four health funds. The high level of centralization and digitalization facilitated effective monitoring of COVID-19 outbreaks, as well as vaccination and response efforts.
Strategically, Israel’s healthcare system is based on the 1994 State Health Insurance Law, which aims to provide accessible healthcare to all Israeli residents. To ensure the continued expansion of healthcare services and technologies, a special intersectoral committee under the auspices of the Ministry of Health meets annually to decide on additions to the healthcare services “basket” available to the Israeli public.
One of the main challenges facing Israel’s healthcare system, which has been further exacerbated by the COVID-19 crisis and Israel’s war with Hamas since October 2023, is the availability and diversity of public mental health services. Both crises increased the need for mental health services and the system is struggling to meet the demand. A significant step toward addressing this issue involved providing special grants for psychologists in the public healthcare system to boost the availability of their services and encourage them to work in the public rather than the private sector.
To offset the costs of an aging population, the Ministry of Health has developed a strategic plan with measurable goals and indicators to monitor the health situation of elderly people and relevant services. Among the programs being implemented are collaborative initiatives with local authorities to promote healthier lifestyles among elderly people. In addition, health funds proactively monitor the health situation, detecting chronic diseases, and improving rehabilitation facilities and services.
Strategically, Israel’s healthcare system is based on the 1994 State Health Insurance Law, which aims to provide accessible healthcare to all Israeli residents. To ensure the continued expansion of healthcare services and technologies, a special intersectoral committee under the auspices of the Ministry of Health meets annually to decide on additions to the healthcare services “basket” available to the Israeli public.
One of the main challenges facing Israel’s healthcare system, which has been further exacerbated by the COVID-19 crisis and Israel’s war with Hamas since October 2023, is the availability and diversity of public mental health services. Both crises increased the need for mental health services and the system is struggling to meet the demand. A significant step toward addressing this issue involved providing special grants for psychologists in the public healthcare system to boost the availability of their services and encourage them to work in the public rather than the private sector.
To offset the costs of an aging population, the Ministry of Health has developed a strategic plan with measurable goals and indicators to monitor the health situation of elderly people and relevant services. Among the programs being implemented are collaborative initiatives with local authorities to promote healthier lifestyles among elderly people. In addition, health funds proactively monitor the health situation, detecting chronic diseases, and improving rehabilitation facilities and services.
Sweden
Several government initiatives aim to bolster the resilience of the Swedish healthcare system, including building a digital infrastructure and integrating the healthcare system into successful preparedness for crises or war. These efforts are set against the backdrop of scarce resources and an aging population that further strains these resources.
The first initiative regarding digital healthcare was adopted in 2006 and updated in 2016. The ehealth vision states that by 2025 Sweden will have the “best” digital healthcare in the world (e.hälsa 2024). Despite the ambitious goal of this vision, regions report that digital care is integrated into healthcare provision, with 75% of the regions currently using digital solutions. Self-monitoring is used by healthcare providers. However, people over 75 tend to use fewer digital services, and there is variation in the usage of such services among the foreign-born population. Regions are also exploring AI and how it could streamline healthcare (Socialstyrelse 2023a). Digital healthcare is also part of the “good and close-by” initiative, a collaboration between the state and the Swedish Association of Local Authorities and Regions (Regeringen 2023a).
The importance of healthcare as part of the total defense strategy has been highlighted in a recent commission of inquiry (SOU, 2020, 23), especially in light of recent geopolitical developments in the region. To ensure the functionality and resilience of healthcare systems during crises, policies and regulations specify how healthcare should be organized. The Health and Medical Services Act (2017:30) (Socialstyrelse 2023b) remains applicable during periods of heightened alert or war. The government aims to strengthen healthcare capacity through reforms and measures, such as implementing state subsidies for preparedness, which replace former agreements between the state and regions and municipalities (Government Offices, 2023a).
After the COVID-19 pandemic, a special investigation was appointed to analyze Sweden’s regulation of disease control to prepare for future pandemics (Regerigen, 2023b). It is the responsibility of the regions and municipalities to plan to maintain their functions in such times, and the Swedish Armed Forces are involved in coordinating the organization (SOU 2020, 23; Government Offices of Sweden, 2023b).
Sweden has an aging population, and the share of people who are 60 years or older has increased (SCB, 2022). Sweden is transitioning its healthcare system toward “good and close-by care,” which is seen as crucial to meet the needs of an aging population.
Funding remains a persistent issue in the Swedish healthcare system, particularly in the aftermath of the pandemic, especially regarding human resources. The government is expected to make a decision on further allocation of resources in 2024 (SKR 2024).
The first initiative regarding digital healthcare was adopted in 2006 and updated in 2016. The ehealth vision states that by 2025 Sweden will have the “best” digital healthcare in the world (e.hälsa 2024). Despite the ambitious goal of this vision, regions report that digital care is integrated into healthcare provision, with 75% of the regions currently using digital solutions. Self-monitoring is used by healthcare providers. However, people over 75 tend to use fewer digital services, and there is variation in the usage of such services among the foreign-born population. Regions are also exploring AI and how it could streamline healthcare (Socialstyrelse 2023a). Digital healthcare is also part of the “good and close-by” initiative, a collaboration between the state and the Swedish Association of Local Authorities and Regions (Regeringen 2023a).
The importance of healthcare as part of the total defense strategy has been highlighted in a recent commission of inquiry (SOU, 2020, 23), especially in light of recent geopolitical developments in the region. To ensure the functionality and resilience of healthcare systems during crises, policies and regulations specify how healthcare should be organized. The Health and Medical Services Act (2017:30) (Socialstyrelse 2023b) remains applicable during periods of heightened alert or war. The government aims to strengthen healthcare capacity through reforms and measures, such as implementing state subsidies for preparedness, which replace former agreements between the state and regions and municipalities (Government Offices, 2023a).
After the COVID-19 pandemic, a special investigation was appointed to analyze Sweden’s regulation of disease control to prepare for future pandemics (Regerigen, 2023b). It is the responsibility of the regions and municipalities to plan to maintain their functions in such times, and the Swedish Armed Forces are involved in coordinating the organization (SOU 2020, 23; Government Offices of Sweden, 2023b).
Sweden has an aging population, and the share of people who are 60 years or older has increased (SCB, 2022). Sweden is transitioning its healthcare system toward “good and close-by care,” which is seen as crucial to meet the needs of an aging population.
Funding remains a persistent issue in the Swedish healthcare system, particularly in the aftermath of the pandemic, especially regarding human resources. The government is expected to make a decision on further allocation of resources in 2024 (SKR 2024).
Citations:
Government Offices of Sweden. 2023a. “Socialtjänstens och hälso- och sjukvårdens beredskap ska styras och följas upp genom statsbidrag.” https://www.regeringen.se/pressmeddelanden/2023/06/socialtjanstens-och-halso–och-sjukvardens-beredskap-ska-styras-och-foljas-upp-genom-statsbidrag
Government Offices of Sweden. 2023b. “Vården ska fungera även i kris och krig.” https://www.regeringen.se/artiklar/2023/06/varden-ska-fungera-aven-i-kris-och-krig/
the Swedish Government Offices and SKR. 2023. God och nära vård 2023 - En omställning av hälso- och sjukvården med primärvården som nav, överenskommelse mellan staten och Sveriges Kommuner och regioner.
Regeringen. 2023. “Dir. 2023:106 Kommittédirektiv Stärkt beredskap inför framtida pandemier.” https://www.regeringen.se/contentassets/1e64598666634a1696621887508b6182/kom.dir.-starkt-beredskap-infor-framtida-pandemier-s2023_02169.pdf
Health and Medical Service Act. 2017. Source. 2017, 30.
SCB. 2022. “SCB publicerar stor kartläggning av Sveriges äldre.” Sveriges statistiska centralbyrå https://www.scb.se/pressmeddelande/scb-publicerar-stor-kartlaggning-av-sveriges-aldre/
SKR. 2024. “Viktigt besked om pengar till regionerna.” https://skr.se/skr/tjanster/pressrum/nyheter/nyhetsarkiv/viktigtbeskedompengartillregionerna.79344.html
Socialsyterelse. 2023a. Tillämpning av digital vård i regionerna - en kartläggning [Implementation of digital care in the regions]. Stockholm: The National Board of Health and Welfare.
Socialstyrelese. 2023b. Health and Medical Service Act (2017, 30) https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2020-1-6564-english.pdf
SOU. 2020, 23. Hälso- och sjukvård i det civila försvaret - underlag till försvarspolitisk inriktning.
Government Offices of Sweden. 2023a. “Socialtjänstens och hälso- och sjukvårdens beredskap ska styras och följas upp genom statsbidrag.” https://www.regeringen.se/pressmeddelanden/2023/06/socialtjanstens-och-halso–och-sjukvardens-beredskap-ska-styras-och-foljas-upp-genom-statsbidrag
Government Offices of Sweden. 2023b. “Vården ska fungera även i kris och krig.” https://www.regeringen.se/artiklar/2023/06/varden-ska-fungera-aven-i-kris-och-krig/
the Swedish Government Offices and SKR. 2023. God och nära vård 2023 - En omställning av hälso- och sjukvården med primärvården som nav, överenskommelse mellan staten och Sveriges Kommuner och regioner.
Regeringen. 2023. “Dir. 2023:106 Kommittédirektiv Stärkt beredskap inför framtida pandemier.” https://www.regeringen.se/contentassets/1e64598666634a1696621887508b6182/kom.dir.-starkt-beredskap-infor-framtida-pandemier-s2023_02169.pdf
Health and Medical Service Act. 2017. Source. 2017, 30.
SCB. 2022. “SCB publicerar stor kartläggning av Sveriges äldre.” Sveriges statistiska centralbyrå https://www.scb.se/pressmeddelande/scb-publicerar-stor-kartlaggning-av-sveriges-aldre/
SKR. 2024. “Viktigt besked om pengar till regionerna.” https://skr.se/skr/tjanster/pressrum/nyheter/nyhetsarkiv/viktigtbeskedompengartillregionerna.79344.html
Socialsyterelse. 2023a. Tillämpning av digital vård i regionerna - en kartläggning [Implementation of digital care in the regions]. Stockholm: The National Board of Health and Welfare.
Socialstyrelese. 2023b. Health and Medical Service Act (2017, 30) https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2020-1-6564-english.pdf
SOU. 2020, 23. Hälso- och sjukvård i det civila försvaret - underlag till försvarspolitisk inriktning.
7
Australia
Australia has a high-performing health system, often regarded as among the best in the world for its quality and affordability. The OECD Health at a Glance (2023) indicators show that Australia performs above the OECD average in 93% of health status indicators, including life expectancy and preventable mortality rates. With an average life expectancy of 83.3 years, Australians generally live three years longer than the OECD average. Along similar lines, the preventable mortality rate was 97 per 100,000 as compared to the OECD average of 158. Australia also performs better than average in terms of indicators of healthcare quality (e.g., 30-day mortality after stroke is 4.8%, as compared with the OECD average of 7.8%) and healthcare access (e.g., the whole population is covered for a core set of service and 71% of people are satisfied with the availability of healthcare services, as compared with the OECD average of 67% of healthcare performance and access).
Despite this strong performance, the health system faces significant pressures from rising costs due to an aging population and increasing chronic diseases, uneven access to services based on income and geography, and gaps in workforce and infrastructure (Butler et al. 2019). The system is also challenged by changing demands, as consumers of health services expect not only cutting-edge treatments but also more personalized and integrated services. Moreover, dental care remains an important gap in the healthcare system, with little public provision and minimal subsidies for privately provided dental care, even for the most vulnerable in the community.
The government is addressing some challenges by investing heavily in medical technology and research through the Medical Research Future Fund (Australian Government 2019) and improving data integration in healthcare provision. There have also been advancements in data connections between different program and services to improve the integration of healthcare provision.
Digital innovations like My Health Record have improved health providers’ ability to coordinate care, although the full potential for improved care and the identification of public health threats remains unrealized.
Despite this strong performance, the health system faces significant pressures from rising costs due to an aging population and increasing chronic diseases, uneven access to services based on income and geography, and gaps in workforce and infrastructure (Butler et al. 2019). The system is also challenged by changing demands, as consumers of health services expect not only cutting-edge treatments but also more personalized and integrated services. Moreover, dental care remains an important gap in the healthcare system, with little public provision and minimal subsidies for privately provided dental care, even for the most vulnerable in the community.
The government is addressing some challenges by investing heavily in medical technology and research through the Medical Research Future Fund (Australian Government 2019) and improving data integration in healthcare provision. There have also been advancements in data connections between different program and services to improve the integration of healthcare provision.
Digital innovations like My Health Record have improved health providers’ ability to coordinate care, although the full potential for improved care and the identification of public health threats remains unrealized.
Citations:
OECD. 2023. Health at a Glance 2023. OECD. https://www.oecd.org/health/health-at-a-glance/
Butler, S., Daddia, J., and Azizi, T. 2019. “The time to act is now.” https://www.pwc.com.au/health/health-matters/the-future-of-health-in-australia.html
Australian Government. 2019. “The Australian Health System.” https://www.health.gov.au/about-us/the-australian-health-system
Australian Digital Health Agency. 2024. “Outcomes.” https://www.digitalhealth.gov.au/national-digital-health-strategy
OECD. 2023. Health at a Glance 2023. OECD. https://www.oecd.org/health/health-at-a-glance/
Butler, S., Daddia, J., and Azizi, T. 2019. “The time to act is now.” https://www.pwc.com.au/health/health-matters/the-future-of-health-in-australia.html
Australian Government. 2019. “The Australian Health System.” https://www.health.gov.au/about-us/the-australian-health-system
Australian Digital Health Agency. 2024. “Outcomes.” https://www.digitalhealth.gov.au/national-digital-health-strategy
Belgium
Belgium has a world-class healthcare system but was ill-prepared for the COVID-19 crisis. Since then, it has invested in data gathering, centralization, and flu-like symptoms warning systems. However, like most of its neighboring countries, but probably less so than the UK, Belgium suffers from the discouraging working conditions in hospitals and in GP practices, which induces increasing bottlenecks in access to timely medical appointments, interferes with the quality of care (mainly at night when hospitalized) and may lead to substantial cracks in the system in the medium term.
The country has a highly trained and large medical workforce and, according to data from Eurostat and the OECD, it features the second-highest number of GPs and nurses per capita in the OECD and has well-equipped hospitals. Healthcare coverage is broad, and access to quality care is thus substantial.
Containing public deficits has partially been achieved by reducing wages and hospital costs, which may not be viable long-term, especially given the aging population. The “numerus clausus” system limits the number of graduates allowed to practice, leading to underpaid or unpaid long working hours (totaling 70-100 hours per week) for young graduates. This makes medicine and nursing less attractive for the youth.
Belgium boasts advanced flu-like symptoms warning systems, even if it performs less well on several cancer types and expected “healthy life years at birth” is close but below the EU average. Although Belgium was part of the WHO’s influenza preparedness initiative, it did not invest in emergency drills nor had concrete plans ready for the case of an epidemic of COVID proportions. As a result, the 2019 Global Health Security Index for Belgium was very high overall but scored a 0 in “Emergency Preparedness and Response Planning” and in “Risk Communication.” This diagnostic proved painfully relevant during the COVID crisis.
The country has a highly trained and large medical workforce and, according to data from Eurostat and the OECD, it features the second-highest number of GPs and nurses per capita in the OECD and has well-equipped hospitals. Healthcare coverage is broad, and access to quality care is thus substantial.
Containing public deficits has partially been achieved by reducing wages and hospital costs, which may not be viable long-term, especially given the aging population. The “numerus clausus” system limits the number of graduates allowed to practice, leading to underpaid or unpaid long working hours (totaling 70-100 hours per week) for young graduates. This makes medicine and nursing less attractive for the youth.
Belgium boasts advanced flu-like symptoms warning systems, even if it performs less well on several cancer types and expected “healthy life years at birth” is close but below the EU average. Although Belgium was part of the WHO’s influenza preparedness initiative, it did not invest in emergency drills nor had concrete plans ready for the case of an epidemic of COVID proportions. As a result, the 2019 Global Health Security Index for Belgium was very high overall but scored a 0 in “Emergency Preparedness and Response Planning” and in “Risk Communication.” This diagnostic proved painfully relevant during the COVID crisis.
