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What is the role of government?

  • Australia

    Three levels of government are collectively responsible for providing universal health care: federal; state and territory; and local. The federal government mainly provides funding and indirect support to the states and health professions, subsidizing primary care providers through the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) and providing funds for state services. It has only a limited role in direct service delivery.

    States have the majority responsibility for public hospitals, ambulance services, public dental care, community health services, and mental health care. They contribute their own funding in addition to that provided by federal government. Local governments play a role in the delivery of community health and preventive health programs, such as immunization and regulation of food standards.

  • Canada

    Provinces and territories in Canada have primary responsibility for organizing and delivering health services and supervising providers. Many have established regional health authorities that plan and deliver publicly funded services locally. Generally, those authorities are responsible for the funding and delivery of hospital, community, and long-term care, as well as mental and public health services. Nearly all health care providers are private. The federal government cofinances provincial and territorial programs, which must adhere to the five underlying principles of the Canada Health Act—the law that sets standards for medically necessary hospital, diagnostic, and physician services. These principles state that each provincial health care insurance plan needs to be: 1) publicly administered; 2) comprehensive in coverage; 3) universal; 4) portable across provinces; and 5) accessible (i.e., without user fees).

    The federal government also regulates the safety and efficacy of medical devices, pharmaceuticals, and natural health products; funds health research; administers a range of services for certain populations, including First Nations, Inuit, Métis, and inmates in federal penitentiaries; and administers several public health functions.

  • China

    In China, the central government has overall responsibility for national health legislation, policy, and administration. It is guided by the principle that every citizen is entitled to receive basic health care services, with local governments—provinces, prefectures, cities, counties, and towns—responsible for providing them according to local circumstances. Health authorities include the National Health and Family Planning Commission and the local Health and Family Planning Commissions (or Bureaus of Health, if they have not been merged with local Family Planning Commissions), which have primary responsibility for organizing and delivering health care and supervising providers (mainly hospitals). Health authorities at the prefectures/city, county, and town levels have limited flexibility in carrying out provincial health policies.

  • Denmark

    Universal access to health care is the underlying principle inscribed in Denmark’s Health Law, which sets out the government’s obligation to promote population health and prevent and treat illness, suffering, and functional limitations. Other core principles include high quality; easy and equal access to care; service integration; choice; transparency; access to information; and short waiting times for care. The law also assigns responsibility to regions and municipalities for delivering health services.

    The national government sets the regulatory framework for health services and is in charge of general planning and supervision. Five administrative regions governed by democratically elected councils are responsible for the planning and delivery of specialized services, but also have tasks related to specialized social care and coordination. The regions own, manage, and finance hospitals and the majority of services delivered by general practitioners (GPs), office-based specialists, physiotherapists, dentists, and pharmacists. Municipalities are responsible for financing and delivering nursing home care, home nurses, health visitors, some dental services, school health services, home help, and treatment for drug and alcohol abuse. Municipalities are also responsible for general prevention and rehabilitation tasks; the regions are responsible for specialized rehabilitation.

  • England

    Responsibility for health legislation and general policy in England rests with Parliament, the Secretary of State for Health, and the Department of Health. (In cases where data for England are unavailable — e.g., financial or funding data — U.K. data are used instead.) Under the Health Act (2006), the Secretary of State has a legal duty to promote a comprehensive health service, providing services free of charge, except for those with charges already in place. Rights for those eligible for National Health Service (NHS) care are summarized in the NHS Constitution; they include access to care without discrimination and within certain timeframes for some categories, such as emergency and planned hospital care. The Department of Health provides stewardship for the overall health system, but day-to-day responsibility for running the NHS belongs to a separate public body, NHS England.

    NHS England manages the NHS budget, oversees 209 local Clinical Commissioning Groups (CCGs), and ensures that the objectives set out in an annual mandate by the Secretary of State for Health are met, including both efficiency and health goals. Budgets for public health are held by local government authorities, which are required to establish “health and well-being boards” to improve coordination of local services and reduce health disparities.

