讨论全球医疗保健系统

DiscussingGlobalHealthcareSystems

TableofContents

summaryOverview

HistoryofHealthcareSystems

TypesofHealthcareSystemsTheBeveridgeModel

TheBismarckModel

TheNationalHealthInsuranceModelTheOut-of-PocketModel

HealthcareSystemsbyCountryBismarckModel

BeveridgeModel

ComparisonandChallengesGlobalPerspective

GlobalHealthIssuesandChallengesHealthcareFinancing

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summary

Thestudyofglobalhealthcaresystemsencompassesanin-depthanalysisoftheirhistory,currentpolitics,strengths,andweaknesses.Thesesystemsarecrucialfordeliver-inghealthservicesandareshapedbyacombinationofresources,organization,financing,andmanagement,withabroadarrayofstakeholders,includinghealthproviders,consumers,financingagencies,andregulatoryentities[1].Understandingthesesystemsrequiresrigorousresearch

andinsightsfromexpertswithextensiveexperiencein

healthcarepolicy,includingthefunctioningofsingle-andmultiple-payersystems[2].Evaluationsofthesesystemsoftenemployeconomicmethodologiestofacilitateefficientresourceallocationbycomparingdifferentactionsintermsoftheircostsandoutcomes[3].

Differentmodelsofhealthcaresystems,suchasthe

Beveridge,Bismarck,NationalHealthInsurance,and

Out-of-Pocketmodels,illustratethediverseapproaches

tohealthcareprovisionglobally[4].TheBeveridgeModel,firstintroducedinBritain,reliesontaxfundingandgov-

ernment-ownedfacilities,ensuringservicesarefreeatthepointofuse[5].Incontrast,theBismarckModel,usedin

Germanyandothercountries,featuresaninsurancesys-temfundedbyemployerandemployeecontributions,allow-ingformultiple,competinginsurers[6].TheNationalHealthInsuranceModelcombineselementsofbothBeveridgeandBismarckmodels,whiletheOut-of-PocketModelispredom-inantinlessdevelopedregions,whereindividualspaydi-rectlyfortheirhealthcareservices[7].Eachmodelpresentsuniqueadvantagesandchallenges,reflectingthecultural,economic,andpoliticalcontextsofdifferentnations[8].

OrganizationsliketheWorldHealthOrganization(WHO)playapivotalroleinsupportinghealthcaresystemsglob-allybyimplementingframeworksandinitiativesaimedatstrengtheningpreparednessandresponsetohealthemer-gencies[9].Additionally,theassessmentofvalue-basedhealthcareseekstoevaluatetheimpactofvariouspaymentmodelsonclinicalandcostoutcomes,particularlyconcern-ingnon-communicablediseasesandintegratedcare[10].Standardizeddatafrominternationalsurveysareusedtomeasurehealthcaresystemperformanceacrossdomainssuchasaccesstocare,administrativeefficiency,equity,

andhealthoutcomes,guidingpolicymakersintheirperfor-

mance-improvementefforts[11].

Despitetheadvancementsanddiverseapproachesin

globalhealthcaresystems,significantchallengesremain,includingdisparitiesinaccess,financing,andqualityof

care.Healthsystemsareheavilyinfluencedbysocietal

normsandexpectations,necessitatingtailoredreformstoachieveuniversalhealthcoverageandequitableaccess-[12].Globalhealthinitiativesandfinancingreformsare

criticalforaddressingthesechallenges,withtheaimof

improvingservicecoverageandfinancialprotectionacrosscountriesatallincomelevels[13].Effectivehealthfinancingpolicies,suchasthosepromotedbyWHO,areessentialfordevelopingsustainableandequitablehealthcaresystemsworldwide[14].

References:

[1]HistoricalEvolutionofHealthcareSystems.

[2]Single-andMultiple-PayerSystemsAnalysis.

[3]EconomicEvaluationinHealthcare.

[4]ModelsofHealthcareSystems.

[5]BeveridgeModel.

[6]BismarckModel.

[7]NationalHealthInsuranceModel.[8jOut-of-PocketModel.

[9jWHOFrameworksandInitiatives.

[10]Value-BasedHealthcareAssessment.

[11]CommonwealthFundInternationalSurveys.

[12]HealthSystemsandSocietalNorms.

[13]GlobalHealthInitiatives.

[14]WHOHealthFinancingPolicies.