Citations:
Doctors and nurses per capita: https://ec.europa.eu/eurostat/statistics-explained/images/e/e3/Physicians%2C_by_speciality%2C_2018_Health20.png
https://www.belgiqueenbonnesante.be/fr/hspa/accessibilite-des-soins/disponibilite-du-personnel-soignant#A-6
https://www.belgiqueenbonnesante.be/images/KCE/A6_Pract_nurse_FR.jpg
https://statbel.fgov.be/fr/themes/datalab/personnel-des-soins-de-sante
Hospital beds and equipment: https://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_resource_statistics_-_beds
https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Healthcare_resource_statistics_-_technical_resources_and_medical_technology
Budget cuts:
https://www.rtbf.be/article/etude-annuelle-belfius-finances-dans-le-rouge-et-appel-a-laide-des-hopitaux-belges-11287034
https://www.levif.be/actualite/belgique/qui-a-coupe-dans-mes-soins-de-sante-sophie-wilmes-a-t-elle-une-part-de-responsabilite/article-normal-1269381.html
Healthy life years: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Healthy_life_years_statistics
Preparedness:
https://www.euro.who.int/en/health-topics/communicable-diseases/influenza/pandemic-influenza/pandemic-preparedness
https://www.covid19healthsystem.org/countries/belgium/livinghit.aspx?Section=3.1%20Planning%20services&Type=Section
https://pubmed.ncbi.nlm.nih.gov/33143076/
https://www.ghsindex.org/country/belgium/
https://www.revuepolitique.be/le-systeme-de-sante-au-prisme-du-virus/
Doctors and nurses per capita: https://ec.europa.eu/eurostat/statistics-explained/images/e/e3/Physicians%2C_by_speciality%2C_2018_Health20.png
https://www.belgiqueenbonnesante.be/fr/hspa/accessibilite-des-soins/disponibilite-du-personnel-soignant#A-6
https://www.belgiqueenbonnesante.be/images/KCE/A6_Pract_nurse_FR.jpg
https://statbel.fgov.be/fr/themes/datalab/personnel-des-soins-de-sante
Hospital beds and equipment: https://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_resource_statistics_-_beds
https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Healthcare_resource_statistics_-_technical_resources_and_medical_technology
Budget cuts:
https://www.rtbf.be/article/etude-annuelle-belfius-finances-dans-le-rouge-et-appel-a-laide-des-hopitaux-belges-11287034
https://www.levif.be/actualite/belgique/qui-a-coupe-dans-mes-soins-de-sante-sophie-wilmes-a-t-elle-une-part-de-responsabilite/article-normal-1269381.html
Healthy life years: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Healthy_life_years_statistics
Preparedness:
https://www.euro.who.int/en/health-topics/communicable-diseases/influenza/pandemic-influenza/pandemic-preparedness
https://www.covid19healthsystem.org/countries/belgium/livinghit.aspx?Section=3.1%20Planning%20services&Type=Section
https://pubmed.ncbi.nlm.nih.gov/33143076/
https://www.ghsindex.org/country/belgium/
https://www.revuepolitique.be/le-systeme-de-sante-au-prisme-du-virus/
Czechia
Healthcare quality in primary, secondary, and preventive care is close to the OECD average. Healthcare expenditure was 9.06% of GDP in 2022, slightly above the OECD average. There was a slight decline after increased spending during the pandemic, reflecting the reduced need for spending to deal with the pandemic and the impact of inflation. There are 4.3 practicing doctors per 1,000 population (OECD average: 3.7) and 9.0 practicing nurses (OECD average: 9.2). Czechia has 6.7 hospital beds per 1,000 population, more than the OECD average of 4.3. [1]
“A National Strategy for Health Service Digitalisation” was published in 2014 and updated in 2020, but progress has been slow. Telemedicine has yet to be regulated, but during the COVID-19 pandemic, health insurance companies reimbursed remote consultations. In 2018, systems of electronic prescriptions and sick notes were launched. Under the strategy and associated legislation, a system was to be in place from 2022 so information could be safely shared between providers, and there was to be a register of providers and patients, with the latter also able to access information. However, a report by the NKÚ revealed that as of October 2023, doctors still could not access all useful information. The legal framework created was inadequate, and elements covered by laws had yet to be implemented. Money spent over the 2019 – 2022 period, therefore, did not lead to the intended results.
“A National Strategy for Health Service Digitalisation” was published in 2014 and updated in 2020, but progress has been slow. Telemedicine has yet to be regulated, but during the COVID-19 pandemic, health insurance companies reimbursed remote consultations. In 2018, systems of electronic prescriptions and sick notes were launched. Under the strategy and associated legislation, a system was to be in place from 2022 so information could be safely shared between providers, and there was to be a register of providers and patients, with the latter also able to access information. However, a report by the NKÚ revealed that as of October 2023, doctors still could not access all useful information. The legal framework created was inadequate, and elements covered by laws had yet to be implemented. Money spent over the 2019 – 2022 period, therefore, did not lead to the intended results.
Citations:
Health at a Glance 2023: Key findings for the Czech Republic. https://www.oecd.org/czechia/health-at-a-glance-Czech-Republic-EN.pdf
https://www.mzcr.cz/narodni-strategie-elektronickeho-zdravotnictvi/
https://www.nku.cz/assets/kon-zavery/k22020.pdf
Health at a Glance 2023: Key findings for the Czech Republic. https://www.oecd.org/czechia/health-at-a-glance-Czech-Republic-EN.pdf
https://www.mzcr.cz/narodni-strategie-elektronickeho-zdravotnictvi/
https://www.nku.cz/assets/kon-zavery/k22020.pdf
France
France has a high-quality health system that is generous and largely inclusive. Since its inception, it has been a public system based on compulsory, uniform insurance for all French citizens, with employers’ and employees’ contributions calculated according to wage levels. In addition, a general social contribution taxes different sources of income. Together with widespread complementary insurance programs, these cover most individual costs. About 12% of GDP is spent on healthcare – one of the highest such ratios in Europe.
The pandemic tested the resilience of the health system. It has left a lasting imprint, and the insufficiencies exposed in the system have not been resolved despite a significant increase in public spending on health in 2021 to 12.3% of GDP, over one percentage point above pre-pandemic levels. Many hospital services are understaffed, as nurses resigned following the pandemic despite efforts to improve salaries. The physician-population ratio is lower than in most Nordic countries, but also lower than in Italy or Spain. In certain regions, it has become difficult to find a general practitioner to consult. This is especially true of rural and semi-rural areas, but also of poorer urban neighborhoods (OECD 2023, p. 10). As physicians are free to choose their places of practice, certain areas have been systematically avoided. A number of measures – especially financial incentives – have been implemented over the past decade with the intention of countering this trend, but with little success.
Some of these shortcomings may be due to coordination costs and inefficient management. The current administration has focused on primary healthcare with the aim of alleviating pressure on hospitals. Regional health authorities (ARS) are now co-managing health expenditures with the ministry at the regional level.
The pandemic tested the resilience of the health system. It has left a lasting imprint, and the insufficiencies exposed in the system have not been resolved despite a significant increase in public spending on health in 2021 to 12.3% of GDP, over one percentage point above pre-pandemic levels. Many hospital services are understaffed, as nurses resigned following the pandemic despite efforts to improve salaries. The physician-population ratio is lower than in most Nordic countries, but also lower than in Italy or Spain. In certain regions, it has become difficult to find a general practitioner to consult. This is especially true of rural and semi-rural areas, but also of poorer urban neighborhoods (OECD 2023, p. 10). As physicians are free to choose their places of practice, certain areas have been systematically avoided. A number of measures – especially financial incentives – have been implemented over the past decade with the intention of countering this trend, but with little success.
Some of these shortcomings may be due to coordination costs and inefficient management. The current administration has focused on primary healthcare with the aim of alleviating pressure on hospitals. Regional health authorities (ARS) are now co-managing health expenditures with the ministry at the regional level.
Citations:
European Observatory on Health Systems and Policies. 2023. “France: Health System Review.”
François Langlot. 2023. “Système de santé : sortir de la ‘crise sans fin’ n’est pas qu’une question de moyens.” The Conversation, January 10.
OECD. 2023. “France: Country Health Profile 2023.” https://eurohealthobservatory.who.int/publications/m/france-country-health-profile-2023
European Observatory on Health Systems and Policies. 2023. “France: Health System Review.”
François Langlot. 2023. “Système de santé : sortir de la ‘crise sans fin’ n’est pas qu’une question de moyens.” The Conversation, January 10.
OECD. 2023. “France: Country Health Profile 2023.” https://eurohealthobservatory.who.int/publications/m/france-country-health-profile-2023
Ireland
The public healthcare system in Ireland is regarded as effective once accessed, but issues such as long waiting lists, negligence, and incompetence contribute to negative perceptions. Key pieces of health infrastructure, including the National Children’s Hospital, have faced considerable delays and budget increases. The lack of access to hospital care is frequently highlighted in the media, especially by the Irish Nurses and Midwives Organisation, which campaigns for better staffing, working conditions and patient outcomes.
Government spending on healthcare reached a record €21 billion in 2022, which is considered costly given the favorable age structure of the population. However, health spending per capita was similar to the EU average in 2021 (OECD 2023). Concerns about continuing overruns in healthcare spending are common (IFAC 2022/23). Revenue buoyancy linked to volatile corporate tax returns enables the government to absorb healthcare overruns in the short term. However, resilience is vulnerable due to an over-reliance on 14 private operators who control 40% of nursing home beds, mostly in the greater Dublin region. There have been 700 recent public bed losses and the closure of 50 private nursing homes (Pepper 2023, ESRI 2023). Elder care is difficult to access, particularly in rural areas. While the home-based care scheme offers resilience, its implementation has been slow (ESRI 2023). Elective surgery waiting lists are being addressed through purchase-abroad schemes (EU) and bilateral arrangements with the UK. Transparency is increasing, with monthly data on waiting lists now published by the Health Service Executive (HSE), making the monitoring of waiting times a political priority.
Pre-COVID-19, Ireland had begun a 10-year program of reform, Sláintecare, aimed at delivering universal, timely access to integrated care. Burke et al. (2021) explain how the Irish government’s pandemic response contributed to health system reform and increased resilience, including delivering universal healthcare. Both policy intent and funding were directed to manage the COVID-19 crisis in Ireland and to build health system resilience.
Government spending on healthcare reached a record €21 billion in 2022, which is considered costly given the favorable age structure of the population. However, health spending per capita was similar to the EU average in 2021 (OECD 2023). Concerns about continuing overruns in healthcare spending are common (IFAC 2022/23). Revenue buoyancy linked to volatile corporate tax returns enables the government to absorb healthcare overruns in the short term. However, resilience is vulnerable due to an over-reliance on 14 private operators who control 40% of nursing home beds, mostly in the greater Dublin region. There have been 700 recent public bed losses and the closure of 50 private nursing homes (Pepper 2023, ESRI 2023). Elder care is difficult to access, particularly in rural areas. While the home-based care scheme offers resilience, its implementation has been slow (ESRI 2023). Elective surgery waiting lists are being addressed through purchase-abroad schemes (EU) and bilateral arrangements with the UK. Transparency is increasing, with monthly data on waiting lists now published by the Health Service Executive (HSE), making the monitoring of waiting times a political priority.
Pre-COVID-19, Ireland had begun a 10-year program of reform, Sláintecare, aimed at delivering universal, timely access to integrated care. Burke et al. (2021) explain how the Irish government’s pandemic response contributed to health system reform and increased resilience, including delivering universal healthcare. Both policy intent and funding were directed to manage the COVID-19 crisis in Ireland and to build health system resilience.
Citations:
CSO. 2023. Irish Health Survey 2019. Dublin: Central Statistics Office.
INMO. 2023. “ED Trolley Watch/Ward Watch Figures below for January 26th 2024.” https://www.inmo.ie/Trolley_Ward_Watch
Pepper, D. 2023. “‘Trend’ of nursing home closures mostly impacting rural areas, as 50 close over four-year period.” The Journal, December 14. https://www.thejournal.ie/hiqa-report-nursing-home-closures-rural-areas-6249470-Dec2023/#:~:text=FIFTY%20NURSING%20HOMES%20have%20closed,and%20Quality%20Authority%20(HIQA)
Walsh, B., and S. Connolly. 2024. “Long-term Residential Care in Ireland: Developments Since the Onset of the COVID-19 Pandemic.” ESRI Research Series 174. https://www.esri.ie/system/files/publications/RS174.pdf
Burke, S., Parker, S., Fleming, P., Barry, S., and Thomas, S. 2021. “Building Health System Resilience through Policy Development in Response to COVID-19 in Ireland: From Shock to Reform.” The Lancet Regional Health–Europe 9. https://doi.org/10.1016/j.lanepe.2021.100223
OECD. 2023. “State of Health in the EU Ireland Country Health Profile 2023.” https://read.oecd.org/10.1787/3abe906b-en?format=pdf
CSO. 2023. Irish Health Survey 2019. Dublin: Central Statistics Office.
INMO. 2023. “ED Trolley Watch/Ward Watch Figures below for January 26th 2024.” https://www.inmo.ie/Trolley_Ward_Watch
Pepper, D. 2023. “‘Trend’ of nursing home closures mostly impacting rural areas, as 50 close over four-year period.” The Journal, December 14. https://www.thejournal.ie/hiqa-report-nursing-home-closures-rural-areas-6249470-Dec2023/#:~:text=FIFTY%20NURSING%20HOMES%20have%20closed,and%20Quality%20Authority%20(HIQA)
Walsh, B., and S. Connolly. 2024. “Long-term Residential Care in Ireland: Developments Since the Onset of the COVID-19 Pandemic.” ESRI Research Series 174. https://www.esri.ie/system/files/publications/RS174.pdf
Burke, S., Parker, S., Fleming, P., Barry, S., and Thomas, S. 2021. “Building Health System Resilience through Policy Development in Response to COVID-19 in Ireland: From Shock to Reform.” The Lancet Regional Health–Europe 9. https://doi.org/10.1016/j.lanepe.2021.100223
OECD. 2023. “State of Health in the EU Ireland Country Health Profile 2023.” https://read.oecd.org/10.1787/3abe906b-en?format=pdf
New Zealand
New Zealand’s health policies have aimed to facilitate resilience in the health system.
First, the country has invested in digital infrastructure and the collection of health data to monitor emerging threats and assess public health matters. In 2023, Te Whatu Ora – Health New Zealand commissioned the development of the National Data Platform (NDP), a single centralized platform for accessing health data that will unify information held by more than 28 health system entities (Ang 2023). New Zealand already operates HealthOne, a shared electronic database that allows general practitioners and other healthcare providers to access patient information. Regulations and frameworks are in place to govern health data privacy, security and consent, including the Health Information Privacy Code and the Health Act.
Second, policies and regulations aim to ensure the availability of health products and services, particularly during times of crisis or emergencies – most importantly, the National Health Emergency Plan and a centrally managed national reserve of critical supplies. Additionally, Health New Zealand may release more short-term plans to reduce pressure on the health system – for example, in the run-up to winter (Palmer 2023). Government agencies are also working to improve New Zealand’s preparedness for pandemics (Crimp 2023). While the country did have a pandemic plan before COVID-19, this plan was geared only toward influenza.
The government seeks to balance rising healthcare costs with quality care provision. Healthcare reforms, such as merging the 20 district health boards into Health New Zealand in July 2022, aim to improve the efficiency and cost-effectiveness of the healthcare system. Additionally, the government has employed health technology assessments to evaluate the value and cost-effectiveness of new medical technologies and treatments (Pharmac 2023). However, like other countries, New Zealand faces challenges related to rising healthcare costs due to an aging population and advancements in medical technology.
Furthermore, the new system established by the Labour government to support better Māori Health services and outcomes may be dismantled before it is fully implemented, due to the new government’s commitment to returning to a single health system (Reti 2023).
First, the country has invested in digital infrastructure and the collection of health data to monitor emerging threats and assess public health matters. In 2023, Te Whatu Ora – Health New Zealand commissioned the development of the National Data Platform (NDP), a single centralized platform for accessing health data that will unify information held by more than 28 health system entities (Ang 2023). New Zealand already operates HealthOne, a shared electronic database that allows general practitioners and other healthcare providers to access patient information. Regulations and frameworks are in place to govern health data privacy, security and consent, including the Health Information Privacy Code and the Health Act.
Second, policies and regulations aim to ensure the availability of health products and services, particularly during times of crisis or emergencies – most importantly, the National Health Emergency Plan and a centrally managed national reserve of critical supplies. Additionally, Health New Zealand may release more short-term plans to reduce pressure on the health system – for example, in the run-up to winter (Palmer 2023). Government agencies are also working to improve New Zealand’s preparedness for pandemics (Crimp 2023). While the country did have a pandemic plan before COVID-19, this plan was geared only toward influenza.
The government seeks to balance rising healthcare costs with quality care provision. Healthcare reforms, such as merging the 20 district health boards into Health New Zealand in July 2022, aim to improve the efficiency and cost-effectiveness of the healthcare system. Additionally, the government has employed health technology assessments to evaluate the value and cost-effectiveness of new medical technologies and treatments (Pharmac 2023). However, like other countries, New Zealand faces challenges related to rising healthcare costs due to an aging population and advancements in medical technology.
Furthermore, the new system established by the Labour government to support better Māori Health services and outcomes may be dismantled before it is fully implemented, due to the new government’s commitment to returning to a single health system (Reti 2023).
Citations:
Ang, A. 2023. “Accenture Delivering New Zealand’s National Health Data Platform.” Healthcare IT News, July 27. https://www.healthcareitnews.com/news/anz/accenture-delivering-new-zealands-national-health-data-platform
Crimp, L. 2023. “Comprehensive pandemic framework created.” RNZ, November 22. https://www.rnz.co.nz/news/national/502996/comprehensive-pandemic-framework-created
Palmer, R. 2023. “Health NZ Te Whatu Ora Unveils Winter Preparedness Plan.” RNZ, May 4. https://www.rnz.co.nz/news/political/489245/health-nz-te-whatu-ora-unveils-winter-preparedness-plan
Pharmac. 2023. “Pharmac Joins International Collaboration to Advance Use of Health Technology Assessments.” https://pharmac.govt.nz/news-and-resources/news/2023-07-20-media-release-pharmac-joins-international-collaboration-to-advance-use-of-health-technology-assessments
Reti, S. 2023. “Damning Māori Health Authority report released.” National Party Press Release, August 4. https://www.national.org.nz/damning_maori_health_authority_report_released#:~:text=%E2%80%9CNational%20will%20deliver%20health%20based,New%20Zealanders%20falling%20health%20outcomes
Ang, A. 2023. “Accenture Delivering New Zealand’s National Health Data Platform.” Healthcare IT News, July 27. https://www.healthcareitnews.com/news/anz/accenture-delivering-new-zealands-national-health-data-platform
Crimp, L. 2023. “Comprehensive pandemic framework created.” RNZ, November 22. https://www.rnz.co.nz/news/national/502996/comprehensive-pandemic-framework-created
Palmer, R. 2023. “Health NZ Te Whatu Ora Unveils Winter Preparedness Plan.” RNZ, May 4. https://www.rnz.co.nz/news/political/489245/health-nz-te-whatu-ora-unveils-winter-preparedness-plan
Pharmac. 2023. “Pharmac Joins International Collaboration to Advance Use of Health Technology Assessments.” https://pharmac.govt.nz/news-and-resources/news/2023-07-20-media-release-pharmac-joins-international-collaboration-to-advance-use-of-health-technology-assessments
Reti, S. 2023. “Damning Māori Health Authority report released.” National Party Press Release, August 4. https://www.national.org.nz/damning_maori_health_authority_report_released#:~:text=%E2%80%9CNational%20will%20deliver%20health%20based,New%20Zealanders%20falling%20health%20outcomes
Norway
Norway has universal health insurance covering the entire population for all health issues except dental care. The country is divided into four health regions, with hospitals organized as public enterprises financed by a combination of state grants, activity-related transfers, and patient co-payments. Primary care is the responsibility of the 357 local authorities. Ten percent of GDP is allocated to health services (2022 numbers). In general, the services are of high quality and accessible to everyone in need.
