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 of 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 the regulation of food standards.
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. The federal government cofinances provincial and territorial programs, which must adhere to the Canada Health Act (1985), which in turn sets standards for “medically necessary” hospital, diagnostic, and physician services. The act states that to be eligible to receive full federal cash contributions for health care, each provincial health care insurance plan needs to be: publicly administered, comprehensive in coverage, universal, portable across provinces, and accessible (for example, 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, members of the Canadian Armed Forces, some veterans, resettled refugees and some refugee claimants, and inmates in federal penitentiaries; and administers several public health functions.
Duties and responsibilities in the Swiss health care system are divided among the federal, cantonal, and municipal levels of government. The system can be considered highly decentralized, as the cantons play a critical role. Each of the 26 cantons (including six half-cantons) has its own constitution and is responsible for licensing providers, coordinating hospital services, and subsidizing institutions and individual premiums. The federal government plays an important role in regulating the financing of the system, which is effected through mandatory health insurance (MHI) and other social insurance; ensuring the quality and safety of pharmaceuticals and medical devices; overseeing public health initiatives; and promoting research and training. The municipalities, in turn, are responsible mainly for long-term care (nursing homes and home care services) and other social support services for vulnerable groups.
The introduction of the new Federal Health Insurance Law in 1996 had three main objectives: 1) to strengthen equality by introducing universal coverage and subsidies for low-income households; 2) to expand the benefit basket and ensure high standards of health services; and 3) to contain the growing costs of the health system.
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, with variations for local circumstances. Health authorities include the National Health and Family Planning Commission and the local Health and Family Planning Commissions, which have primary responsibility for organizing and delivering health care and supervising providers (mainly hospitals). Health authorities at the prefecture, county, and town levels have limited flexibility in carrying out provincial health policies.
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 ensuring: a high quality of care; 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 finance the majority of services delivered by private 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. The municipalities are also responsible for general prevention and rehabilitation tasks; the regions are responsible for specialized rehabilitation.
Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by two systems, namely: 1) competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”—there were 118 as of January 2016) in the statutory health insurance (SHI) system; and 2) substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities and own about half of all hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. To a large degree, regulation is delegated to self-governing associations within sickness funds and provider associations, which are together represented by the most important body, the Federal Joint Committee.
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. Over the past two decades, 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 ministry is represented in the regions by the 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 Councils, which are the governing bodies at the local (departmental) level.
Responsibility for health legislation and general policy in England rests with Parliament, the Secretary of State for Health, and the Department of Health. Under the Health Act (2006), the Secretary of State has a legal duty to promote a comprehensive health service that provides care free of charge, apart from services with charges already in place. Rights for those eligible for National Health Service (NHS) care are summarized in the NHS Constitution; they include the right to access to care without discrimination and within certain time limits 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 rests with 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 host “health and well-being boards” to improve coordination of local services and reduce health disparities.
The constitution of India considers the “right to life” to be fundamental and obliges the government to ensure the “right to health” for all.
To a significant extent, India’s health sector has been shaped by its federal structure and the federal–state divisions of responsibilities and financing. The states are responsible for organizing and delivering health services to their residents. The central government is responsible for international health treaties, medical education, prevention of food adulteration, quality control in drug manufacturing, national disease control, and family planning programs. It also sets national health policy including the regulatory framework and supports the states.
The draft National Health Policy prepared in 2015 proposes that health be made a fundamental right and views government’s role as critical. If accepted, it would clarify, strengthen, and prioritize the role of government in shaping the health system.
Government, through the Ministry of Health, is responsible for population health and the overall functioning of the health care system (including the regulation of health care insurers and providers). 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 provides financing for the public health service and is active in areas such as the control of communicable diseases, screening, health promotion and education, and environmental health, as well as the direct provision of various other services. It is also actively involved in the financial and quality regulation of key health system actors, including health plans, hospitals, and health care professionals.
The Italian National Health Service (Servizio Sanitario Nazionale) was set up in 1978, with universal coverage, solidarity, human dignity, and health needs as its guiding principles. It is regionally based and organized at the national, regional, and local levels. Under the Italian constitution, 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, or LEA). The 19 regions and two autonomous provinces have the responsibility to organize and deliver 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.
Government regulates nearly all aspects of the universal Statutory Health Insurance System (SHIS). The national and local governments are required by law to ensure a system that efficiently provides good-quality medical care. National government sets the SHIS 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 their own budgets and funds allocated by the national government. More than 1,700 municipalities operate components of the SHIS and organize health promotion activities for their residents.
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 (a comprehensive system with universal coverage) for the basic benefit package (through subsidies from general taxation and reallocation of payroll levies among insurers via 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. Municipalities and health insurers are responsible for most outpatient long-term services and all youth care under a provision-based approach (with a high level of freedom at the local level).
Government is responsible for providing health care to the population, in accordance with the stated goal of equal access to health care regardless of age, race, gender, income, or area of residence. Primary health and social care is the responsibility of the municipalities, with Norway’s ministry of health playing an indirect role through legislation and funding mechanisms. In specialist care, the ministry also plays a direct role through its ownership of hospitals and its provision of directives to the boards of regional health care authorities (RHAs).
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. Through the New Zealand Health Strategy, government plays a central role in setting the policy agenda and service requirements and in determining the publicly funded annual health budget.
Responsibility for planning, purchasing, and providing health services, as well as 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.
The government of Singapore planned, built, and continues to develop and maintain the nation’s public health care system. It 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 responsible for the financing policies and governance of the public health care system.
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 are responsible for financing and delivering health services to citizens. At the local level, 290 municipalities are responsible for 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:
- Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community.
- Need and solidarity: Those in greatest need take precedence in being treated.
- Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between costs and benefits, with cost measured in relation to improvement in health and quality of life.
Article 157 of the constitution of Taiwan, Republic of China, calls for the national government to promote health maintenance and implement the public provision of health care for all citizens. That article is the constitutional platform for the National Health Insurance Act, passed by Taiwan’s legislature in 1994.
The act stipulates that national health insurance is compulsory and that the government is to provide health care and medical services to the insured in case of illness, injury, and childbirth. It further stipulates that the government and contracted providers should regularly make public information on the quality of health care.
The National Health Insurance program (NHI) is administered by the National Health Insurance Administration (NHIA) under the Ministry of Health and Welfare (MoHW) through six regional offices supported by a health information infrastructure. Municipal and district governments may offer additional benefits for residents within their jurisdiction, such as subsidies for out-of-pocket costs for poor residents.
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 some people with disabilities, and works in partnership with state governments to administer both Medicaid and the Children’s Health Insurance Program (CHIP), 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.