Overview

Thestudyofglobalhealthcaresystemsinvolvesadetailedanalysisoftheirhistory,currentpolitics,strengths,andweaknesses.Thisanalysisisgroundedinrigorousresearchandimmersioninrelevantliterature,oftencarriedoutbyexpertswho

havesubstantialpersonalexperiencewiththepoliticsofhealthcarepolicyinvariouspaymentsystems,includingsingle-andmultiple-payersystems[1].

Inevaluatingtheefficiencyandeffectivenessofthesesystems,severalmethodolo-giesareemployed.Economicevaluation,forinstance,isamethoddevelopedtofacilitateefficientresourceallocationbycomparingalternativecoursesofactionintermsoftheircostsandconsequences[2].

Tofurthersupporthealthcaresystems,organizationsliketheWorldHealthOrgani-zation(WHO)haveimplementedframeworksandinitiativesaimedatstrengtheningpreparednessandresponsetohealthemergencies.TheWHO'sEmergencyRe-

sponseFrameworkhasbeenrevisedusinginsightsfromrecenthealthemergencies,andtheycontinuetosupportthestrengtheningandregulartestingofnationalandregionalpreparednessthroughinitiativessuchastheGlobalHealthEmergency

Corps(GHEC),thePublicHealthEmergencyOperationsNetwork(EOC-NET),andtheWHOGlobalLogisticsHubinDubai,amongothers[3].

Moreover,theassessmentofvalue-basedhealthcare(VBHC)aimstoanalyzethe

impactofvariousvalue-basedpayment(VBP)modelsonclinicalandcostoutcomes

withinthecontextofnon-communicablediseases(NOC)andtransmuralcare.This

VBPmodeltype[4].

Intermsofmeasuringhealthcaresystemperformance,standardizeddatafrom

analysisseekstoidentifythefacilitatingandinhibitingfactorsassociatedwitheach

sourcesliketheCommonwealthFundinternationalsurveysareused.Thesedataareorganizedintofiveperformancedomains:accesstocare,careprocess,adminis-trativeefficiency,equity,andhealthcareoutcomes.Measureswithinthesedomainsareselectedbasedontheirimportance,standardization,relevancetopolicymakers,andtheirroleinperformance-improvementefforts[5].

HistoryofHealthcareSystems

Theconceptofahealthcaresystemhasevolvedsignificantlyovertime,reflectingthechangingneeds,values,andcapabilitiesofsocieties.Historically,healthcare

systemswererelativelyrudimentary,oftenrelyingoninformalnetworksofcarewithincommunitiesorreligiousinstitutions.However,asmedicalknowledgeadvancedandsocietiesbecamemorecomplex,sotoodidtheirhealthcaresystems.

Themodernhealthcaresystemcanbecharacterizedasastructuredcombinationofresources,organization,financing,andmanagementdesignedtoprovidehealthservicestothepopulation[6].Thissystemincludesabroadarrayofstakeholderssuchashealthproviders,consumers,healthfinancingagencies,resourcessuppliers,andgovernmental/regulatoryentities[6].

Inthelate20thcentury,therewasasignificantshiftinthemanagementandor-

ganizationofhealthcare.Forexample,in1986,apivotalchangeoccurredwhen

theuniversalityofcertainhealthcaresystemswasestablished,ensuringbroader

accesstocare.Concurrently,themanagementofpublichealthcarebegantobedele-gatedtoautonomouscommunities,whichallowedformorelocalizedandresponsivehealthcaregovernance[7].By1997,publicauthoritieswerepermittedtodelegatethemanagementofpubliclyfundedhealthcaretoprivatecompanies,markingashifttowardsamixedpublic-privateapproachinhealthcaremanagement[7].

Theevolutionofhealthcaresystemsalsosawtheemergenceofdifferentmodels.

Somenationsadoptedthenationalhealthinsurancemodel,whileothersemployed

theout-of-pocketmodelortheBismarckmodel,whichisoftenreferredtoasthesocial

healthinsurancemodel[8].Thesediverseapproachesreflectedthevaryingcultural,

economic,andpoliticalcontextsofdifferentcountries.

Thetransformationanddevelopmentofhealthcaresystemswerenotlimitedto

organizationalchangesbutalsoincludedfinancialreforms.Forexample,theflowofresourcesindevelopingcountrieshasbeensignificantlyinfluencedbydevelopmentassistance,particularlyfollowingtheintroductionoftheMillenniumDevelopment

Goals,whichaccountedforasubstantialportionofhealthcarespending[9].Further-more,theimpactofhealthcareexpenditureonhealthoutputs,suchaslifeexpectancyandperceivedhealthstatus,hasbeenacriticalareaofstudyinOECDcountries,highlightingtheimportanceofefficienthealthcarefinancing[10].