The aging population implies a need for better coordination of resources and responsibilities between local primary care services and specialized medical treatments in hospitals. Programs to implement new digital infrastructure for communication between different actors and administrative levels have been launched; however, they have failed to deliver expected results. Shortages of key personnel, particularly nurses and auxiliary staff, have fostered an interest in new technologies that may enable more efficient communication and allow patients to better manage their own health challenges. Innovation projects are ongoing, but so far, have not resulted in new general, cost-saving, and labor-saving practices.
The Ministry of Health has long aimed to implement a modernized national system for recording and sharing patient information across different units in the health and social care sectors. However, this project has yet to deliver on its promise. A separate directorate for digitized health was established in 2016 and closed in 2023. No national information management system is forthcoming, and the various regional health enterprises have begun developing their own systems.
The aging population implies a need for better coordination of resources and responsibilities between local primary care services and specialized medical treatments in hospitals. Programs to implement new digital infrastructure for communication between different actors and administrative levels have been launched; however, they have failed to deliver expected results. Shortages of key personnel, particularly nurses and auxiliary staff, have fostered an interest in new technologies that may enable more efficient communication and allow patients to better manage their own health challenges. Innovation projects are ongoing, but so far, have not resulted in new general, cost-saving, and labor-saving practices.
The Ministry of Health has long aimed to implement a modernized national system for recording and sharing patient information across different units in the health and social care sectors. However, this project has yet to deliver on its promise. A separate directorate for digitized health was established in 2016 and closed in 2023. No national information management system is forthcoming, and the various regional health enterprises have begun developing their own systems.
Citations:
Helsedirektoratet. 2023. “Én innbygger – én journal.” https://www.ehelse.no/strategi/en-innbygger-en-journal
Helsedirektoratet. 2023. “Én innbygger – én journal.” https://www.ehelse.no/strategi/en-innbygger-en-journal
Spain
The implementation of digital medical records and prescriptions, patient portals, and electronic appointments accounts in large part for Spain’s high ranking in Bertelsmann Stiftung’s Digital Health Index. The index also points to the loss of joint efficiency in monitoring because there is no shared digital health strategy among the levels of government.
The RRP sets the goals of enhancing the health system’s resilience (30.8% of the total health investment of the RRP) and digital transformation through the development of shared massive data analysis (5.8% of the total health investment). Accordingly, the national Digital Health Strategy (2021 – 2026) foresees areas for joint decision-making between the national Ministry of Health and the autonomous communities, which have full responsibility for planning and developing digital health services. These areas include the interoperability of clinical information between health services and the integration of essential data for each person in the NHS (Government of Spain 2022).
To implement the strategy, the Intergovernmental Council of the NHS established a Digital Health Commission to streamline information sharing, collaboration, and decision-making among all actors in the NHS, such as in disease prevention. In this context, the Ministry of Health, with the participation of all autonomous communities, is launching the National Health Data Space, a large national health data pool to facilitate research and decision-making in health through the use of new technologies and Artificial Intelligence.
Moreover, the government established a new General Secretariat for Digital Health. Its main objectives are promoting innovation and reinforcing performance assessment and data analysis capabilities.
The Spanish Agency of Medicines and Healthcare Products aims to guarantee medicine supplies and improve coordination. While the unequal distribution of health professionals hinders access, new policies, such as the implementation of telehealth, have been speeded up due to investments from the RRP. The agency’s annual budget was reduced in 2022 – 2023 to levels prior to 2016. The RRP also sets out a new approach for the rational use of medicines and ensuring sustainability. During the reviewed period, the centralization of medicine purchases continued to be managed at the regional level.
Per capita health spending in Spain remains below the EU average and varies significantly among autonomous communities (OECD 2022). Over the past decade, there has been a widening gap between Spain and EU countries in total health expenditure, reflecting slower growth. The increase in spending is attributed to an aging population and advancements in medical technology. To counteract the rising costs, measures such as the digitalization of the health system, research and innovation in health, and talent attraction are considered essential. However, specific targeted actions have yet to be implemented.
The RRP sets the goals of enhancing the health system’s resilience (30.8% of the total health investment of the RRP) and digital transformation through the development of shared massive data analysis (5.8% of the total health investment). Accordingly, the national Digital Health Strategy (2021 – 2026) foresees areas for joint decision-making between the national Ministry of Health and the autonomous communities, which have full responsibility for planning and developing digital health services. These areas include the interoperability of clinical information between health services and the integration of essential data for each person in the NHS (Government of Spain 2022).
To implement the strategy, the Intergovernmental Council of the NHS established a Digital Health Commission to streamline information sharing, collaboration, and decision-making among all actors in the NHS, such as in disease prevention. In this context, the Ministry of Health, with the participation of all autonomous communities, is launching the National Health Data Space, a large national health data pool to facilitate research and decision-making in health through the use of new technologies and Artificial Intelligence.
Moreover, the government established a new General Secretariat for Digital Health. Its main objectives are promoting innovation and reinforcing performance assessment and data analysis capabilities.
The Spanish Agency of Medicines and Healthcare Products aims to guarantee medicine supplies and improve coordination. While the unequal distribution of health professionals hinders access, new policies, such as the implementation of telehealth, have been speeded up due to investments from the RRP. The agency’s annual budget was reduced in 2022 – 2023 to levels prior to 2016. The RRP also sets out a new approach for the rational use of medicines and ensuring sustainability. During the reviewed period, the centralization of medicine purchases continued to be managed at the regional level.
Per capita health spending in Spain remains below the EU average and varies significantly among autonomous communities (OECD 2022). Over the past decade, there has been a widening gap between Spain and EU countries in total health expenditure, reflecting slower growth. The increase in spending is attributed to an aging population and advancements in medical technology. To counteract the rising costs, measures such as the digitalization of the health system, research and innovation in health, and talent attraction are considered essential. However, specific targeted actions have yet to be implemented.
Citations:
Government of Spain. 2022. “Estrategia de salud digital.” https://www.sanidad.gob.es/areas/saludDigital/doc/Estrategia_de_Salud_Digital_del_SNS.pdf
Government of Spain. 2022. “Estrategia de Salud Pública 2022.”
https://www.bertelsmann-stiftung.de/de/unsere-projekte/der-digitale-patient/projektthemen/smarthealthsystems/digital-health-index
OECD. 2023. Spain Country Health Profile 2023.
Government of Spain. 2022. “Estrategia de salud digital.” https://www.sanidad.gob.es/areas/saludDigital/doc/Estrategia_de_Salud_Digital_del_SNS.pdf
Government of Spain. 2022. “Estrategia de Salud Pública 2022.”
https://www.bertelsmann-stiftung.de/de/unsere-projekte/der-digitale-patient/projektthemen/smarthealthsystems/digital-health-index
OECD. 2023. Spain Country Health Profile 2023.
Netherlands
The Dutch healthcare sector is facing multiple challenges, including a shortage of specific medicines and alarming levels of unavailability of essential drugs. In 2023, more than 1,500 medicines were unavailable for over two weeks, affecting millions of people who rely on generic drugs such as antibiotics, sleep aids and ADHD medications. Financially, the sector is under strain, with the average returns of healthcare providers nearly halved by 2022, an increase in providers operating at a loss and a rise in the number of healthcare providers under special management.
The Dutch Ministry of Health recognizes the need for affordable, accessible care of improved quality. E-health, or remote healthcare through digital technologies, is identified as a potential solution. Between 2021 and 2023, he ministry explored the transition of healthcare components to e-health. This includes diverse applications such as video consultations with general practitioners, health apps for patients and informational websites. To measure this transition, RIVM, Nivel and NeLL are developing a monitor that identifies what parties are utilizing e-health, for what purposes, and captures user satisfaction.
Within this initiative, the organizations analyzed the data, or indicators, needed for effective e-health implementation. Examples include the usage of e-health mechanisms by general practitioners, citizens making online appointments with hospitals and users’ satisfaction levels. These indicators aim to provide insights into the progress toward meeting goals set by the Dutch Ministry of Health, including enhancing healthcare quality and organization, empowering patients, emphasizing prevention and supporting healthcare personnel. This collaborative effort seeks to bring transparency to the evolving landscape of e-health in the Dutch healthcare sector.
The Dutch Ministry of Health recognizes the need for affordable, accessible care of improved quality. E-health, or remote healthcare through digital technologies, is identified as a potential solution. Between 2021 and 2023, he ministry explored the transition of healthcare components to e-health. This includes diverse applications such as video consultations with general practitioners, health apps for patients and informational websites. To measure this transition, RIVM, Nivel and NeLL are developing a monitor that identifies what parties are utilizing e-health, for what purposes, and captures user satisfaction.
Within this initiative, the organizations analyzed the data, or indicators, needed for effective e-health implementation. Examples include the usage of e-health mechanisms by general practitioners, citizens making online appointments with hospitals and users’ satisfaction levels. These indicators aim to provide insights into the progress toward meeting goals set by the Dutch Ministry of Health, including enhancing healthcare quality and organization, empowering patients, emphasizing prevention and supporting healthcare personnel. This collaborative effort seeks to bring transparency to the evolving landscape of e-health in the Dutch healthcare sector.
Citations:
De staat van de zorg. 2023. Nederlandse zorgautoriteit, October 12. https://www.nza.nl/onderwerpen/stand-van-de-zorg
De E-healthmonitor. 2021-2023. “Plan van aanpak op hoofdlijnen.” RIVM. https://open.overheid.nl/documenten/ronl-d0462ee1-7a94-4b34-b510-c5dbdaa555b6/pdf
EY Barometer Nederlandse Gezondheidszorg. 2023. “Resultaten 2023: Nederlandse zorgsector in zeer zwaar weer beland.” https://www.ey.com/nl_nl/health/ey-barometer-nederlandse-gezondheidszorg
Het Integraal Zorgakkoord - samenwerken aan gezonde zorg, Het Integraal Zorgakkoord - samenwerken aan gezonde zorg
Kiezen voor houdbare zorg. Mensen, middelen en maatschappelijk draagvlak, WRR, 15-09. https://www.wrr.nl/publicaties/rapporten/2021/09/15/kiezen-voor-houdbare-zorg
https://www.rijksoverheid.nl/onderwerpen/prinsjesdag/zorg-en-gezondheid
https://vng.nl/nieuws/uitvoering-integraal-zorgakkoord-iza-onder-druk
De staat van de zorg. 2023. Nederlandse zorgautoriteit, October 12. https://www.nza.nl/onderwerpen/stand-van-de-zorg
De E-healthmonitor. 2021-2023. “Plan van aanpak op hoofdlijnen.” RIVM. https://open.overheid.nl/documenten/ronl-d0462ee1-7a94-4b34-b510-c5dbdaa555b6/pdf
EY Barometer Nederlandse Gezondheidszorg. 2023. “Resultaten 2023: Nederlandse zorgsector in zeer zwaar weer beland.” https://www.ey.com/nl_nl/health/ey-barometer-nederlandse-gezondheidszorg
Het Integraal Zorgakkoord - samenwerken aan gezonde zorg, Het Integraal Zorgakkoord - samenwerken aan gezonde zorg
Kiezen voor houdbare zorg. Mensen, middelen en maatschappelijk draagvlak, WRR, 15-09. https://www.wrr.nl/publicaties/rapporten/2021/09/15/kiezen-voor-houdbare-zorg
https://www.rijksoverheid.nl/onderwerpen/prinsjesdag/zorg-en-gezondheid
https://vng.nl/nieuws/uitvoering-integraal-zorgakkoord-iza-onder-druk
6
Austria
In terms of total current healthcare expenditures as a percent of GDP, Austria has consistently ranked in the top third of OECD countries, as confirmed by 2022 figures.
Recent developments in Austria regarding spending on preventive and health programs (as a percentage of current healthcare expenditure) are particularly noteworthy. According to figures provided by the OECD, at 10.3%, the share spent on such measures in 2021 was more than four times higher than the average for the previous decade (2.2) and about three times higher than in 2020 (3.4). This placed Austria second among OECD countries, surpassed only by the UK.
Austria has long been among the leading countries for the number of hospital beds per 1,000 inhabitants. In 2022, it ranked third among OECD countries, behind Japan and Germany. However, like most other countries, the overall number of beds has slightly decreased over the past decade. Some even more impressive figures require further context: for example, Austria has had the highest number of physicians per 1,000 inhabitants among OECD countries, being the only country aside from New Zealand to ever exceed 5%, with a score of 5.48% in 2022. Nevertheless, a recurrent issue in recent political debates on healthcare in Austria has been the increasing shortage of physicians in some non-urban regions. More importantly, the share of physicians who were contracted partners of the public health insurance system (“Kassenärzte”) decreased from 4,213 to 4,054 between 2010 and 2020, and this trend has continued. According to a survey from 2023, more than two-thirds of Austrians were acutely aware of the increasing lack of “Kassenärzte” (Der Standard 2023).
In terms of state-of-the-art equipment, such as computed tomography scanners, Austria has been only in the middle field of OECD countries, even falling slightly below the average score. However, according to the “Health at a Glance” OECD report for 2023 (see Figure 5.24), regarding the use of CT, MRI, and PET diagnostic scanners, Austria was in the top group of OECD countries – alongside the United States, Luxembourg, Korea, and France.
No less importantly, Austria has recently experienced a shortage or unavailability of many standard pharmaceuticals. In 2023, approximately 600 pharmaceuticals were reported to be temporarily unavailable on the Austrian market (Kleine Zeitung 2023).
At the height of the coronavirus pandemic, the Austrian healthcare system was tested to its limits. Life expectancy for people living in Austria decreased slightly, though less dramatically than in several other countries. A recent assessment of the government’s and health system’s performance, published in late 2023, found that mistakes were made, but the overall performance was fair (see Krutzler 2023). Some indicators suggest, however, that the long-term effects of the pandemic may have been underestimated. For example, the number of reported cases of depression increased significantly more in Austria than in many other OECD countries.
Despite several positive aspects mentioned earlier, many observers have assessed the prospects of the Austrian health system as deficient, particularly in its ability to handle the challenges of an aging population. In 2023, the Standard, one of the country’s quality papers, launched a series of articles titled “The health system at its limits” (Springer 2023).
Apart from the lack of contracted physicians available to all insured patients, working conditions in Austrian hospitals have deteriorated over the last decade. Reports of personnel shortages and the closure of some hospital departments have surfaced (Krutzler and Müller 2023). In a representative study of nursing personnel in general departments of Austrian hospitals, almost one-third of nursing staff stated that their department is rarely or never adequately staffed to fulfill its tasks. Additionally, 84.4% of nursing staff reported at least one nursing intervention related to acute patient care was omitted in the past two weeks (Cartaxo, Eberl, and Mayer 2022). Waiting times for normally insured patients have increased in some regions.
The pandemic provided Austria with an opportunity to become one of the first Western European countries to develop an official electronic vaccination data system with electronic vaccination certificates. Meanwhile, digitalization has extended into other areas. Since mid-2022, there have been “e-prescriptions” replacing traditional paper prescriptions (see Digital Austria 2024).
The two-tier medical system has become a reality. Patients with private insurance have access to a wide variety of private physicians and clinics. In public hospitals, privately insured patients generally experience significantly shorter waiting times and receive better rooms and food.
One major problem concerns the rising costs. Although a specific agreement (“15a-Vereinbarung Zielsteuerung Gesundheit”) has been in place to reduce annual increases from 3.6% in 2017 to 3.2%, the agreed spending limits were more significantly exceeded in 2022 than in 2021 and appear poised to increase further (see Parlamentskorrespondenz 2023).
Recent developments in Austria regarding spending on preventive and health programs (as a percentage of current healthcare expenditure) are particularly noteworthy. According to figures provided by the OECD, at 10.3%, the share spent on such measures in 2021 was more than four times higher than the average for the previous decade (2.2) and about three times higher than in 2020 (3.4). This placed Austria second among OECD countries, surpassed only by the UK.
Austria has long been among the leading countries for the number of hospital beds per 1,000 inhabitants. In 2022, it ranked third among OECD countries, behind Japan and Germany. However, like most other countries, the overall number of beds has slightly decreased over the past decade. Some even more impressive figures require further context: for example, Austria has had the highest number of physicians per 1,000 inhabitants among OECD countries, being the only country aside from New Zealand to ever exceed 5%, with a score of 5.48% in 2022. Nevertheless, a recurrent issue in recent political debates on healthcare in Austria has been the increasing shortage of physicians in some non-urban regions. More importantly, the share of physicians who were contracted partners of the public health insurance system (“Kassenärzte”) decreased from 4,213 to 4,054 between 2010 and 2020, and this trend has continued. According to a survey from 2023, more than two-thirds of Austrians were acutely aware of the increasing lack of “Kassenärzte” (Der Standard 2023).
