US Healthcare systems Final

Canada Demographics

- 2019, population was 37.6 million people (fastest growing country in the group of 7)(G7) - population is aging ~0-14: 11.14% ~15-24: 11.41% ~25-54: 39.81% ~55-64: 14.08% ~65 years and older: 18.98%

True or False: High healthcare expenditure always leads to better health outcomes.

False

Cash transfers have been used to encourage health care utilization of the public system for newborn deliveries

True

Mandatory health insurance was created to increase health care funding in Russia

True

Every individual or partnership of GPs must hold an NHS GP contract to run an NHS-commissioned general practice.

True

Ghana lacks adequate health care infrastructure which has led to disparities in the availability of health care facilities, particularly in rural areas.

True

India has the most number of new cases of COVID-19 per day currently

True

Post WWII, the United Kingdom switched from the Bismarck health care model to the Beveridge model

True

Sickness funds are required to offer members the option of enrolling in a family physician care model, which has been shown to provide better services than traditional care approaches and often provides incentives for complying with gatekeeping rules.

True

Supply and demand factors have contributed to long waiting times.

True

The Cuban health care system focuses on prevention and early detection

True

The Health and Social Care Act of 2012 extended market-based approaches to the delivery of health care by instituting the "any willing provider" provision.

True

The majority of Chinese was covered by health insurances in 2019:

True

True or False: The national health care service in Portugal provides universal health coverage and is entirely free for individuals under 18 and over 65.

True

True/False: The SUS in Brazil covers Metformin, insulins, and self-monitoring blood glucose supplies.

True

Russia: Delivery

-Public -Private

Why are wait time so bad? (How can Canada improve worsening wait times? (reading))

- A lot of delays are driven by the fact that hospitals operate at very high capacity because there are large numbers of patients requiring alternate levels of care [who have nowhere else to go]. - There's a limited number of specialists, limited operating room time allocated to surgeons, limited machines for advanced imaging, and that keeps patients on wait lists for long periods. -Often there are profound failures of understanding and communication. A third of referrals may not make it to specialists. Error is rife — errors in process, in communication, and in practice.

How can Canada improve worsening wait times? (reading)

- About one in three Canadians who need joint replacements or cataract surgery don't get those procedures within recommended times.

Is part of the problem that Canadians accept these waits as the price of publicly funded health care? (How can Canada improve worsening wait times? (reading))

- Canadians have accepted that some delay is reasonable in order to have an equitable health care system, and that's not necessarily a bad thing. But one of the things we're doing in Kingston now is a major project to guarantee that every patient who is referred to a specialist waits no more than three months. - In the United Kingdom, [certain] urgent cancer cases must receive treatment in two weeks. Not to say there aren't people who fall through the cracks, but they have a system in place that recognizes the need for timely care.

Description of the Health Care System- Medical Technology (Germany)

- Germany is one of the largest manufacturers of medical technology worldwide

Social Ethics 3: Multi-tiered Health System

- Health care is really just another private consumption good for which the patient should be financially responsible. This, it is perfectly alright to let the quality of health care and the entire health care experience vary by income class - country examples: most low-income countries

Long Waits for U.K. Hospital Treatment as N.H.S. Fights Coronavirus (reading)

- Many patients like Ms. Fawcett are experiencing a significant deterioration in their health because of the delay and are growing anxious and frustrated because of the lack of guidance as to where they are placed on the list, or how long they will have to wait before they can receive treatment.- The number of people on the waiting list for elective care fell from 3.94 million in April to 3.84 million in May, according to N.H.S. figures published on Thursday. However, the drop has been attributed to fewer people being referred for testing and treatment during the pandemic — numbers are expected to start climbing again when services resume. - "Despite responding rapidly to the coronavirus pandemic and the need to ensure over 100,000 patients could receive hospital care, N.H.S. staff also provided more than five million urgent tests, checks and treatment in a safe way during the peak of the virus." - About 2.4 million people were waiting for cancer treatment or tests in June, according to the charity Cancer Research U.K., and thousands of people have missed out on hospital referrals for the diagnostic tests that are critical in the early detection and successful treatment of cancer - "Women's health is a big issue, but most matters are dismissed because they are not seen as life-threatening," Ms. Kip said. "But when the whole health system is on hold for non-urgent treatment, that can lead to other problems. For example, women can suffer from mental health issues because of hormonal imbalances."

National Health Insurance Model

- Mix of both Beveridge and Bismark model -Government-run insurance program and private sector providers ~ single player tends to have considerable market power to negotiate for lower prices ~ control costs by limiting the medical services they will pay for, or by making patients wait for treatment -Examples: Canada, Taiwan, South Korea

Population and Geography (Cuba)

- Most populous country in the Caribbean - Largest island in the region - Fairly uniform population

The Distributive Social Ethics Imposed on the Health System

- Nations distribute health care fair and appropriate

What are some obvious fixes to the access challenges Canadians are facing?

- One of the things that has been underutilized has been single entry models [where patients enter a single queue for a certain specialty or procedure]. If we distributed patients to the first available provider, rather than having individual lineups for different providers, we could gain 20%-30% efficiency. - Lots of time is spent trying to organize tests and referrals only to hear back, "My wait is too long. Send them somewhere else." Especially during the pandemic, we're having to re direct referrals multiple times. - Support for team-based care with allied health providers like nurse practitioners and social workers and psychologists could also help share some of the work — [funding for that model] has been frozen for years in Ontario. - We need to empower patients with information. The silence of the system is painful. It is destructive to patient care.