TypesofHealthcareSystems

Healthcaresystemsaroundtheworldvarysignificantlyintheirstructure,funding,anddeliverymethods.

TheBeveridgeModel

TheBeveridgeModel,alsoknownas"socializedmedicine,"wasfirstintroducedbyBritisheconomistandsocialreformerWilliamBeveridgein1948.Thismodelaimstoprovidehealthcareforallcitizensandisfundedthroughtaxpayments[11].UndertheBeveridgeModel,mosthospitalsandclinicsareownedbythegovernment,andmanydoctorsandhealthcareprofessionalsaregovernmentemployees.However,privateinstitutionsalsoexistandcollectfeesfromthegovernment[12].ThismodelisprimarilyusedinGreatBritain,Spain,andNewZealand[12].Oneofthekey

advantagesofthissystemisthathealthservicesarefreeatthepointofuse,makingthemaccessibletoeverycitizen[13].However,itoftenfaceschallengessuchaslongwaitinglistsfortreatment[13].

TheBismarckModel

TheBismarckModel,namedafterGermanChancellorOttovonBismarck,employsaninsurancesystemwhereinsurersareknownas"sicknessfunds,"financedjointlybyemployersandemployeesthroughpayrolldeductions.UnliketheBeveridgeMod-el,theBismarckModelinvolvesmultiple,competinginsurers[12].AlthoughprimarilyusedinGermany,variationsofthismodelarealsofoundincountrieslikeFrance,Belgium,andSwitzerland.Thismodeltendstobemoredecentralizedandreliesonprivatehealthcareproviders[12].

TheNationalHealthInsuranceModel

TheNationalHealthInsurance(NHI)ModelincorporateselementsfromboththeBeveridgeandBismarckmodels.Itusesprivate-sectorprovidersbutisfundedbyagovernment-runinsuranceprogramthateverycitizenpaysintothroughpremiumsortaxes[12].ThismodelisprevalentincountrieslikeCanadaandTaiwan.ThekeyadvantageoftheNHImodelisthatittendstobelessexpensiveandhaslower

administrativecostscomparedtofor-profitinsuranceplans[12].

TheOut-of-PocketModel

Inmanycountries,particularlyinlessdevelopedregions,peoplemustpayfor

healthcareservicesoutoftheirownpockets.Thismodelishighlydecentralizedandoftenresultsinsignificantdisparitiesinaccesstohealthcarebasedonindividualsfinancialcapabilities.Inplaceswherenoorganizedhealthsystemexists,localhealersandtraditionalmedicineoftenfillthegap[14].

Eachhealthcaresystemtypepresentsitsownsetofadvantagesandchallenges,reflectingthediverseapproachestodeliveringandfinancinghealthservicesglobally.

HealthcareSystemsbyCountry

BismarckModel

TheBismarckModel,alsoknownastheSocialHealthInsuranceModel,ischaracter-

izedbythefundingofhealthcarethroughcontributionstoahealthfund,whichpays

forhealthservicesprovidedbyeitherstate-owned,government-owned,orprivate

institutions.IntroducedbyOttovonBismarckinGermanyin1883,thismodelinitially

aimedtoprovidecaretoworkersandtheirfamilies[15][16].CountriessuchasGer-

many,Austria,Switzerland,andtheCzechRepublicoperateunderthissystem[16].

TheprimaryadvantagesoftheBismarckModelincludesignificantlyhigheracces-

sibility,lowerwaitingtimes,andoftenhigherqualityandmoreconsumer-oriented

healthcare,attributedtothecompetitionbetweenhealthcareproviders[15][16].

However,theBismarckModelfacescriticismregardingtheprovisionofcarefor

individualsunabletoworkoraffordcontributions,suchasagingpopulationsand

theimbalancebetweenretireesandemployees[15].Toaddressthis,manyBismarck

systemshaveevolvedtoprovidestateinsuranceorcontributionstothoseunableto

pay,aimingtoensureuniversalcoverage[16].

BeveridgeModel

TheBeveridgeModel,createdbyeconomistandsocialreformerWiliamBeveridge,wasfirstimplementedintheUnitedKingdomwiththeestablishmentoftheNationalHealthService(NHS)in1948[14][11].Thismodelisbuiltontheprincipleofhealth-careasahumanright,withfundingprimarilythroughtaxation.CountriesemployingvariationsoftheBeveridgeModelincludetheUnitedKingdom,Italy,Spain,Denmark,Sweden,Norway,NewZealand,andothers[14[11].Underthismodel,healthcareservicesaregenerallyfreeatthepointofuse,withthecostcoveredbythepatientstaxcontributions[11].