In terms of state-of-the-art equipment, such as computed tomography scanners, Austria has been only in the middle field of OECD countries, even falling slightly below the average score. However, according to the “Health at a Glance” OECD report for 2023 (see Figure 5.24), regarding the use of CT, MRI, and PET diagnostic scanners, Austria was in the top group of OECD countries – alongside the United States, Luxembourg, Korea, and France.
No less importantly, Austria has recently experienced a shortage or unavailability of many standard pharmaceuticals. In 2023, approximately 600 pharmaceuticals were reported to be temporarily unavailable on the Austrian market (Kleine Zeitung 2023).
At the height of the coronavirus pandemic, the Austrian healthcare system was tested to its limits. Life expectancy for people living in Austria decreased slightly, though less dramatically than in several other countries. A recent assessment of the government’s and health system’s performance, published in late 2023, found that mistakes were made, but the overall performance was fair (see Krutzler 2023). Some indicators suggest, however, that the long-term effects of the pandemic may have been underestimated. For example, the number of reported cases of depression increased significantly more in Austria than in many other OECD countries.
Despite several positive aspects mentioned earlier, many observers have assessed the prospects of the Austrian health system as deficient, particularly in its ability to handle the challenges of an aging population. In 2023, the Standard, one of the country’s quality papers, launched a series of articles titled “The health system at its limits” (Springer 2023).
Apart from the lack of contracted physicians available to all insured patients, working conditions in Austrian hospitals have deteriorated over the last decade. Reports of personnel shortages and the closure of some hospital departments have surfaced (Krutzler and Müller 2023). In a representative study of nursing personnel in general departments of Austrian hospitals, almost one-third of nursing staff stated that their department is rarely or never adequately staffed to fulfill its tasks. Additionally, 84.4% of nursing staff reported at least one nursing intervention related to acute patient care was omitted in the past two weeks (Cartaxo, Eberl, and Mayer 2022). Waiting times for normally insured patients have increased in some regions.
The pandemic provided Austria with an opportunity to become one of the first Western European countries to develop an official electronic vaccination data system with electronic vaccination certificates. Meanwhile, digitalization has extended into other areas. Since mid-2022, there have been “e-prescriptions” replacing traditional paper prescriptions (see Digital Austria 2024).
The two-tier medical system has become a reality. Patients with private insurance have access to a wide variety of private physicians and clinics. In public hospitals, privately insured patients generally experience significantly shorter waiting times and receive better rooms and food.
One major problem concerns the rising costs. Although a specific agreement (“15a-Vereinbarung Zielsteuerung Gesundheit”) has been in place to reduce annual increases from 3.6% in 2017 to 3.2%, the agreed spending limits were more significantly exceeded in 2022 than in 2021 and appear poised to increase further (see Parlamentskorrespondenz 2023).
Citations:
https://kontrast.at/kassenarzt-wahlarzt-oesterreich/
Der Standard. 2023. “Zwei Drittel spüren den Kassenarzt-Mangel.” https://www.derstandard.at/story/2000146190053/zwei-drittel-spueren-den-kassenarzt-mangel
Kleine Zeitung. 2023. “Diese Medikamente fehlen derzeit in Österreich.” https://www.kleinezeitung.at/oesterreich/6260946/Offizielle-Liste_Diese-Medikamente-fehlen-derzeit-in-Oesterreich
Krutzler, David. 2023. “Corona-Aufarbeitung in Österreich mit Lücken.” https://www.derstandard.at/story/3000000200881/corona-aufarbeitung-in-oesterreich-mit-luecken
Krutzler, David, and Walter Müller. 2023. “Spitäler sind in ganz Österreich am Limit.” https://www.derstandard.at/story/2000145674427/spitaeler-in-ganz-oesterreich-am-limit
Springer, Gudrun. 2023. “Wo Österreichs Gesundheitssystem an seine Grenzen gerät.” https://www.derstandard.at/story/2000144918798/wo-oesterreichs-gesundheitssystem-an-seine-grenzen-geraet
https://misscare-austria.univie.ac.at/
Cartaxo, A., Eberl, I., and Mayer, H. 2022. “Die MISSCARE-Austria-Studie – Teil III.” HBScience 13 (Suppl 2): 61–78. https://doi.org/10.1007/s16024-022-00390-2
Digital Austria. 2024. “Digital Austria Act – Das Digitale Arbeitsprogramm der Bundesregierung/Einblicke in den Digital Austria Act/Digitales Gesundheitswesen.” https://www.digitalaustria.gv.at/Strategien/Digital-Austria-Act—das-digitale-Arbeitsprogramm-der-Bundesregierung/Einblicke-in-den-Digital-Austria-Act/Digitales-Gesundheitswesen.html
Parlamentskorrespondenz. 2023. https://www.parlament.gv.at/aktuelles/pk/jahr_2023/pk0973#:~:text=Da%20sich%20die%20%C3%B6ffentlichen%20Gesundheitsausgaben,17%2C08%20%25)%20%C3%BCberschritten
https://kontrast.at/kassenarzt-wahlarzt-oesterreich/
Der Standard. 2023. “Zwei Drittel spüren den Kassenarzt-Mangel.” https://www.derstandard.at/story/2000146190053/zwei-drittel-spueren-den-kassenarzt-mangel
Kleine Zeitung. 2023. “Diese Medikamente fehlen derzeit in Österreich.” https://www.kleinezeitung.at/oesterreich/6260946/Offizielle-Liste_Diese-Medikamente-fehlen-derzeit-in-Oesterreich
Krutzler, David. 2023. “Corona-Aufarbeitung in Österreich mit Lücken.” https://www.derstandard.at/story/3000000200881/corona-aufarbeitung-in-oesterreich-mit-luecken
Krutzler, David, and Walter Müller. 2023. “Spitäler sind in ganz Österreich am Limit.” https://www.derstandard.at/story/2000145674427/spitaeler-in-ganz-oesterreich-am-limit
Springer, Gudrun. 2023. “Wo Österreichs Gesundheitssystem an seine Grenzen gerät.” https://www.derstandard.at/story/2000144918798/wo-oesterreichs-gesundheitssystem-an-seine-grenzen-geraet
https://misscare-austria.univie.ac.at/
Cartaxo, A., Eberl, I., and Mayer, H. 2022. “Die MISSCARE-Austria-Studie – Teil III.” HBScience 13 (Suppl 2): 61–78. https://doi.org/10.1007/s16024-022-00390-2
Digital Austria. 2024. “Digital Austria Act – Das Digitale Arbeitsprogramm der Bundesregierung/Einblicke in den Digital Austria Act/Digitales Gesundheitswesen.” https://www.digitalaustria.gv.at/Strategien/Digital-Austria-Act—das-digitale-Arbeitsprogramm-der-Bundesregierung/Einblicke-in-den-Digital-Austria-Act/Digitales-Gesundheitswesen.html
Parlamentskorrespondenz. 2023. https://www.parlament.gv.at/aktuelles/pk/jahr_2023/pk0973#:~:text=Da%20sich%20die%20%C3%B6ffentlichen%20Gesundheitsausgaben,17%2C08%20%25)%20%C3%BCberschritten
Estonia
Estonia has a solidary health insurance system that includes some non-Bismarckian features, such as general practitioners. In 2022, the Estonian Health Insurance Fund (EHIF) covered 96% of the population. Eligibility is determined by regulation and, for the majority of the population, is linked to employment, pensioner or child status, or the individual’s membership in a socially vulnerable group. Those with insecure or informal jobs are more likely to be uninsured (OECD 2023).
Health expenditure has recently grown, but as a percentage of GDP, it remains below the OECD average. There has long been concern that the Estonian health financing system, based on a health insurance fund, is not sustainable due to a shrinking working-age population and the increasing prevalence of flexible employment (see also “Sustainable Taxation”). Starting in 2022, the state began transferring 13% of pensions on behalf of nonworking pensioners to the EHIF to supplement the existing earmarked payroll tax of 13% paid by employers. Still, the share of the population reporting unmet medical needs is 8% – four times higher than the OECD average (OECD 2023). According to the latest National Audit Report (NAO2022), the population is likely to have to accept that the availability and quality of health services will not consistently meet expected levels in the near future due to both a shortage of health professionals and a lack of funding.
Digital tools, such as personalized ehealth portals and teleconsultation, which were already growing practices before COVID-19, have increased and improved access to care. Additionally, the resilience of the health system during COVID-19 was commendable, and several other health indicators, like low infant mortality, underscore the quality of the Estonian health system.
However, while recent changes have sought to increase the flexibility of medical education, the shortage of health workers remains an issue (NOA 2022) due both to low enrollment in university medical programs and high rates of physician burnout, a trend accelerated by the COVID-19 crisis. Furthermore, the number of physicians per capita is lower than the OECD average.
Health expenditure has recently grown, but as a percentage of GDP, it remains below the OECD average. There has long been concern that the Estonian health financing system, based on a health insurance fund, is not sustainable due to a shrinking working-age population and the increasing prevalence of flexible employment (see also “Sustainable Taxation”). Starting in 2022, the state began transferring 13% of pensions on behalf of nonworking pensioners to the EHIF to supplement the existing earmarked payroll tax of 13% paid by employers. Still, the share of the population reporting unmet medical needs is 8% – four times higher than the OECD average (OECD 2023). According to the latest National Audit Report (NAO2022), the population is likely to have to accept that the availability and quality of health services will not consistently meet expected levels in the near future due to both a shortage of health professionals and a lack of funding.
Digital tools, such as personalized ehealth portals and teleconsultation, which were already growing practices before COVID-19, have increased and improved access to care. Additionally, the resilience of the health system during COVID-19 was commendable, and several other health indicators, like low infant mortality, underscore the quality of the Estonian health system.
However, while recent changes have sought to increase the flexibility of medical education, the shortage of health workers remains an issue (NOA 2022) due both to low enrollment in university medical programs and high rates of physician burnout, a trend accelerated by the COVID-19 crisis. Furthermore, the number of physicians per capita is lower than the OECD average.
Citations:
National Audit Office. 2022. “Healthcare trends in Estonia.” https://www.riigikontroll.ee/tabid/215/Audit/3555/WorkerTab/Audit/WorkerId/40/language/et-EE/Default.aspx
OECD. 2023. “State of Health in the EU Estonia Country Health Profile 2023.” https://www.oecd.org/estonia/estonia-country-health-profile-2023-bc733713-en.htm
National Audit Office. 2022. “Healthcare trends in Estonia.” https://www.riigikontroll.ee/tabid/215/Audit/3555/WorkerTab/Audit/WorkerId/40/language/et-EE/Default.aspx
OECD. 2023. “State of Health in the EU Estonia Country Health Profile 2023.” https://www.oecd.org/estonia/estonia-country-health-profile-2023-bc733713-en.htm
Greece
During the Greek crisis of the previous decade and more recently, health policy has hindered the resilience of the health system. Although Greece’s healthy life expectancy (71 years) is above the OECD average (WHO 2019), the country is among the lowest spenders on healthcare as a percentage of GDP and on preventive health programs (OECD 2022).
The public healthcare system is underfunded and understaffed. However, the government has pledged to increase healthcare spending and hire 6,000 doctors and nurses for the country’s 130 public hospitals. These measures aim to improve the availability of health products and services and address rising costs due to an aging population and advancements in medical technology.
Despite these efforts, transparency in health services remains a concern. Chronic mismanagement of public hospitals and the high demand for private health services, including diagnostic tests, have led to Greece having the highest number of computed tomography scanners among OECD countries (OECD 2021).
The challenges of managing the COVID-19 pandemic and the government’s responsiveness to demands for better public healthcare have prompted policy shifts aimed at enhancing the resilience of the public health system.
The government’s priorities now include the digital transformation of the public healthcare system and early diagnosis (International Trade Association 2023). A national strategy for healthcare reform, led by the Ministry of Health, is outlined in the “National Action Plan for Public Health 2021–2025” (Ministry of Health 2021).
The digital transformation plan, financially supported by the EU’s Recovery and Resilience Facility, is part of the “Greece 2.0” plan and includes five specific programs: National Digital Patient Health Record, Cancer Treatment Digital Transformation Program, Improvement of Hospital Digital Readiness, Telemedicine, and National Insurance Fund Digital Transformation (Greek Government 2022).
In summary, despite lingering problems, health policies are largely aligned with the goal of achieving a resilient health system.
The public healthcare system is underfunded and understaffed. However, the government has pledged to increase healthcare spending and hire 6,000 doctors and nurses for the country’s 130 public hospitals. These measures aim to improve the availability of health products and services and address rising costs due to an aging population and advancements in medical technology.
Despite these efforts, transparency in health services remains a concern. Chronic mismanagement of public hospitals and the high demand for private health services, including diagnostic tests, have led to Greece having the highest number of computed tomography scanners among OECD countries (OECD 2021).
The challenges of managing the COVID-19 pandemic and the government’s responsiveness to demands for better public healthcare have prompted policy shifts aimed at enhancing the resilience of the public health system.
The government’s priorities now include the digital transformation of the public healthcare system and early diagnosis (International Trade Association 2023). A national strategy for healthcare reform, led by the Ministry of Health, is outlined in the “National Action Plan for Public Health 2021–2025” (Ministry of Health 2021).
The digital transformation plan, financially supported by the EU’s Recovery and Resilience Facility, is part of the “Greece 2.0” plan and includes five specific programs: National Digital Patient Health Record, Cancer Treatment Digital Transformation Program, Improvement of Hospital Digital Readiness, Telemedicine, and National Insurance Fund Digital Transformation (Greek Government 2022).
In summary, despite lingering problems, health policies are largely aligned with the goal of achieving a resilient health system.
Citations:
Greek Government. 2021. “Greece 2.0 – Pillars & Components.” https://greece20.gov.gr/en/pillars-and-components/
Μinistry of Health. 2021. “National Action Plan for Public Health 2021-2025.” https://www.moh.gov.gr/articles/health/domes-kai-draseis-gia-thn-ygeia/ethnika-sxedia-drashs/8776-ethniko-sxedio-drashs-gia-th-dhmosia-ygeia-2021-2025
OECD. 2021. “Health Care Resources.” https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC
OECD. 2022. “Health Expenditure and Financing.” https://stats.oecd.org/Index.aspx?DataSetCode=SHA.
WHO. 2019. “Healthy Life Expectancy – Data by Country.” https://www.who.int/data/gho/d
ata/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-birth
Greek Government. 2021. “Greece 2.0 – Pillars & Components.” https://greece20.gov.gr/en/pillars-and-components/
Μinistry of Health. 2021. “National Action Plan for Public Health 2021-2025.” https://www.moh.gov.gr/articles/health/domes-kai-draseis-gia-thn-ygeia/ethnika-sxedia-drashs/8776-ethniko-sxedio-drashs-gia-th-dhmosia-ygeia-2021-2025
OECD. 2021. “Health Care Resources.” https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC
OECD. 2022. “Health Expenditure and Financing.” https://stats.oecd.org/Index.aspx?DataSetCode=SHA.
WHO. 2019. “Healthy Life Expectancy – Data by Country.” https://www.who.int/data/gho/d
ata/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-birth
Italy
Italy’s national health system provides universal, comprehensive coverage for the entire population. The system is mainly financed by the central government, though healthcare is provided and managed by regional authorities, which have considerable autonomy in designing their organizational systems. Services provided are generally of medium to high quality across the country, although significant differences exist between regions.
Public spending on health was 6.8% of GDP in 2022, slightly below the OECD and EU averages. Private expenditure corresponded to 25% of public funding. After a peak in public spending in 2020 and 2021, the level returned to pre-2019 levels in 2022, despite high inflation around 12% that year. This indicates that both the Draghi and Meloni governments preferred to invest additional public funds in health at the expense of other policy objectives.
The system’s resilience is influenced by its regionalization, resulting in 20 different healthcare systems within Italy. This means national guidelines and programs are implemented differently across regions. During the COVID-19 pandemic, the best-performing regions had integrated health systems, such as Veneto, Toscana, and Emilia Romagna, compared to those with hospital-centered organizations.
The system is closely monitored at the central level, but this does not improve the quality of differentiated implementation. Digitalization and medical technology are well developed in the central and northern regions, while lagging in southern regions. Consequently, resilience is expected to vary significantly during crises. Concerns exist about the future capacity of the health system to maintain current standards, given insufficient public funding to guarantee technological equipment quality, recruit the required number of doctors, and address the chronic shortage of nurses.
Public spending on health was 6.8% of GDP in 2022, slightly below the OECD and EU averages. Private expenditure corresponded to 25% of public funding. After a peak in public spending in 2020 and 2021, the level returned to pre-2019 levels in 2022, despite high inflation around 12% that year. This indicates that both the Draghi and Meloni governments preferred to invest additional public funds in health at the expense of other policy objectives.
The system’s resilience is influenced by its regionalization, resulting in 20 different healthcare systems within Italy. This means national guidelines and programs are implemented differently across regions. During the COVID-19 pandemic, the best-performing regions had integrated health systems, such as Veneto, Toscana, and Emilia Romagna, compared to those with hospital-centered organizations.
The system is closely monitored at the central level, but this does not improve the quality of differentiated implementation. Digitalization and medical technology are well developed in the central and northern regions, while lagging in southern regions. Consequently, resilience is expected to vary significantly during crises. Concerns exist about the future capacity of the health system to maintain current standards, given insufficient public funding to guarantee technological equipment quality, recruit the required number of doctors, and address the chronic shortage of nurses.