  • France

    The provision of health care in France is a national responsibility. The Ministry of Social Affairs, Health, and Women’s Rights is responsible for defining national strategy. The French system has evolved from a labor-based Bismarckian system to a mixed public–private system. Over the past two decades, however, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance (SHI).

    Planning and regulation within health care involve negotiations among provider representatives, the state, and SHI. Outcomes of these negotiations are translated into laws passed by parliament.

    In addition to setting national strategy, the responsibilities of the central government include allocating budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and, with respect to hospitals, among regions.

    The Administration of Health and Social Affairs is represented by Regional Health Agencies, which are responsible for population health and health care, including prevention and care delivery, public health, and social care. Health and social care for elderly and disabled people come under the jurisdiction of the General Council, which is the governing body at the local level.

  • Germany

    Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”; there were 124 as of January 2015) in the statutory health insurance (SHI) system, or by substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities, and own about half of hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. A large degree of regulation is delegated to self-governing associations of the sickness funds and the provider associations, which together constitute the most important body, the Federal Joint Committee.

  • India

    The constitution of India considers the “right to life” to be fundamental and obliges government to ensure the “right to health” for all, without any discrimination. More recently, the National Health Bill, introduced in 2009, views health care as a public good and health as a human right of every individual. The goal of India’s national health policy is universal access to good-quality health care services without financial hardship.

    Under the constitution, areas of public policy are divided between the central and state governments. States are responsible for organizing and delivering health services to their population. The central government, meanwhile, plays an important role with respect to international treaties, medical education, prevention of food adulteration, quality control in drug manufacturing, national disease control, and family planning programs. It also carries out a stewardship role with respect to policymaking, developing the regulatory framework, and supporting the work of the states.

    At the local level, Panchayati Raj institutions (PRIs)—a decentralized system of local governance formalized in 1992—and their elected representatives participate in the functioning of district and subdistrict institutions through various committees.

  • Israel

    Government, through the Ministry of Health, is responsible for population health and the overall functioning of the health care system. It also owns and operates a large network of maternal and child health centers, about half of the nation’s acute care bed capacity, and about 80 percent of its psychiatric bed capacity.

    In 1995, Israel passed a national health insurance (NHI) law, which provides for universal coverage. In addition to financing insurance, government also provides financing for the public health service, and is active in areas such as control of communicable diseases, screening, health promotion and education, and environmental health, as well as providing various other services provided directly by the government. It is also actively involved in financial and quality regulation of key health system actors, including health plans, hospitals, health care professionals, and others.

  • Italy

    The Italian National Health Service (Servizio Sanitario Nazionale) is regionally based and organized at the national, regional, and local levels. Under the Italian constitution, responsibility for health care is shared by the national government and the 19 regions and 2 autonomous provinces. The central government controls the distribution of tax revenue for publicly financed health care and defines a national statutory benefits package to be offered to all residents in every region—the “essential levels of care” (livelli essenziali di assistenza). The 19 regions and two autonomous provinces have responsibility for the organization and delivery of health services through local health units. Regions enjoy significant autonomy in determining the macro structure of their health systems. Local health units are managed by a general manager appointed by the governor of the region, and deliver primary care, hospital care, outpatient specialist care, public health care, and health care related to social care.

  • Japan

    Government regulates nearly all aspects of the universal public health insurance system (PHIS). The national and local governments are required by law to ensure a system that efficiently provides good-quality and well-suited medical care to the nation. National government sets the fee schedule and gives subsidies to local governments, insurers, and providers. It also establishes and enforces detailed regulations for insurers and providers. Japan’s 47 prefectures (regions) implement those regulations and develop regional health care delivery with funds allocated by the national government. More than 1,700 municipalities operate components of the PHIS and long-term care insurance and organize health promotion activities for their residents.