TheBeveridgeModelemphasizesuniversalcoverageprovidedbythegovernment,ensuringthatallresidentshaveaccesstohealthcare[11].IntheUnitedStates,

aspectsofthismodelareappliedtoveteransandNativeAmericans[14].

ComparisonandChallenges

Nocountryhasaperfecthealthcaresystem,andinadequatehealthcareremainsaglobalissue[15].Healthsystemsareheavilyinfluencedbythenormsandvaluesoftheirrespectivesocietiesandreflectdeeplyrootedsocialandculturalexpectations[15].TheWorldHealthOrganization(WHO)identifiesthegoalsofhealthcaresystemsasensuringgoodhealthforcitizens,responsivenesstothepopulation'sexpectations,andfairfundingmechanisms[17].

Healthfinancingreformsmustbetailoredtoeachcountry'suniquecontextand

existinghealthfinancingarrangements.Labelssuchas"socialhealthinsurance,""communityinsurance,"or"tax-fundedsystems"oftenobscurethecomplexchoicesandoptionsavailabletocountriesastheystrivetoraise,pool,andusefunds

effectively[18].Realprogressispossibleacrosscountriesatallincomelevels,andeachcountry'spathwaywilldifferbasedonlocalcontexts[18].

GlobalPerspective

Globally,healthcaresystemsrangefromhighlyregulatedstructurestolocal,

shaman-dependentsetups,demonstratingthediversityinapproachestohealthcareprovision[14].Despitethisdiversity,lessonsfromtop-performingcountriescanin-formimprovementsinhealthcaresystemsworldwide[5].Forexample,single-payersystems,whereasingleentitycollectsandpaysforhealthcareservices,aremorecommonamongwealthynationsandareoftencontrastedwithmulti-payersystems,suchasthatoftheUnitedStates[19].

Ultimately,recognizingthediversityofstakeholdersandthecomplexityofhealthsystemsiscrucialfordevelopingeffective,evidence-basedhealthcarepolicies[17].Qualityimprovementinitiativesarefrequentlyimplementedtobridgepolicygapsandenhancehealthcaredelivery[17].

GlobalHealthIssuesandChallenges

Universalaccesstohealthistheguidingprincipleandhealthequityamongnationsandforallpeopleisthemajorobjectiveofglobalhealth.Globalhealthinitiatives

wereestablishedtotackleincreasingglobalhealththreats,reducedisparitieswithincommunitiesandbetweennations,andcontributetoaworldwherepeoplelive

healthier,safer,andlongerlives.TheseinitiativesaddressvariousareasincludingAIDS,tuberculosis,malaria,immunizationprograms,maternalandchildhealth,

tobaccouse,humanresources,emergingdiseases,nutrition,healthpromotion,andhealthsystemstrengthening[20].

However,protractedsocialandpoliticalunrestinmanygrant-recipientcountries

remainsasignificantchallenge.Insecurityintheseregionshampersaccesstosocialservices,withthehealthsectorbeingtheworstaffected.Thelossofhumancapitalhasseverelyweakenedhealthservicesandsystemsinaffectedcountries.Addition-ally,globalhealthinitiativeshavesometimescreatedparallelsystemsthatunderminetheholisticapproachtohealthsystemdevelopment.Theprinciplesofexternalaid,suchasownershipandharmonization,arenotalwaysadequatelyapplied,furthercomplicatingtheeffectivenessoftheseinitiatives[20].

TheGlobalFundandGavi,theVaccineAlliance,aretwomaininstitutionsprovidingsubstantialfundingtoeligiblecountries.Theirsupportincludessubsidizingaccesstoessentialmedicinesandexpandingcommunityhealthinsurancecoverage,suchasinRwandawheretheGlobalFundhasfacilitatedcoveragefor3.3millionpeople,includingthoselivingwithHIV/AIDSandorphans[20][21].

Effortstoconnect"local"and"global"healthcareinitiativessuggestthatUS-basedclinicians,organizationalstewards,andresearcherscouldbenefitfromengagingwithandlearningfromlow-resourcesettingsthatdeliverhigh-quality,cost-effective,inclusivecare.Traditionally,threeargumentshavebolsteredglobalengagement:amoralobligationtoensureopportunitiestolive,adutytoprotectagainsthealth

threats,andadesiretoguardagainsteconomicdownturnsprecipitatedbyhealthcrises[22].