Japan
Digitalization of healthcare services has accelerated since the establishment of the Digital Agency in September 2021. The gradual implementation of the My Number system – a 12-digit personal number for each citizen – is critical for this reform. Health insurance cards are planned to be integrated with My Number in 2024, but there have repeatedly been problems with the system’s implementation. In May 2023, it was found that 60% of medical institutions with an online insurance confirmation system had experienced issues with My Number, including linking patients’ data with wrong individuals.
The COVID-19 pandemic exposed structural deficiencies of the Japanese healthcare system in crisis situations, such as problems with coordinating the allocation of medical resources, insufficient collaboration between healthcare providers, local governments and public agencies, inability of the government to mobilize the resources of private hospitals, lack of clearly designated gatekeepers to healthcare and inaccuracy of official statistics on medical resources. As a result, Japan’s response to the COVID-19 pandemic was relatively slow. Moreover, due to a rigid drug approval system, the initial COVID-19 vaccination rollout proceeded at a slow pace.
Public social spending has increased massively in the last three decades, turning Japan from a small public welfare state to one that spends a similar amount as the large Western European welfare states. Most of the spending hike is due to increased spending on old age and healthcare, and is linked to demographic aging. While spending per head has been kept relatively stable, the rapid expansion of the elderly population has made it difficult to rein in total spending. The government has implemented some measures to offset rising healthcare costs, for example, introducing a community-based integrated care system, which combines various kinds of care for elders at the local level. Japan was also one of the first countries in the world to introduce Long-Term Care Insurance, to which all residents 40 years of age or older must contribute. The challenges posed by demographic aging, however, cannot be considered solved and will grow in severity over the coming years.
The COVID-19 pandemic exposed structural deficiencies of the Japanese healthcare system in crisis situations, such as problems with coordinating the allocation of medical resources, insufficient collaboration between healthcare providers, local governments and public agencies, inability of the government to mobilize the resources of private hospitals, lack of clearly designated gatekeepers to healthcare and inaccuracy of official statistics on medical resources. As a result, Japan’s response to the COVID-19 pandemic was relatively slow. Moreover, due to a rigid drug approval system, the initial COVID-19 vaccination rollout proceeded at a slow pace.
Public social spending has increased massively in the last three decades, turning Japan from a small public welfare state to one that spends a similar amount as the large Western European welfare states. Most of the spending hike is due to increased spending on old age and healthcare, and is linked to demographic aging. While spending per head has been kept relatively stable, the rapid expansion of the elderly population has made it difficult to rein in total spending. The government has implemented some measures to offset rising healthcare costs, for example, introducing a community-based integrated care system, which combines various kinds of care for elders at the local level. Japan was also one of the first countries in the world to introduce Long-Term Care Insurance, to which all residents 40 years of age or older must contribute. The challenges posed by demographic aging, however, cannot be considered solved and will grow in severity over the coming years.
Citations:
Japan International Cooperation Agency. 2022. “Community-based Integrated Care in Japan – Suggestions for developing countries from cases in Japan.” https://openjicareport.jica.go.jp/pdf/1000048192.pdf
“My Number glitches undermine Japan’s digital future.” The Japan Times, June 9. https://www.japantimes.co.jp/opinion/2023/06/09/editorials/my-number-failure/
Nakahara, Shinji, Haruhiko Inada, Masao Ichikawa, and Jun Tomio. 2021. “Japan’s Slow Response to Improve Access to Inpatient Care for COVID-19 Patients.” Front Public Health 9: 791182. https://doi.org/10.3389/fpubh.2021.791182
OECD. 2023. “Health at a Glance 2023 Country Note Japan.” Paris: OECD. https://www.oecd.org/japan/health-at-a-glance-Japan-EN.pdf
Swift, Rocky. 2021. “Japan vaccine chief blames drug approval system for slow inoculation drive.” Reuters May 13.
Japan International Cooperation Agency. 2022. “Community-based Integrated Care in Japan – Suggestions for developing countries from cases in Japan.” https://openjicareport.jica.go.jp/pdf/1000048192.pdf
“My Number glitches undermine Japan’s digital future.” The Japan Times, June 9. https://www.japantimes.co.jp/opinion/2023/06/09/editorials/my-number-failure/
Nakahara, Shinji, Haruhiko Inada, Masao Ichikawa, and Jun Tomio. 2021. “Japan’s Slow Response to Improve Access to Inpatient Care for COVID-19 Patients.” Front Public Health 9: 791182. https://doi.org/10.3389/fpubh.2021.791182
OECD. 2023. “Health at a Glance 2023 Country Note Japan.” Paris: OECD. https://www.oecd.org/japan/health-at-a-glance-Japan-EN.pdf
Swift, Rocky. 2021. “Japan vaccine chief blames drug approval system for slow inoculation drive.” Reuters May 13.
Lithuania
Health outcomes in Lithuania are among the poorest in the EU. Lithuania has one of the lowest expected healthy life expectancies at birth and one of the lowest overall life expectancies. According to the OECD country report 2023, life expectancy in Lithuania was 74.2 years – 6.1 years below the OECD average. The preventable mortality in Lithuania was 326 deaths per 100,000 – much higher than the OECD average of 158 – with the treatable mortality at 155 per 100,000, also higher than the OECD average of 79. Additionally, government spending on health services as a percentage of GDP remains one of the lowest such figures among OECD countries.
According to OECD data, excess mortality during the COVID-19 pandemic (2020 – 2021) in Lithuania was close to the OECD average. However, the number of COVID-19-related deaths in Lithuania during this period was significantly higher, reaching 2,645 per million compared to the OECD average of 1,634 per million. The number of hospital discharges and the waiting times for surgery in Lithuania in 2020 increased significantly more than the OECD average.
In terms of resilience, one of the key lessons learned by policymakers during this crisis was the need not only to maintain sufficient reserves of protective medical equipment but also to have timely access to data on key crisis management indicators, such as the number of infected individuals and their distribution, available hospital facilities, and vaccination dynamics. Having the capacity for data analysis was also seen to be critical.
The coalition government formed in late 2020 has been straightforward about these issues, stating them upfront in its program. In addition to poor health outcomes, it also identified a relatively fast-aging society as a challenge complicating efforts to improve health indicators. Among its goals in the healthcare sector, the program highlighted the need to strengthen the resilience of the healthcare system with regard to future threats and crises.
Placing a high priority on increasing resilience, as well as on being able to adapt to the fast-changing environment and manage those changes effectively, it outlined the following initiatives. First, it aims to enhance readiness for threats and crises such as future pandemics or accidents at the nuclear power station in nearby Belarus. The plan highlights the need to establish sufficient reserves of civilian protection instruments, educate society and train healthcare workers in relevant competencies.
Second, the plan emphasizes the need for the healthcare system to be prepared for future challenges such as climate change, an aging society, antibiotic resistance and growing volumes of disinformation. To address these challenges, it commits to making the healthcare system open to future changes and innovations, while also developing the use of information technologies and artificial intelligence; strengthening cooperation with NGOs, media and various stakeholders; developing good practices; and improving the prestige of the medical profession. However, it does not set indicators of success explicitly linked to increasing the resilience of the country’s healthcare system.
In July 2021, the government allocated €268 million as a part of the New Generation Lithuania plan, funded by the EU Recovery and Resilience Facility, for a component described as “a resilient and future-proof health system.” Under this component, the government plans a series of reforms and investments aimed at: 1) improving the quality and accessibility of healthcare services and promoting innovation, 2) enhancing long-term care services, and 3) strengthening the resilience of the healthcare system to handle emergencies.
Regarding reforms, the focus is on shifting further to outpatient care, reorganizing the hospital network, digitalizing healthcare, improving the working conditions of health professionals, addressing healthcare staff shortages and skills, introducing measures to enhance the quality of healthcare, scaling up prevention measures, improving access to long-term care, and reforming healthcare financing to reduce dependence on employment-related contributions.
In terms of investments, the plan includes targeted measures to create a center for advanced therapies, establish a health professionals’ competence platform, digitalize the health system, develop an integrated healthcare quality assessment model, and set up long-term care day centers and mobile teams. To ensure the efficient delivery of health services during emergencies and to strengthen the resilience of the health system, investments are proposed to modernize the infrastructure of healthcare facilities to ensure their effective functioning in emergency and crisis situations.
Among the main achievements listed in its annual report for 2022, the government highlighted the consolidation of public healthcare organizations to improve coordination of their activities, as well as the adoption of by-laws on the repeated use of health data accumulated in information registers for the purposes of scientific research, innovations, knowledge management and healthcare policy changes.
According to OECD data, excess mortality during the COVID-19 pandemic (2020 – 2021) in Lithuania was close to the OECD average. However, the number of COVID-19-related deaths in Lithuania during this period was significantly higher, reaching 2,645 per million compared to the OECD average of 1,634 per million. The number of hospital discharges and the waiting times for surgery in Lithuania in 2020 increased significantly more than the OECD average.
In terms of resilience, one of the key lessons learned by policymakers during this crisis was the need not only to maintain sufficient reserves of protective medical equipment but also to have timely access to data on key crisis management indicators, such as the number of infected individuals and their distribution, available hospital facilities, and vaccination dynamics. Having the capacity for data analysis was also seen to be critical.
The coalition government formed in late 2020 has been straightforward about these issues, stating them upfront in its program. In addition to poor health outcomes, it also identified a relatively fast-aging society as a challenge complicating efforts to improve health indicators. Among its goals in the healthcare sector, the program highlighted the need to strengthen the resilience of the healthcare system with regard to future threats and crises.
Placing a high priority on increasing resilience, as well as on being able to adapt to the fast-changing environment and manage those changes effectively, it outlined the following initiatives. First, it aims to enhance readiness for threats and crises such as future pandemics or accidents at the nuclear power station in nearby Belarus. The plan highlights the need to establish sufficient reserves of civilian protection instruments, educate society and train healthcare workers in relevant competencies.
Second, the plan emphasizes the need for the healthcare system to be prepared for future challenges such as climate change, an aging society, antibiotic resistance and growing volumes of disinformation. To address these challenges, it commits to making the healthcare system open to future changes and innovations, while also developing the use of information technologies and artificial intelligence; strengthening cooperation with NGOs, media and various stakeholders; developing good practices; and improving the prestige of the medical profession. However, it does not set indicators of success explicitly linked to increasing the resilience of the country’s healthcare system.
In July 2021, the government allocated €268 million as a part of the New Generation Lithuania plan, funded by the EU Recovery and Resilience Facility, for a component described as “a resilient and future-proof health system.” Under this component, the government plans a series of reforms and investments aimed at: 1) improving the quality and accessibility of healthcare services and promoting innovation, 2) enhancing long-term care services, and 3) strengthening the resilience of the healthcare system to handle emergencies.
Regarding reforms, the focus is on shifting further to outpatient care, reorganizing the hospital network, digitalizing healthcare, improving the working conditions of health professionals, addressing healthcare staff shortages and skills, introducing measures to enhance the quality of healthcare, scaling up prevention measures, improving access to long-term care, and reforming healthcare financing to reduce dependence on employment-related contributions.
In terms of investments, the plan includes targeted measures to create a center for advanced therapies, establish a health professionals’ competence platform, digitalize the health system, develop an integrated healthcare quality assessment model, and set up long-term care day centers and mobile teams. To ensure the efficient delivery of health services during emergencies and to strengthen the resilience of the health system, investments are proposed to modernize the infrastructure of healthcare facilities to ensure their effective functioning in emergency and crisis situations.
Among the main achievements listed in its annual report for 2022, the government highlighted the consolidation of public healthcare organizations to improve coordination of their activities, as well as the adoption of by-laws on the repeated use of health data accumulated in information registers for the purposes of scientific research, innovations, knowledge management and healthcare policy changes.
Citations:
OECD. 2023. “Health at a Glance 2023 Country Note: Lithuania.” https://www.oecd.org/health/health-at-a-glance/
OECD. 2023. Ready for the Next Crisis? Investing in Health System Resilience. Paris: OECD Publishing. https://doi.org/10.1787/1e53cf80-en
The Seimas, the Resolution on The Program of the Eighteenth Government of Lithuania (in Lithuanian). 11 December 2020. No. XIV-72.
Ministry of Finance. “Materials on New Generation Lithuania Plan.” https://finmin.lrv.lt/en/eu-and-international-cooperation/new-generation-lithuania/
Council of the European Union. 2023. Annex to the Council Implementing Decision Amending Implementing Decision of 20 July 2021 on the Approval of the Assessment of the Recovery and Resilience Plan for Lithuania, Interinstitutional File: 2023/0387 (NLE), Brussels, 27 October 2023.
Seimui teikiama Vyriausybės 2022 metų veiklos ataskaita. 2023. “The Government Annual Report for 2022, 17 May 2023 (in Lithuanian).” https://epilietis.lrv.lt/lt/naujienos/seimui-teikiama-vyriausybes-2022-metu-veik-los-ataskaita
OECD. 2023. “Health at a Glance 2023 Country Note: Lithuania.” https://www.oecd.org/health/health-at-a-glance/
OECD. 2023. Ready for the Next Crisis? Investing in Health System Resilience. Paris: OECD Publishing. https://doi.org/10.1787/1e53cf80-en
The Seimas, the Resolution on The Program of the Eighteenth Government of Lithuania (in Lithuanian). 11 December 2020. No. XIV-72.
Ministry of Finance. “Materials on New Generation Lithuania Plan.” https://finmin.lrv.lt/en/eu-and-international-cooperation/new-generation-lithuania/
Council of the European Union. 2023. Annex to the Council Implementing Decision Amending Implementing Decision of 20 July 2021 on the Approval of the Assessment of the Recovery and Resilience Plan for Lithuania, Interinstitutional File: 2023/0387 (NLE), Brussels, 27 October 2023.
Seimui teikiama Vyriausybės 2022 metų veiklos ataskaita. 2023. “The Government Annual Report for 2022, 17 May 2023 (in Lithuanian).” https://epilietis.lrv.lt/lt/naujienos/seimui-teikiama-vyriausybes-2022-metu-veik-los-ataskaita
Portugal
While the country effectively addressed the Covid-19 pandemic, the post-pandemic period has aggravated existing deficiencies in Portugal’s national health system, resulting in severe strain. Efforts to curb public expenditure over the past few decades have financially pressured the healthcare sector. This, combined with the failure to execute promised investments over the last decade, has led to significant reductions in some services, longer wait times for consultations and surgeries, and resignations by medical directors in protest. Consequently, hospitals across the country have faced significant constraints, with some services even occasionally closing (RTP, 2023).
The government is trying to increase the recruitment of doctors and nurses into the health system, seeking to implement a speedier, simpler, and less bureaucratic process. In December 2023, it opened nearly 1,000 new job openings for newly graduated specialist doctors. In April of the same year, it had already conducted a similar recruitment process (Público, 2023). However, past experience with recruiting programs like these shows that if working conditions and wages do not improve, many job opportunities will remain unfilled.
To address existing deficiencies and enhance the resilience of the health system, the Portuguese government is undertaking a significant reform in the use of technology within the national health service (NHS). This involves an investment of over €300 million from the Recovery and Resilience Plan for the digital transformation of health. This substantial investment aims to expedite the enhancement of infrastructures and data networks, develop new tools for citizens, value the work of healthcare professionals, and create more efficient systems for data storage and usage. A notable portion of this investment, €117 million, is allocated for acquiring advanced medical equipment. The goal is to modernize the technology available to healthcare providers and patients, with the anticipated benefit of increasing the production of diagnostic tests and reducing waiting times (Observador, 2023).
The utilization of Recovery and Resilience Plan (RRP) funds primarily focuses on overcoming challenges that hinder the digital transition in the NHS. These challenges include the scarcity of adequate hardware and software for health professionals, the need to standardize information systems, and the imperative to enhance user experience and data accessibility. The implementation plan encompasses several measures, including the integration of functionalities for telehealth and telemonitoring. If these initiatives are implemented, they may significantly contribute to modernizing the NHS, making healthcare more accessible and efficient for both healthcare providers and patients in Portugal. However, to achieve this, the plan must avoid the large gap between what is idealized and what is actually delivered that plagues public policy across many areas.
The government is trying to increase the recruitment of doctors and nurses into the health system, seeking to implement a speedier, simpler, and less bureaucratic process. In December 2023, it opened nearly 1,000 new job openings for newly graduated specialist doctors. In April of the same year, it had already conducted a similar recruitment process (Público, 2023). However, past experience with recruiting programs like these shows that if working conditions and wages do not improve, many job opportunities will remain unfilled.
To address existing deficiencies and enhance the resilience of the health system, the Portuguese government is undertaking a significant reform in the use of technology within the national health service (NHS). This involves an investment of over €300 million from the Recovery and Resilience Plan for the digital transformation of health. This substantial investment aims to expedite the enhancement of infrastructures and data networks, develop new tools for citizens, value the work of healthcare professionals, and create more efficient systems for data storage and usage. A notable portion of this investment, €117 million, is allocated for acquiring advanced medical equipment. The goal is to modernize the technology available to healthcare providers and patients, with the anticipated benefit of increasing the production of diagnostic tests and reducing waiting times (Observador, 2023).