  • The Netherlands

    In the Netherlands, the national government has overall responsibility for setting health care priorities, introducing legislative changes when necessary, and monitoring access, quality, and costs. It also partly finances social health insurance for the basic benefit package (through subsidies from general taxation and reallocation of payroll levies among insurers through a risk adjustment system) and the compulsory social health insurance system for long-term care. Prevention and social support are not part of social health insurance but are financed through general taxation. The 2015 national reforms to long-term care made municipalities and health insurers responsible for most outpatient long-term services and all youth care under a provision-based approach (with a great level of freedom at the local level).

  • New Zealand

    Beginning with passage of the Social Security Act in 1938, a consensus has developed in New Zealand that government has a fundamental role in providing for the population’s health care needs. At the same time, there is continued public support for a private sector role as well. Government plays a central role in setting the policy agenda and service requirements for the health system and in setting the annual publicly funded health budget.

    Responsibility for planning, purchasing, and providing health services and disability support for those over age 65 lies with 20 geographically defined district health boards (DHBs), each of which comprises seven locally elected members and up to four members appointed by the Minister of Health. These boards pursue government objectives, targets, and service requirements while operating government-owned hospitals and health centers, providing community services, and purchasing services from nongovernment and private providers.

  • Norway

    Government is responsible for providing health care to the population. Norway’s 428 municipalities are responsible for providing primary health and social care, with the Ministry of Health playing an indirect role, mainly through legislation and funding mechanisms. The ministry plays a direct role, however, in specialist care, through its ownership of hospitals and provision of directives to the boards of regional health care authorities (RHAs), as well as through legislation and funding.

  • Singapore

    The government of Singapore planned, built, and continues to develop and maintain the nation’s public health care system. It also regulates both public and private health insurance in the country. The health care system is administered by the Ministry of Health, which has responsibility for assessing health needs and for planning and delivering services through networks of health and hospital facilities, day care centers, and nursing homes. The ministry manages, plans for, and maintains staffing throughout the system and is also responsible for financing policies and governance of the entire public health care system. Because Singapore is a very small nation-state, there is little regional- or local-level funding or regulation; the national government takes on full responsibility for the health system. Singapore offers universal health care coverage to citizens, with a financing system anchored in the twin philosophies of individual responsibility and affordable health care for all.

  • Sweden

    All three levels of Swedish government are involved in the health care system. At the national level, the Ministry of Health and Social Affairs is responsible for overall health and health care policy, working in concert with eight national government agencies. At the regional level, 12 county councils and nine regional bodies (regions) are responsible for financing and delivering health services to their citizens. At the local level, 290 municipalities are responsible care of the elderly and the disabled. The local and regional authorities are represented by the Swedish Association of Local Authorities and Regions (SALAR).

    Three basic principles apply to all health care in Sweden:

    1. Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community.
    2. Need and solidarity: Those in greatest need take precedence in being treated.
    3. Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between the costs and the benefits of health care, measuring cost in relationship to improved health and quality of life.
  • Switzerland

    Duties and responsibilities in the Swiss health care system are divided among the federal, cantonal, and communal levels of government. The system can be considered highly decentralized, as the cantons are given a critical role. The 26 cantons (including six half-cantons) are responsible for licensing providers, coordinating hospital services, and subsidizing institutions and organizations. Cantons are like U.S. states in that they are sovereign in all matters, including health care, that are not specifically designated as the responsibility of the Swiss Confederation by the federal constitution. Each canton and half-canton has its own constitution articulating a comprehensive body of legislation.

  • United States

    The Affordable Care Act (ACA), enacted in 2010, established “shared responsibility” between the government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health insurance. However, health coverage remains fragmented, with numerous private and public sources as well as wide gaps in insured rates across the U.S. population. The Centers for Medicare and Medicaid Services (CMS) administers Medicare, a federal program for adults 65 and older and people with disabilities, and works in partnership with state governments to administer both Medicaid and the Children’s Health Insurance Program, a conglomeration of federal–state programs for certain low-income populations.

    Private insurance is regulated mostly at the state level. In 2014, state- and federally administered health insurance marketplaces were established to provide additional access to private insurance coverage, with income-based premium subsidies for low- and middle-income people. In addition, states were given the option of participating in a federally subsidized expansion of Medicaid eligibility.