Whileglobaldeclarationsandcountrycommitments,suchasthosebytheUnitedNationsGeneralAssemblyonUniversalHealthCoverage(UHC),haveputUHCatthecenterofhealthpoliciesandstrategies,progressisunevenacrosscountries,

andsignificantgapsremain[23].Additionally,mosthealthexpendituresindevel-

opingcountriesarefundedthroughhouseholds'out-of-pocketpayments,themostregressiveandinequitablefinancingmechanism.Globalhealthinitiativeshelpreducethisburdenbysubsidizingaccesstoessentialmedicinesandabolishinguser-fees,whichhaveproventoincreaseaccessandtreatmentadherenceforlow-income

populations[21].

Remotemonitoring,diagnosis,andtreatmenttechnologieshavethepotentialto

significantlyimprovepatientcarebymakingitmoreconvenientandimproving

compliancewithcareregimes.Theseadvancementsalsohavethepotentialto

changethenatureofthepatient-providerrelationship,fosteringtrustandbetterhealthoutcomes[24].Accesstocriticalclinicalandadministrativeinformation,alongwithinformation-managementanddecision-supporttools,isessentialforphysicianstoparticipateinandleadcareteamseffectively[24].

Ultimately,carefullydesignedandimplementedhealthfinancingpoliciescanhelpaddressissuesofaccessandqualityofcare.Contractingandpaymentarrangementscanincentivizecarecoordinationandimprovecarequality,whiletimelydisbursementoffundscanensureadequatestaffingandavailabilityofmedicines[18].However,uncontrolledcosts,especiallyinsystemsnotalignedwithpublichealthneeds,posesignificantchallenges,furtheremphasizingtheneedforefficientresourceallocationandeconomicevaluationtoimprovehealthcaresystemsglobally[25][2].

HealthcareFinancing

Healthcarefinancingvariessignificantlyacrosstheglobe,influencedbyamixof

publicandprivatefundingsources,theroleofgovernment,andtheeconomicstatusofeachcountry.

Developingcountrieshaveseentheirhealthcarefinancingshapedlargelybyde-

velopmentassistance,particularlyfollowingtheintroductionoftheMillenniumDe-velopmentGoals,whichledtoasteepincreaseinresourceschanneledthrough

aid.Theseflowsaccountforabout0.7%ofthehealthcareresourcesspentby

high-incomecountries[9].Countrieswithlowpublichealthcarespendingandlimitedprivatevoluntaryinsurancetypicallyseehighout-of-pocketexpenditure(e.g.,India,Afghanistan,Sudan)[9].

Incontrast,inhigh-incomecountrieswithsubstantialpublicfundsorprivatevoluntaryinsurance,out-of-pocketspendingisrelativelylow.Thisfinancialstructuringaimstoprovide'prepaidcare'throughcompulsorysocialinsuranceorfundingfromgeneralgovernmentrevenue[9].Healthfinancingisacorefunctionthatcandriveprogresstowarduniversalhealthcoverage(UHC)byimprovingservicecoverageandfinancialprotection[18].

WHO'shealthfinancingteamcollaborateswithhealthministriesandfinanceauthor-itiestodevelopbetterbudgetingprocessesandalignpublicfinancialmanagementreformswithhealthfinancingsystems[26].Effectivehealthcarefinancingrequiresacomprehensivefinancialframework,whichcouldincludemechanismslikemonthlypremiumsorannualtaxestoensureadequatefundingforhealthcarebenefits[17].Countriesoftenrelyonamixoffundingsources.Forinstance,theGlobalFund'sgrantsareperformance-based,whichencouragesefficiencyandproductivityin

healthsystemsandpromotesnationalownershipofhealthprograms[21].Additional-ly,enhancedtaxenforcementcanraiseconsiderablepublicfundsforhealthcare,ad-dressingfinancialgapsandimprovingequityinaccess[27].Donorgovernmentsandfinancialinstitutionssometimescoverasignificantportionofhealthcarespendinginlow-andmiddle-incomecountries,withdatafrom2021showingthatin32countries,over25%ofhealthcarespendingwasfundedbyexternalsources[27].

Differenthealthcaremodelsalsoimpactfinancingstructures.TheBismarckmodel,forexample,reliesonapremium-financedsocialin