The utilization of Recovery and Resilience Plan (RRP) funds primarily focuses on overcoming challenges that hinder the digital transition in the NHS. These challenges include the scarcity of adequate hardware and software for health professionals, the need to standardize information systems, and the imperative to enhance user experience and data accessibility. The implementation plan encompasses several measures, including the integration of functionalities for telehealth and telemonitoring. If these initiatives are implemented, they may significantly contribute to modernizing the NHS, making healthcare more accessible and efficient for both healthcare providers and patients in Portugal. However, to achieve this, the plan must avoid the large gap between what is idealized and what is actually delivered that plagues public policy across many areas.
Citations:
RTP. 2023. “Constrangimentos no SNS. Médicos mantêm escusas, enfermeiros entram em greve.” RTP Notícias, November 3.
https://www.rtp.pt/noticias/pais/constrangimentos-no-sns-medicos-mantem-escusas-enfermeiros-entram-em-greve_n1526668
Público. 2023. “Governo abre quase 1000 vagas no SNS para médicos especialistas recém-formados.” Público, December 2.
https://www.publico.pt/2023/12/02/sociedade/noticia/governo-abre-quase-1000-vagas-sns-medicos-recemespecialistas-2072330
Observador. 2023. “Governo anuncia 117 milhões para modernização tecnológica do SNS.” Observador, November 23.
https://observador.pt/2023/11/23/governo-anuncia-117-milhoes-para-modernizacao-tecnologica-do-sns/
RTP. 2023. “Constrangimentos no SNS. Médicos mantêm escusas, enfermeiros entram em greve.” RTP Notícias, November 3.
https://www.rtp.pt/noticias/pais/constrangimentos-no-sns-medicos-mantem-escusas-enfermeiros-entram-em-greve_n1526668
Público. 2023. “Governo abre quase 1000 vagas no SNS para médicos especialistas recém-formados.” Público, December 2.
https://www.publico.pt/2023/12/02/sociedade/noticia/governo-abre-quase-1000-vagas-sns-medicos-recemespecialistas-2072330
Observador. 2023. “Governo anuncia 117 milhões para modernização tecnológica do SNS.” Observador, November 23.
https://observador.pt/2023/11/23/governo-anuncia-117-milhoes-para-modernizacao-tecnologica-do-sns/
Switzerland
Major characteristics of the Swiss health system are decentralization and liberalism. There is one federal health system and 26 cantonal health systems; within the cantonal health systems, there are also variations by municipality. The cantonal competence is in the field of health provisions (such as services in case of emergencies or catastrophes, and provision of transportation or rescue services), hospitals, health policy, training of medical staff, licensing to practice medicine and medical services, and the provision of subsidies for health insurance premiums for low-income groups. Competencies on the federal level are mainly in the field of general health policy issues, supervision of health insurance providers, pharmaceutical industry oversight and regulation of medical staff training.
In 1996, health insurance was made obligatory for all residents. Premiums for health insurance do not depend on income and do not take into account the number of family members. Hence, insurance must be bought for each member of the family, although premiums are reduced for children. In recent years, this liberal model has been modified through the provision of subsidies for low-wage earners and their families. The cantons decide on the extent of subsidies; the federation covers about half the cost of these cantonal subsidies.
Mandatory healthcare insurance is provided by a large number of competing mutual funds (nonprofit insurance programs), all of which are required to offer the same benefits. However, health insurance companies can make a profit on optional healthcare insurance packages (see section P.11.3). Hence, there is no competition in the area of benefits, but only in the field of premiums, which is largely a function of administrative costs and membership structure. Considerable discussion has focused on whether this competitive market structure should be replaced by a single state-owned insurance company. In 2014, voters decided in a popular vote to retain the present system.
Total costs of the Swiss health sector amount to about 12% of GDP, and 13% of all employees work in the health sector (Trein et al. 2022: 904; Trein et al. 2023). In comparative view, Switzerland numbers among the countries with the highest healthcare costs, and arguably those with the highest quality of healthcare (see for instance the large Lancet study on comparative mortality index GBD 2015). The availability of health products and services is generally good, although the system has equity issues (see next subsection).
In 2021, the healthcare system was financed by the public sector (23%), by private mutual funds (health insurance providers) (36%), by other (private) health insurance providers (9%) and by patient own payments (22%) (FSO 2023). The health sector depends crucially on foreign labor, in particular physicians and nurses, since the Swiss education system does not attract and train enough such specialists.
Given this decentralized structure and the strong role of private (and competing) actors, there is no single answer to the question of how health policy contributes to the resilience of the health system.
Digitalization of health systems is a concern, in particular at the federal level (Federal Council 2019: 12-15). The system produces sufficient health products and services when and where they are needed, even in times of crisis. This was demonstrated during the pandemic when the health system was placed under strong pressure but did not collapse at any time.
While the resilience of the healthcare system in terms of quality, health outcomes and sufficient supply of health services is exceptional, the system has limited resilience in many regards, above all with regard to rising costs in the health sector. Currently, a number of attempts to curb the rapid increase in health expenditures are meeting with stiff resistance from vested interests, such as doctors, hospitals and health insurance funds. Arguably, the political elites have no consensus and or even convincing ideas regarding a grand cost-curbing strategy. Likewise, a salient issue is the strong increases in healthcare insurance premiums, which tend to overburden the household budgets of low- to middle-income earners. This raises the question of whether the system of competing mutual funds with parallel administrations is sustainable, and whether the liberal model of flat rate per capita premiums – albeit weakened by subsidies for low-income earners – can still be defended. Resilience is also limited regarding environmental durability: the Swiss health system could better take into account the close interactions between human, animal and environmental health (Senn et al. 2022). Resilience is also lacking with respect to the complex governance of the Swiss health system that is not sustainable in its current form, with its fragmentation across governance levels, lack of a central overview and steering body, poor foresight capacity regarding labor shortages, and excessive influence of insurance companies in the policymaking process (Monod et al. 2023). Finally, the system has room for improvement regarding its capacities to meet future challenges, be it population aging or health crises.
In 1996, health insurance was made obligatory for all residents. Premiums for health insurance do not depend on income and do not take into account the number of family members. Hence, insurance must be bought for each member of the family, although premiums are reduced for children. In recent years, this liberal model has been modified through the provision of subsidies for low-wage earners and their families. The cantons decide on the extent of subsidies; the federation covers about half the cost of these cantonal subsidies.
Mandatory healthcare insurance is provided by a large number of competing mutual funds (nonprofit insurance programs), all of which are required to offer the same benefits. However, health insurance companies can make a profit on optional healthcare insurance packages (see section P.11.3). Hence, there is no competition in the area of benefits, but only in the field of premiums, which is largely a function of administrative costs and membership structure. Considerable discussion has focused on whether this competitive market structure should be replaced by a single state-owned insurance company. In 2014, voters decided in a popular vote to retain the present system.
Total costs of the Swiss health sector amount to about 12% of GDP, and 13% of all employees work in the health sector (Trein et al. 2022: 904; Trein et al. 2023). In comparative view, Switzerland numbers among the countries with the highest healthcare costs, and arguably those with the highest quality of healthcare (see for instance the large Lancet study on comparative mortality index GBD 2015). The availability of health products and services is generally good, although the system has equity issues (see next subsection).
In 2021, the healthcare system was financed by the public sector (23%), by private mutual funds (health insurance providers) (36%), by other (private) health insurance providers (9%) and by patient own payments (22%) (FSO 2023). The health sector depends crucially on foreign labor, in particular physicians and nurses, since the Swiss education system does not attract and train enough such specialists.
Given this decentralized structure and the strong role of private (and competing) actors, there is no single answer to the question of how health policy contributes to the resilience of the health system.
Digitalization of health systems is a concern, in particular at the federal level (Federal Council 2019: 12-15). The system produces sufficient health products and services when and where they are needed, even in times of crisis. This was demonstrated during the pandemic when the health system was placed under strong pressure but did not collapse at any time.
While the resilience of the healthcare system in terms of quality, health outcomes and sufficient supply of health services is exceptional, the system has limited resilience in many regards, above all with regard to rising costs in the health sector. Currently, a number of attempts to curb the rapid increase in health expenditures are meeting with stiff resistance from vested interests, such as doctors, hospitals and health insurance funds. Arguably, the political elites have no consensus and or even convincing ideas regarding a grand cost-curbing strategy. Likewise, a salient issue is the strong increases in healthcare insurance premiums, which tend to overburden the household budgets of low- to middle-income earners. This raises the question of whether the system of competing mutual funds with parallel administrations is sustainable, and whether the liberal model of flat rate per capita premiums – albeit weakened by subsidies for low-income earners – can still be defended. Resilience is also limited regarding environmental durability: the Swiss health system could better take into account the close interactions between human, animal and environmental health (Senn et al. 2022). Resilience is also lacking with respect to the complex governance of the Swiss health system that is not sustainable in its current form, with its fragmentation across governance levels, lack of a central overview and steering body, poor foresight capacity regarding labor shortages, and excessive influence of insurance companies in the policymaking process (Monod et al. 2023). Finally, the system has room for improvement regarding its capacities to meet future challenges, be it population aging or health crises.
Citations:
Federal Council. 2019. “Health2030 – the Federal Council’s health policy strategy for the period 2020–2030.” https://www.bag.admin.ch/bag/en/home/strategie-und-politik/gesundheit-2030/gesundheitspolitische-strategie-2030.html
FSO (Federal Statistical Office, Bundesanmt für Statistik). 2023. “Kosten. Finanzierung.” https://www.bfs.admin.ch/bfs/de/home/statistiken/gesundheit/kosten-finanzierung.html
GBD 2015 Healthcare Access and Quality Collaborators. 2017. “Healthcare Access and Quality Index based on mortality from causes amenable to personal healthcare in 195 countries and territories, 1990–2015: A novel analysis from the Global Burden of Disease Study 2015.” The Lancet 390 (10091): 231-266.
Monod, S., Cavalli, V., Pin, S., and Grandchamp, C. 2023. “Système de santé suisse : y a-t-il un pilote dans la machine?” Rev Med Suisse 19 (819): 583–588. https://www.revmed.ch/revue-medicale-suisse/2023/revue-medicale-suisse-819/systeme-de-sante-suisse-y-a-t-il-un-pilote-dans-la-machine
Nicolas Senn, Marie Gaille, María del Río Carral, Julia Gonzalez Holguera. 2022. Santé et environnement: Vers une nouvelle approche globale. Chêne-Bourg: Editions Médecine et Hygiène.
Trein, Philipp, Adrian Vatter, and Christian Rüefli. 2022. “Gesundheitspolitik.” In Handbuch der Schweizer Politik, eds. Yannis Papadopoulos, Pascal Sciarini, Adrian Vatter, Silja Häusermann, Patrick Emmenegger, and Flavia Fossati. 7th ed. Zürich: NZZ Libro, 903-930.
Trein, Philipp, Christian Rüefli, and Adrian Vatter. 2023. “Health Policy.” In The Oxford Handbook of Swiss Politics, eds. Patrick Emmenegger, Flavia Fossati, Silja Häusermann, Yannis Papadopoulos, Pascal Sciarini, and Adrian Vatter. Oxford: Oxford University Press, 714–732. https://doi.org/10.1093/oxfordhb/9780192871787.013.37
Federal Council. 2019. “Health2030 – the Federal Council’s health policy strategy for the period 2020–2030.” https://www.bag.admin.ch/bag/en/home/strategie-und-politik/gesundheit-2030/gesundheitspolitische-strategie-2030.html
FSO (Federal Statistical Office, Bundesanmt für Statistik). 2023. “Kosten. Finanzierung.” https://www.bfs.admin.ch/bfs/de/home/statistiken/gesundheit/kosten-finanzierung.html
GBD 2015 Healthcare Access and Quality Collaborators. 2017. “Healthcare Access and Quality Index based on mortality from causes amenable to personal healthcare in 195 countries and territories, 1990–2015: A novel analysis from the Global Burden of Disease Study 2015.” The Lancet 390 (10091): 231-266.
Monod, S., Cavalli, V., Pin, S., and Grandchamp, C. 2023. “Système de santé suisse : y a-t-il un pilote dans la machine?” Rev Med Suisse 19 (819): 583–588. https://www.revmed.ch/revue-medicale-suisse/2023/revue-medicale-suisse-819/systeme-de-sante-suisse-y-a-t-il-un-pilote-dans-la-machine
Nicolas Senn, Marie Gaille, María del Río Carral, Julia Gonzalez Holguera. 2022. Santé et environnement: Vers une nouvelle approche globale. Chêne-Bourg: Editions Médecine et Hygiène.
Trein, Philipp, Adrian Vatter, and Christian Rüefli. 2022. “Gesundheitspolitik.” In Handbuch der Schweizer Politik, eds. Yannis Papadopoulos, Pascal Sciarini, Adrian Vatter, Silja Häusermann, Patrick Emmenegger, and Flavia Fossati. 7th ed. Zürich: NZZ Libro, 903-930.
Trein, Philipp, Christian Rüefli, and Adrian Vatter. 2023. “Health Policy.” In The Oxford Handbook of Swiss Politics, eds. Patrick Emmenegger, Flavia Fossati, Silja Häusermann, Yannis Papadopoulos, Pascal Sciarini, and Adrian Vatter. Oxford: Oxford University Press, 714–732. https://doi.org/10.1093/oxfordhb/9780192871787.013.37
UK
Health is a competence of the devolved administrations in the UK, for whom it represents the largest spending area. Public health agencies operate in all four nations of the UK. According to a study by the Tony Blair Institute, the UK “has become one of the unhealthiest populations in the OECD,” an outcome the study attributes primarily to “the country’s failure to manage demand,” that is, to prevent rather than treat ill-health. A striking statistic from the report indicates that in the fiscal year 2021-22, £3.3 billion was spent on public health grants, barely 1.5% of the £229 billion total health expenditure. Obesity, smoking, and mental health are cited as underlying causes, and the aftermath of the pandemic has aggravated an already poor record. Mental health has been highlighted as needing greater public support, despite promises to spend more on it in the Mental Health Recovery Action Plan announced for England in 2021. Dentistry is also problematic, with the availability of NHS surgeries collapsing and many patients struggling to obtain, let alone pay for, private care.
In Scotland, a discussion paper launched in January 2023 acknowledged that too little was being invested in health protection. The paper identifies two overarching challenges: low and falling life expectancy and widening health inequalities. There has also been regular media coverage of the very high rate of drug abuse deaths in Scotland.
The main instrument for preventive medicine in England is the NHS Health Check, introduced in 2009, aimed at assessing six major risk factors that drive early death, disability, and health inequality: alcohol intake, cholesterol levels, blood pressure, obesity, lack of physical activity, and smoking. Checks are supposed to be done every five years. A review in 2021 claimed the check had largely achieved its aims, although it reached only two in five eligible people. Other evidence notes geographical disparities in the take-up and quality of follow-up.
At its best, the NHS offers high-quality treatment free at the point of delivery, but its use of IT is frequently criticized. Media stories often highlight the lack of interoperability of IT systems, even within the same hospital, and the burden on medical staff in reconciling these systems. Rapid changes in the use of digitized services occurred during the pandemic, but there is a need to build on these improvements.
There is a vicious circle in healthcare: primary healthcare struggles to cope as appointments with physicians become harder to obtain, leading patients to go to emergency rooms, thereby increasing hospital waiting times. Failings in social care provision make it harder to move patients out of the hospital. These and other difficulties have been examined by organizations like the King’s Fund, the Commission on Health and Prosperity launched by the Institute for Public Policy Research, and a commission under the auspices of The Times newspaper. While there are some advances, such as an increase in cancer screening, the health system is notoriously slow to adapt, even when the directions for change are evident and well-documented.
In Scotland, a discussion paper launched in January 2023 acknowledged that too little was being invested in health protection. The paper identifies two overarching challenges: low and falling life expectancy and widening health inequalities. There has also been regular media coverage of the very high rate of drug abuse deaths in Scotland.
The main instrument for preventive medicine in England is the NHS Health Check, introduced in 2009, aimed at assessing six major risk factors that drive early death, disability, and health inequality: alcohol intake, cholesterol levels, blood pressure, obesity, lack of physical activity, and smoking. Checks are supposed to be done every five years. A review in 2021 claimed the check had largely achieved its aims, although it reached only two in five eligible people. Other evidence notes geographical disparities in the take-up and quality of follow-up.
At its best, the NHS offers high-quality treatment free at the point of delivery, but its use of IT is frequently criticized. Media stories often highlight the lack of interoperability of IT systems, even within the same hospital, and the burden on medical staff in reconciling these systems. Rapid changes in the use of digitized services occurred during the pandemic, but there is a need to build on these improvements.
There is a vicious circle in healthcare: primary healthcare struggles to cope as appointments with physicians become harder to obtain, leading patients to go to emergency rooms, thereby increasing hospital waiting times. Failings in social care provision make it harder to move patients out of the hospital. These and other difficulties have been examined by organizations like the King’s Fund, the Commission on Health and Prosperity launched by the Institute for Public Policy Research, and a commission under the auspices of The Times newspaper. While there are some advances, such as an increase in cancer screening, the health system is notoriously slow to adapt, even when the directions for change are evident and well-documented.
Citations:
https://www.gov.uk/government/publications/nhs-health-check-programme-review/preventing-illness-and-improving-health-for-all-a-review-of-the-nhs-health-check-programme-and-recommendations#what-the-review-found
https://www.institute.global/insights/public-services/fit-future-how-healthy-population-will-unlock-stronger-britain
https://publichealthscotland.scot/media/17437/public-health-approach-to-prevention-and-the-role-of-nhsscotland.pdf
https://www.gov.uk/government/publications/nhs-health-check-programme-review/preventing-illness-and-improving-health-for-all-a-review-of-the-nhs-health-check-programme-and-recommendations#what-the-review-found
https://www.institute.global/insights/public-services/fit-future-how-healthy-population-will-unlock-stronger-britain
https://publichealthscotland.scot/media/17437/public-health-approach-to-prevention-and-the-role-of-nhsscotland.pdf
Health policies are only somewhat aligned with the goal of achieving a resilient health system.
5
Latvia
Healthcare services are financed through various means – the state budget, private insurance, or out-of-pocket payments by patients. Patients make a co-payment for state-funded services, which is a small portion of the total cost, while the state covers the majority based on national service tariffs. For those with health insurance, the coverage for specific services depends on the terms of their policy.
In 2023, the Latvian government approved a budget law that allocates €1.6 billion to the health sector. Of this amount, €1.35 billion is designated for outpatient and inpatient healthcare services, including general practice, laboratory tests, specialist consultations, emergency services, and medication. Specialized healthcare will receive €124 million, covering emergency medical services, blood services, forensic examinations, and anti-doping policies. Higher medical education is allocated €59 million, while healthcare finance administration and the Medical Risk Fund will receive €15 million. For disease prevention, health promotion, and healthcare service supervision, €11.3 million is planned. Additionally, €32.3 million is allocated for European Structural Fund projects and €5.6 million for sector management. An additional €85.8 million has been allocated for 2023 to address specific healthcare challenges (Veselības ministrija, 2023).
While a core set of healthcare services covers the entire population, satisfaction with the quality and availability of healthcare is relatively low. Only 57% of the population is satisfied, compared to the OECD average of 67%. This discrepancy suggests potential gaps in healthcare quality or accessibility. One in ten people did not visit a doctor in 2022. Additionally, 27% reported not visiting due to long wait times, while 25% cited affordability issues.
Financially, Latvia’s healthcare system relies less on mandatory prepayment (69%) compared to the OECD average of 76%, reflecting a higher dependence on out-of-pocket spending. This is further demonstrated by 4% of Latvians reporting unmet healthcare needs, surpassing the OECD average of 2.3%.
Analyzing life expectancy and health outcomes, Latvia faces significant challenges. The average life expectancy is 73.1 years, which is 7.2 years lower than the OECD average. The country also experiences higher rates of preventable and treatable mortality, indicating potential inefficiencies in healthcare provision or public health measures. The perceived health status is concerning as well, with 13.1% of the population rating their health as bad or very bad, notably higher than the OECD average of 7.9%.
Expenditure of $3,445 per capita on health is below the OECD average of $4,986, equating to 8.8% of GDP compared to the OECD average of 9.2%. This lower investment is evident in the healthcare workforce, as Latvia has fewer practicing doctors and nurses per 1,000 population than the OECD average. However, it compensates somewhat with a higher number of hospital beds. This imbalance in healthcare resources and expenditure could contribute to the country’s overall health challenges.
Latvia has adapted its healthcare system in response to the COVID-19 pandemic and other recent crises. This adaptation includes policies aimed at mitigating impacts on healthcare service delivery and investing in system recovery and resilience. The pandemic led to significant changes in hospital occupancy and service provision, trends that mirror those across the EU. Latvia’s COVID-19 booster vaccination rates, especially among older adults, have been notably lower than the EU average.
Despite having one of the lowest healthcare spending levels in the EU, Latvia has seen an increase in public health expenditure in recent years, aided by higher social security contributions and targeted funding. Substantial investments in healthcare infrastructure, digitalization, and workforce development are planned and funded through the Recovery and Resilience Facility and EU Cohesion Policy funds. The country is undergoing a primary healthcare reform to enhance service provision, accessibility, and workforce capabilities.
Additionally, Latvia focuses on combating antimicrobial resistance, with one of the lowest antibiotic consumption rates in the EU and national strategies for responsible antibiotic use.
As of January 1, 2024, mobile palliative care team services have been available at the patient’s residence (henceforth referred to as the service). This service includes healthcare services, such as treatment and alleviation of symptoms caused by illness, social care, and psychosocial rehabilitation services. These encompass hospice care, psychological support, social support, spiritual support, and assistance for the patient’s relatives and others during the grieving period following the loss of a loved one.
Accessing the Ehealth portal now involves changes to the authentication process to enhance system security. The shift to qualified identification tools is designed to secure access to personal health data, thereby strengthening the overall security of the Ehealth system and protecting personal data.
Regarding differences in medication prices in the Baltic States, the ombudsman addressed the issue of significant price variations. A study published by the Ministry of Health (Conceptual Report on the Financial Accessibility of Medicines, July 27, 2022) outlined the reasons for high medication prices in Latvia and proposed solutions. The ombudsman continues to monitor the issue and raises it at the government level when necessary.
In 2023, the Latvian government approved a budget law that allocates €1.6 billion to the health sector. Of this amount, €1.35 billion is designated for outpatient and inpatient healthcare services, including general practice, laboratory tests, specialist consultations, emergency services, and medication. Specialized healthcare will receive €124 million, covering emergency medical services, blood services, forensic examinations, and anti-doping policies. Higher medical education is allocated €59 million, while healthcare finance administration and the Medical Risk Fund will receive €15 million. For disease prevention, health promotion, and healthcare service supervision, €11.3 million is planned. Additionally, €32.3 million is allocated for European Structural Fund projects and €5.6 million for sector management. An additional €85.8 million has been allocated for 2023 to address specific healthcare challenges (Veselības ministrija, 2023).
While a core set of healthcare services covers the entire population, satisfaction with the quality and availability of healthcare is relatively low. Only 57% of the population is satisfied, compared to the OECD average of 67%. This discrepancy suggests potential gaps in healthcare quality or accessibility. One in ten people did not visit a doctor in 2022. Additionally, 27% reported not visiting due to long wait times, while 25% cited affordability issues.
Financially, Latvia’s healthcare system relies less on mandatory prepayment (69%) compared to the OECD average of 76%, reflecting a higher dependence on out-of-pocket spending. This is further demonstrated by 4% of Latvians reporting unmet healthcare needs, surpassing the OECD average of 2.3%.
Analyzing life expectancy and health outcomes, Latvia faces significant challenges. The average life expectancy is 73.1 years, which is 7.2 years lower than the OECD average. The country also experiences higher rates of preventable and treatable mortality, indicating potential inefficiencies in healthcare provision or public health measures. The perceived health status is concerning as well, with 13.1% of the population rating their health as bad or very bad, notably higher than the OECD average of 7.9%.
Expenditure of $3,445 per capita on health is below the OECD average of $4,986, equating to 8.8% of GDP compared to the OECD average of 9.2%. This lower investment is evident in the healthcare workforce, as Latvia has fewer practicing doctors and nurses per 1,000 population than the OECD average. However, it compensates somewhat with a higher number of hospital beds. This imbalance in healthcare resources and expenditure could contribute to the country’s overall health challenges.
Latvia has adapted its healthcare system in response to the COVID-19 pandemic and other recent crises. This adaptation includes policies aimed at mitigating impacts on healthcare service delivery and investing in system recovery and resilience. The pandemic led to significant changes in hospital occupancy and service provision, trends that mirror those across the EU. Latvia’s COVID-19 booster vaccination rates, especially among older adults, have been notably lower than the EU average.
Despite having one of the lowest healthcare spending levels in the EU, Latvia has seen an increase in public health expenditure in recent years, aided by higher social security contributions and targeted funding. Substantial investments in healthcare infrastructure, digitalization, and workforce development are planned and funded through the Recovery and Resilience Facility and EU Cohesion Policy funds. The country is undergoing a primary healthcare reform to enhance service provision, accessibility, and workforce capabilities.
Additionally, Latvia focuses on combating antimicrobial resistance, with one of the lowest antibiotic consumption rates in the EU and national strategies for responsible antibiotic use.
As of January 1, 2024, mobile palliative care team services have been available at the patient’s residence (henceforth referred to as the service). This service includes healthcare services, such as treatment and alleviation of symptoms caused by illness, social care, and psychosocial rehabilitation services. These encompass hospice care, psychological support, social support, spiritual support, and assistance for the patient’s relatives and others during the grieving period following the loss of a loved one.
Accessing the Ehealth portal now involves changes to the authentication process to enhance system security. The shift to qualified identification tools is designed to secure access to personal health data, thereby strengthening the overall security of the Ehealth system and protecting personal data.
Regarding differences in medication prices in the Baltic States, the ombudsman addressed the issue of significant price variations. A study published by the Ministry of Health (Conceptual Report on the Financial Accessibility of Medicines, July 27, 2022) outlined the reasons for high medication prices in Latvia and proposed solutions. The ombudsman continues to monitor the issue and raises it at the government level when necessary.
Citations:
Nacionālais veselības dienests. 2023. “Par veselības aprūpi Latvijā.” https://www.vmnvd.gov.lv/lv/par-veselibas-aprupi-latvija
Veselības ministrija. 2023. “Veselības nozares finansējums 2023. gadā – 1.6 miljardi eiro; prioritātes – onkoloģija, bērnu veselības aprūpe un ārstniecības personu atalgojuma palielinājums.” https://www.vm.gov.lv/lv/jaunums/veselibas-nozares-finansejums-2023-gada-16-miljardi-eiro-prioritates-onkologija-bernu-veselibas-aprupe-un-arstniecibas-personu-atalgojuma-palielinajums
OECD. 2023. “Health at a Glance: Latvia.” https://www.oecd.org/latvia/health-at-a-glance-Latvia-EN.pdf
Centrālā statistikas pārvalde. 2023. “Veselības pašvērtējums.” https://stat.gov.lv/lv/statistikas-temas/soc-aizsardziba-veseliba/veselibas-pasvertejums/publikacijas-un-infografikas-0
OECD. 2023. “Health at a Glance: Latvia.” https://www.oecd.org/latvia/health-at-a-glance-Latvia-EN.pdf
Nacionālais veselības dienests. 2023. “Paliatīvās aprūpes mobilo komandu pakalpojumi pacienta dzīvesvietā.” https://www.vmnvd.gov.lv/lv/jaunums/paliativas-aprupes-mobilas-komandas-pakalpojumi-pacienta-dzivesvieta
Nacionālais veselības dienests. 2023. “Atgādina par pieslēgšanās izmaiņām E-veselībā no 1. janvāra.” https://www.vmnvd.gov.lv/lv/jaunums/atgadina-par-pieslegsanas-izmainam-e-veseliba-no-1-janvara
Tiesībsargs. 2023. 2022. gada ziņojums. https://www.tiesibsargs.lv/wp-content/uploads/2023/03/tiesibsarga_2022_gada_zinojums.pdf
Nacionālais veselības dienests. 2023. “Par veselības aprūpi Latvijā.” https://www.vmnvd.gov.lv/lv/par-veselibas-aprupi-latvija
Veselības ministrija. 2023. “Veselības nozares finansējums 2023. gadā – 1.6 miljardi eiro; prioritātes – onkoloģija, bērnu veselības aprūpe un ārstniecības personu atalgojuma palielinājums.” https://www.vm.gov.lv/lv/jaunums/veselibas-nozares-finansejums-2023-gada-16-miljardi-eiro-prioritates-onkologija-bernu-veselibas-aprupe-un-arstniecibas-personu-atalgojuma-palielinajums
OECD. 2023. “Health at a Glance: Latvia.” https://www.oecd.org/latvia/health-at-a-glance-Latvia-EN.pdf
Centrālā statistikas pārvalde. 2023. “Veselības pašvērtējums.” https://stat.gov.lv/lv/statistikas-temas/soc-aizsardziba-veseliba/veselibas-pasvertejums/publikacijas-un-infografikas-0
OECD. 2023. “Health at a Glance: Latvia.” https://www.oecd.org/latvia/health-at-a-glance-Latvia-EN.pdf
Nacionālais veselības dienests. 2023. “Paliatīvās aprūpes mobilo komandu pakalpojumi pacienta dzīvesvietā.” https://www.vmnvd.gov.lv/lv/jaunums/paliativas-aprupes-mobilas-komandas-pakalpojumi-pacienta-dzivesvieta
Nacionālais veselības dienests. 2023. “Atgādina par pieslēgšanās izmaiņām E-veselībā no 1. janvāra.” https://www.vmnvd.gov.lv/lv/jaunums/atgadina-par-pieslegsanas-izmainam-e-veseliba-no-1-janvara
Tiesībsargs. 2023. 2022. gada ziņojums. https://www.tiesibsargs.lv/wp-content/uploads/2023/03/tiesibsarga_2022_gada_zinojums.pdf
Slovakia
Slovakia’s health-related digital infrastructure is still under development. The existing system, E-zdravie, supports “transactions” and helps collect data. Several specialized bodies are responsible for gathering data to monitor emerging threats and accurately assess public health matters, such as the Institute for Health Analyses and the Institute for Research and Development at the Ministry of Health, the National Health Information Centre, and the Public Health Authority of the Slovak Republic. These institutions collect significant amounts of data. However, the extent to which these data are utilized to prevent emerging threats and accurately assess public health matters remains problematic.
The primary limiting factors are the very limited resources of the Slovak health system (OECD, 2021) and the country’s limited capacity for evidence-based policymaking, which became particularly evident during the COVID-19 pandemic (Grendzinska et al., 2022).
The limited resources prevent ensuring the availability of health products and services when and where they are needed, a situation exacerbated during the COVID-19 crisis. The OECD/European Observatory report (2021: 22) states: “The COVID-19 crisis and related containment measures limited access to services in 2020 and 2021. In early 2021, 23% of people reported forgoing care during the first 12 months of the pandemic, slightly more than the EU average of 21%.” The situation slightly improved in 2022–2023, but waiting lists are still too long. The intention to set the maximum waiting time for treatment at one year was postponed to 2025.
The government is failing to implement effective measures to offset healthcare risks. The OECD/European Observatory report (2021: 22) states: “Slovakia has one of the highest mortality rates from preventable and treatable causes, yet spends the least on prevention in the EU. Substantial scope remains for improvement in effective public health policies to reduce avoidable hospitalizations and premature deaths.”
Moreover, the reforms are not properly presented to stakeholders; therefore, reform attempts are hindered by regional and professional priorities, such as plans to reduce the number of hospitals or to push for specialization within hospitals. There are also problems with basic services and personnel. Hospitals struggle with a constant lack of medical doctors and nurses. In 2022, the trade union representative said that Slovak hospitals need 5,000 doctors but have only 3,700 (Folentová, 2022). The country also lacks 2,200 nurses, roughly one-fifth of the required number. In the summer of 2022, three thousand medical doctors – almost all of the current hospital staff – threatened to resign in protest of the poor state of health service. They demanded reforms and higher salaries.
The primary limiting factors are the very limited resources of the Slovak health system (OECD, 2021) and the country’s limited capacity for evidence-based policymaking, which became particularly evident during the COVID-19 pandemic (Grendzinska et al., 2022).
The limited resources prevent ensuring the availability of health products and services when and where they are needed, a situation exacerbated during the COVID-19 crisis. The OECD/European Observatory report (2021: 22) states: “The COVID-19 crisis and related containment measures limited access to services in 2020 and 2021. In early 2021, 23% of people reported forgoing care during the first 12 months of the pandemic, slightly more than the EU average of 21%.” The situation slightly improved in 2022–2023, but waiting lists are still too long. The intention to set the maximum waiting time for treatment at one year was postponed to 2025.
The government is failing to implement effective measures to offset healthcare risks. The OECD/European Observatory report (2021: 22) states: “Slovakia has one of the highest mortality rates from preventable and treatable causes, yet spends the least on prevention in the EU. Substantial scope remains for improvement in effective public health policies to reduce avoidable hospitalizations and premature deaths.”
Moreover, the reforms are not properly presented to stakeholders; therefore, reform attempts are hindered by regional and professional priorities, such as plans to reduce the number of hospitals or to push for specialization within hospitals. There are also problems with basic services and personnel. Hospitals struggle with a constant lack of medical doctors and nurses. In 2022, the trade union representative said that Slovak hospitals need 5,000 doctors but have only 3,700 (Folentová, 2022). The country also lacks 2,200 nurses, roughly one-fifth of the required number. In the summer of 2022, three thousand medical doctors – almost all of the current hospital staff – threatened to resign in protest of the poor state of health service. They demanded reforms and higher salaries.
Citations:
OECD/European Observatory on Health Systems and Policies. 2021. Slovakia: Country Health Profile 2021. Paris: OECD Publishing and Brussels: European Observatory on Health Systems and Policies.
Grendzinska, J., Hoffman, I., Klimovský, D., Malý, I., and Nemec, J. 2022. “Four Cases, the Same Story? The Roles of the Prime Ministers in the V4 Countries during the COVID-19 Crisis.” Transylvanian Review of Administrative Sciences, Special Issue: 28-44.
Folentová, V. 2022. “Odborár Visolajský. Výpovede lekárov dokáže zastaviť len vláda.” https://dennikn.sk/2935825/odborar-visolajsky-vypovede-lekarov-dokaze-zastavit-len-vlada/?ref=mpm
OECD/European Observatory on Health Systems and Policies. 2021. Slovakia: Country Health Profile 2021. Paris: OECD Publishing and Brussels: European Observatory on Health Systems and Policies.
Grendzinska, J., Hoffman, I., Klimovský, D., Malý, I., and Nemec, J. 2022. “Four Cases, the Same Story? The Roles of the Prime Ministers in the V4 Countries during the COVID-19 Crisis.” Transylvanian Review of Administrative Sciences, Special Issue: 28-44.
Folentová, V. 2022. “Odborár Visolajský. Výpovede lekárov dokáže zastaviť len vláda.” https://dennikn.sk/2935825/odborar-visolajsky-vypovede-lekarov-dokaze-zastavit-len-vlada/?ref=mpm
Slovenia
The Slovenian healthcare system, while publicly available to all, faces significant challenges exacerbated by the COVID-19 pandemic, ongoing corruption, and increasing privatization. These issues have led to shortages of healthcare professionals and prolonged waiting times for essential services. Despite attempts at reform, such as emergency measures in 2022, waiting times have continued to grow.
In 2021, unmet medical needs rose notably due to increased waiting times, particularly for dental care and primary healthcare services. By May 2023, a concerning 81% of patients awaiting initial examinations exceeded permitted wait times, and 63% waited over 14 days for therapeutic-diagnostic procedures. Civil society initiatives criticized the government’s handling of the crisis, leading to the health minister’s resignation in July 2023.
To address issues like long waiting times and a shortage of personal GPs, the government replaced supplementary health insurance with a compulsory health contribution in January 2024. Despite being the highest-paid civil servants, doctors went on strike that same month, demanding better salaries and the implementation of previously agreed-upon agreements with the ministry. Critics argue that the healthcare system’s inefficiencies, compounded by doctors working in private facilities, contribute to the shortage.
In terms of long-term care, the Janša government passed the Long-Term Care Act, although its implementation faced delays. The revised law, effective from January 2024, aims to address these challenges. However, Slovenia still trails behind OECD averages in healthcare resilience indicators, with healthcare spending and hospital beds per capita falling below the OECD average. Nonetheless, life expectancy in Slovenia remains relatively high at almost 82 years.
In 2021, unmet medical needs rose notably due to increased waiting times, particularly for dental care and primary healthcare services. By May 2023, a concerning 81% of patients awaiting initial examinations exceeded permitted wait times, and 63% waited over 14 days for therapeutic-diagnostic procedures. Civil society initiatives criticized the government’s handling of the crisis, leading to the health minister’s resignation in July 2023.
To address issues like long waiting times and a shortage of personal GPs, the government replaced supplementary health insurance with a compulsory health contribution in January 2024. Despite being the highest-paid civil servants, doctors went on strike that same month, demanding better salaries and the implementation of previously agreed-upon agreements with the ministry. Critics argue that the healthcare system’s inefficiencies, compounded by doctors working in private facilities, contribute to the shortage.
In terms of long-term care, the Janša government passed the Long-Term Care Act, although its implementation faced delays. The revised law, effective from January 2024, aims to address these challenges. However, Slovenia still trails behind OECD averages in healthcare resilience indicators, with healthcare spending and hospital beds per capita falling below the OECD average. Nonetheless, life expectancy in Slovenia remains relatively high at almost 82 years.
Citations:
G. K., La. Da., and Al. Ma. 2023. “Healthcare Reform Is Being Implemented and Remains a Key Priority of This Government.” MMC RTV, December 18. https://www.rtvslo.si/slovenija/golob-zdravstvena-reforma-se-izvaja-in-ostaja-kljucna-prioriteta-te-vlade/691990
La. Da. 2024. “Dopolnilnega zdravstvenega zavarovanja ni več. Nov prispevek se trga od dohodka.” MMC RTV, January 1. https://www.rtvslo.si/zdravje/dopolnilnega-zdravstvenega-zavarovanja-ni-vec-nov-prispevek-se-trga-od-dohodka/693321
NIJZ. 2023. “Nacionalno spremljanje čakalnih dob. Mesečno poročilo za stanje na dan 1.5. 2023.” https://nijz.si/wp-content/uploads/2023/05/Porocilo-eNarocanje-1.5.-2023.pdf
Barbara M. Smajila. 2023. “Zgodbe izza številk: Ljudje, ki so ostali brez zdravnika.” N1, January 21. https://n1info.si/poglobljeno/zgodbe-izza-stevilk-ljudje-ki-so-ostali-brez-zdravnika/
OECD: OECD Better Life Slovenia. https://www.oecdbetterlifeindex.org/countries/slovenia/
UMAR. 2023. “Poročilo o razvoju 2023.” https://www.umar.gov.si/fileadmin/user_upload/razvoj_slovenije/2023/slovenski/POR2023-splet.pdf
RTVSLO. 2024. “Več denarja, več zdravja?” Available at https://www.rtvslo.si/rtv365/arhiv/175026818?s=tv
G. K., La. Da., and Al. Ma. 2023. “Healthcare Reform Is Being Implemented and Remains a Key Priority of This Government.” MMC RTV, December 18. https://www.rtvslo.si/slovenija/golob-zdravstvena-reforma-se-izvaja-in-ostaja-kljucna-prioriteta-te-vlade/691990
La. Da. 2024. “Dopolnilnega zdravstvenega zavarovanja ni več. Nov prispevek se trga od dohodka.” MMC RTV, January 1. https://www.rtvslo.si/zdravje/dopolnilnega-zdravstvenega-zavarovanja-ni-vec-nov-prispevek-se-trga-od-dohodka/693321
NIJZ. 2023. “Nacionalno spremljanje čakalnih dob. Mesečno poročilo za stanje na dan 1.5. 2023.” https://nijz.si/wp-content/uploads/2023/05/Porocilo-eNarocanje-1.5.-2023.pdf
Barbara M. Smajila. 2023. “Zgodbe izza številk: Ljudje, ki so ostali brez zdravnika.” N1, January 21. https://n1info.si/poglobljeno/zgodbe-izza-stevilk-ljudje-ki-so-ostali-brez-zdravnika/
OECD: OECD Better Life Slovenia. https://www.oecdbetterlifeindex.org/countries/slovenia/
UMAR. 2023. “Poročilo o razvoju 2023.” https://www.umar.gov.si/fileadmin/user_upload/razvoj_slovenije/2023/slovenski/POR2023-splet.pdf
RTVSLO. 2024. “Več denarja, več zdravja?” Available at https://www.rtvslo.si/rtv365/arhiv/175026818?s=tv
USA
The U.S. healthcare system is highly fragmented. About half of Americans receive healthcare through their employer or a family member’s employer. Approximately 20% obtain healthcare from Medicare, which is public health insurance for those over 65 years old. Another 20% receive their healthcare through Medicaid, which is public health insurance for those who are impoverished. A small proportion get their healthcare through other public health insurance programs such as the Indian Health Service, which serves Native Americans, and the Veterans Administration, which covers current and former soldiers and their dependents. The remaining U.S. population must purchase health insurance on the private market, though some are eligible for a tax credit subsidy thanks to the Affordable Care Act (ACA, often referred to as “Obamacare”).
This patchwork healthcare system has various negative implications. For one, it limits labor mobility. Workers are reluctant to change jobs if it risks depriving them and their families of health insurance. Although Medicaid is federally funded, state governments administer it, setting different qualification thresholds and inconsistently covering treatments and health services depending on the state.
The federal government funds certain programs to help improve health system resilience, such as the Public Health Emergency Preparedness program administered by the Centers for Disease Control and Prevention (CDC). The program focuses on six main areas of preparedness for local public health systems: community resilience, incident management, information management, countermeasures and mitigation, surge management, and bio-surveillance.
The COVID-19 pandemic highlighted the massive inequalities at the center of the U.S. healthcare system. Immediately after becoming president, Biden signed several executive orders to reverse some of the Trump-era policies on healthcare that aimed to weaken the ACA. In March 2021, the American Rescue Plan was signed, incorporating temporary increases in premium tax credits and other measures to improve access to healthcare coverage. The administration aims to make these policies, which are only in effect until the end of 2022, permanent, a move that would positively impact healthcare provision in the United States.
In general, the fragmented character of the healthcare system and the influence of special interest groups makes it hard to achieve the goal of a resilient health system for all people.
This patchwork healthcare system has various negative implications. For one, it limits labor mobility. Workers are reluctant to change jobs if it risks depriving them and their families of health insurance. Although Medicaid is federally funded, state governments administer it, setting different qualification thresholds and inconsistently covering treatments and health services depending on the state.
The federal government funds certain programs to help improve health system resilience, such as the Public Health Emergency Preparedness program administered by the Centers for Disease Control and Prevention (CDC). The program focuses on six main areas of preparedness for local public health systems: community resilience, incident management, information management, countermeasures and mitigation, surge management, and bio-surveillance.
The COVID-19 pandemic highlighted the massive inequalities at the center of the U.S. healthcare system. Immediately after becoming president, Biden signed several executive orders to reverse some of the Trump-era policies on healthcare that aimed to weaken the ACA. In March 2021, the American Rescue Plan was signed, incorporating temporary increases in premium tax credits and other measures to improve access to healthcare coverage. The administration aims to make these policies, which are only in effect until the end of 2022, permanent, a move that would positively impact healthcare provision in the United States.
In general, the fragmented character of the healthcare system and the influence of special interest groups makes it hard to achieve the goal of a resilient health system for all people.
4
Poland
Poland’s healthcare system relies heavily on government ownership of most hospitals and clinics, with public control at the regional level. The National Health Fund (Narodowy Fundusz Zdrowia, NFZ) serves as the sole payer and government-operated insurer. Despite this extensive coverage, the system faces significant challenges.
The healthcare system in Poland is characterized by one of the EU’s lowest levels of public financing, and faces systemic issues. Approximately 20% of Polish hospitals, particularly those at the county level, face financial problems and significant debts due to the need to provide services beyond their contracted agreements. Other pressing issues include the fragmented nature of the healthcare system, the duplication of services, staffing shortages and long waiting times for services. As a result, patients incur substantial costs, particularly for medications, which comprise about two-thirds of overall healthcare expenses.
Poland also faces rising rates of cancer, cardiac issues and obesity, especially among children. The country is ranked at 32nd place in the World Index of Healthcare Innovation, a drop from 31st in 2021. It is weakest in the categories of choice (32nd) and science and technology (31st). These rankings reflect problematic issues with regard to patient-centered care, inadequate infrastructure and limited scientific impact.
Despite these challenges, Poland’s healthcare system remains relatively stable, earning an 11th-place ranking in the category of fiscal sustainability. This stability is attributed to the country’s 17th-place position in national solvency, 11th-place position in public healthcare spending and 8th-place position with regard to the growth of public healthcare spending. The consistent funding level since 2015 – around 6.5% of GDP – has contributed to this stability. Stringent price controls and access limitations have helped manage spending growth, though this has come with notable drawbacks for patients (The Foundation for Research on Equal Opportunity 2023).
The pandemic accelerated the implementation of digital tools in healthcare. The Internetowe Konto Pacjenta (IKP), an online patient account system, allows over 17 million Poles to manage prescriptions and referrals, select or change doctors, and access their medical records. This initiative, part of the React-EU program, now covers more than half the population.
The system’s inflexibility and inefficiency were evident during the COVID-19 pandemic. This led to the introduction of the e-Gabinet program to improve accessibility and efficiency in the primary healthcare sector (POZ). In 2023, the Dostępność Plus project aimed to remove barriers to accessing medical products and services, such as communication aids and training. The enhancement of teleinformatics infrastructure has improved the public’s access to medical services, providing quicker and easier access to treatment history and medical documentation for medical personnel and citizens.
The healthcare system in Poland is characterized by one of the EU’s lowest levels of public financing, and faces systemic issues. Approximately 20% of Polish hospitals, particularly those at the county level, face financial problems and significant debts due to the need to provide services beyond their contracted agreements. Other pressing issues include the fragmented nature of the healthcare system, the duplication of services, staffing shortages and long waiting times for services. As a result, patients incur substantial costs, particularly for medications, which comprise about two-thirds of overall healthcare expenses.
Poland also faces rising rates of cancer, cardiac issues and obesity, especially among children. The country is ranked at 32nd place in the World Index of Healthcare Innovation, a drop from 31st in 2021. It is weakest in the categories of choice (32nd) and science and technology (31st). These rankings reflect problematic issues with regard to patient-centered care, inadequate infrastructure and limited scientific impact.
Despite these challenges, Poland’s healthcare system remains relatively stable, earning an 11th-place ranking in the category of fiscal sustainability. This stability is attributed to the country’s 17th-place position in national solvency, 11th-place position in public healthcare spending and 8th-place position with regard to the growth of public healthcare spending. The consistent funding level since 2015 – around 6.5% of GDP – has contributed to this stability. Stringent price controls and access limitations have helped manage spending growth, though this has come with notable drawbacks for patients (The Foundation for Research on Equal Opportunity 2023).
The pandemic accelerated the implementation of digital tools in healthcare. The Internetowe Konto Pacjenta (IKP), an online patient account system, allows over 17 million Poles to manage prescriptions and referrals, select or change doctors, and access their medical records. This initiative, part of the React-EU program, now covers more than half the population.
The system’s inflexibility and inefficiency were evident during the COVID-19 pandemic. This led to the introduction of the e-Gabinet program to improve accessibility and efficiency in the primary healthcare sector (POZ). In 2023, the Dostępność Plus project aimed to remove barriers to accessing medical products and services, such as communication aids and training. The enhancement of teleinformatics infrastructure has improved the public’s access to medical services, providing quicker and easier access to treatment history and medical documentation for medical personnel and citizens.
Citations:
The Foundation for Research on Equal Opportunity. 2023. “Poland: #32 in the 2022 World Index of Healthcare Innovation.” https://freopp.org/poland-32-in-the-2022-world-index-of-healthcare-innovation-f5226a985068
https://www.oecd-ilibrary.org/docserver/f597c810-en.pdf?expires=1709477587&id=id&accname=guest&checksum=F96D8B9A016F82630A2CF29EF2293BFF
The Foundation for Research on Equal Opportunity. 2023. “Poland: #32 in the 2022 World Index of Healthcare Innovation.” https://freopp.org/poland-32-in-the-2022-world-index-of-healthcare-innovation-f5226a985068
https://www.oecd-ilibrary.org/docserver/f597c810-en.pdf?expires=1709477587&id=id&accname=guest&checksum=F96D8B9A016F82630A2CF29EF2293BFF
3
Hungary
Health outcomes in Hungary lag behind most other EU member states due to the low performance of the healthcare system and unhealthy lifestyles. In OECD comparisons, Hungary is below average on almost all indicators. Life expectancy in Hungary is lower than in most of the country’s EU neighbors, and disparities across gender and socioeconomic groups are substantial. Hungary has one of the highest avoidable death rates in the European Union, and child mortality rates are also high. Healthy life expectancy is very low, and perceived health status reflects these numbers accurately; that is, Hungarians are aware of the problem. Healthcare in Hungary has suffered from limited budgets, with spending per capita at around 50% of the EU average. Many medical doctors and nurses have emigrated to the West for better salaries. The ratio of practicing doctors is 3.3 per 1,000 population (OECD average 3.7), and the ratio of practicing nurses is 5.3 per 1,000 population (OECD average 9.2). In terms of available hospital beds (6.8 per 1,000 population), Hungary exceeds the OECD average of 4.3. The healthcare system remains excessively hospital-centric, and the country ranks in the lowest third with regard to unmet need for medical care. Those who can afford it often seek treatment from private healthcare institutions, which have been multiplying under the Orbán regime. This shift has provided medical staff with significant opportunities to earn extra income in addition to their poorly paid positions in state-run hospitals. However, out-of-pocket payments have remained high for the less well-off, even though previously problematic informal payments have been criminalized since 2021 (Gaal et al. 2021). Policymaking has suffered from the absence of a separate ministry tasked with addressing healthcare issues. The COVID-19 pandemic exposed the weaknesses of the Hungarian health system, prompting a hectic response. This reaction can be characterized as the militarization of healthcare. The Medical Service Act transformed the governance system of healthcare (Albert 2021). The newly created National Hospital Chief Directorate (Országos Kórházi Főigazgatóság, Okfö) has become the centralized point of governance for all medical institutions. As a result, hospital directors have lost their primary decision-making powers, especially with regard to budgeting and employment matters. While public sector physicians have seen a significant wage increase, they have also been placed under a new, almost military employment regime. This regime allows Okfö and/or hospital directors to send physicians to work at other hospitals on short notice and limits their opportunities to operate private practices and work part-time in the private healthcare sector. The tremendous pressure of the pandemic on the weak and underfinanced healthcare system has led to exhaustion among medical staff and further accelerated the country’s brain-drain problem. Despite these issues, the OECD resilience indicator shows relatively high levels of resilience for Hungary, comparable to countries like Japan, Portugal and the Netherlands. This is unsurprising, as maintaining resilience from a low base is more manageable than upholding high quality standards.
Citations:
Albert, F. 2021. “Hungary Reforms Its Healthcare System: A Useful Step Forward but Which Raises Some Concerns.” European Social Policy Network. 2021. ESPN Flash Report 2021/14. Brussels: European Commission.
OECD. 2023. “Health at a Glance 2023 Country Note Hungary.” https://www.oecd.org/hungary/health-at-a-glance-Hungary-EN.pdf
Gaal, P., Velkey, Z., Szerencses, V., and Webb, E. 2021. “The 2020 Reform of the Employment Status of Hungarian Health Workers: Will It Eliminate Informal Payments and Separate the Public and Private Sectors from Each Other?” Health Policy 125(7): 833-840.
Albert, F. 2021. “Hungary Reforms Its Healthcare System: A Useful Step Forward but Which Raises Some Concerns.” European Social Policy Network. 2021. ESPN Flash Report 2021/14. Brussels: European Commission.
OECD. 2023. “Health at a Glance 2023 Country Note Hungary.” https://www.oecd.org/hungary/health-at-a-glance-Hungary-EN.pdf
Gaal, P., Velkey, Z., Szerencses, V., and Webb, E. 2021. “The 2020 Reform of the Employment Status of Hungarian Health Workers: Will It Eliminate Informal Payments and Separate the Public and Private Sectors from Each Other?” Health Policy 125(7): 833-840.
Health policies are not at all aligned with the goal of achieving a resilient health system.
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