Chaoulli v Quebec: Cause or Symptom of Quebec Health System Privatization? (reading)

- One year after the Chaoulli ruling, the Quebec government enacted Bill 33, An Act to amend the Act respecting health services and social services and other legislative provisions. This legislation did allow for the purchase of private insurance, but only for three procedures (hip, knee, and cataract surgeries). However, it also provided that procedures for which private insurance would be allowed would be determined by regulation, thereby facilitating the subsequent expansions - The introduction of Bill 33 was contentious. While the Quebec government asserted that it was a necessary response to a Supreme Court of Canada ruling, commentators claimed that other options were possible. Consequences of Bill 33 - the provisions allowing specialized medical centers (i.e., private medical clinics performing surgical procedures) to contract with the public sector, duplicative private health insurance for specific procedures, and wait times targets. The first two were highly contentious elements that were thought to pave the way for increased privatization of the system, while the third could be a positive development for the public system, helping it to address the problem of wait times that justified the legal challenge in the first instance.

Access and quality of health care in Canada: Insights from 1998 to the present (reading)

- Over time, the data series reveals that an increasing majority of the public report receiving quality care, rising from a national average of 53% in 2002 to 61% in 2018. - Regionally, the variation in quality care has been relatively narrow, ranging from 52% in the Atlantic and Prairie provinces to 65% in Ontario in 2018. - Professionals' ratings for delivery of quality care in 2018 were slightly higher than the public, averaging 65% and ranging from 58% among nurses to 72% and 74% among physicians and administrators. - Despite the favorable ratings received for quality of healthcare, a persistent and growing issue in all regions of the country is concern around timely access to care. - The Canadian Medicare system is currently recognized as a valued component of our national identity. However, sub-optimal access continues to undermine quality of care. In the absence of improved access, healthcare quality and outcomes will also remain sub-optimal.

Pre-World War 2: Government Involvement

- Seldom intervened to regulate the practice of medicine - Provided support to care for the poor - Most involved in implementing policy for sanitation, maintenance, and cleanliness of towns and markets - Intervened during epidemics by imposing quarantine, distributing medications, creating health offices - Shared responsibility between provinces and federal government ~ provinces responsible for hospitals, public health, professional regulations ~ federal government responsible for external matters with respect to quarantine

COVID-19 conceals deepening privatization of the NHS

- Since the passing of the Health and Social Care Act in 2012 the NHS in England has been forced down a route of increased marketisation and privatization - and the Government has accelerated its aggressive outsourcing to private firms during the COVID-19 pandemic. - This pandemic has already highlighted the disastrous effect of austerity politics on our patients and the health and care system - with once comprehensive public health services cut to the bone, social care stretched beyond reason and more or less the entire NHS, for so many years run at full capacity with no flex, having to shut down to ensure intensive care services are not overwhelmed - Urgent action is required to protect the NHS and ensure taxpayer money is spent in a responsible manner. In the long term the health service must be protected and returned to being a genuinely publicly funded, publicly provided and publicly accountable system.

Pros and cons of privatizing the NHS (reading)

- The moral argument for a public system which delivers free care to everybody, regardless of wealth or status, was once unassailable - and even advocates for increased privatization still do not question the principle, at least in public. ~Yet the service was set up "in the face of political opposition", says Hawking. Public opinion may shift again - particularly when the argument is made that the service is simply too expensive to run now, given an aging population unforeseen by its founders.~ -Private firms will not carry on providing an unprofitable service any longer than they have to. This could lead to a lack of continuity, with some patients finding their health providers change during an illness .-The US healthcare system "suffers from [this] bizarre phenomenon", writes Elisabeth Rosenthal on CNN. Year on year, the cost of drugs and other treatments increase. Instead of getting cheaper as they become more widespread, new medicines, tests and procedures actually become more expensive. "When one hospital system manages to get away with charging extremely high prices, it provides cover for others to raise theirs," says Rosenthal. -The NHS is often seen as a one-size-fits-all system by its detractors, while a privatized service might allow patients to better choose where to be treated - and what treatment to have. In fact, a substantial degree of patient choice has been introduced into the service over the past two decades

What have been the barriers to meaningful reform? (How can Canada improve worsening wait times? (reading))

- We haven't really embraced the notion that we need to measure and publicly report wait times beyond a few politically advantaged procedures, like hip and knee and cataract surgery. - Part of it is money. [When it comes to access to family doctors,] there's a distribution problem and a shortage of physicians, not in total numbers, but in the number providing comprehensive primary care.

We know COVID-19 has created new challenges in access to care, but what opportunities do you see it creating? (How can Canada improve worsening wait times? (reading))

- We've learned that we can do more by virtual care than we previously had been doing. If we look at U.S. data, virtual care actually created new health care utilization, far more than it replaced face-to-face care. - I like to think telemedicine will expedite access because people can be assured of [more direct] communication. A wise nurse once told me, "Communication is medicine. When we fail to communicate with the patient, we're depriving them of important reassurance, guidance and care."

fair distribution of health care

- a fair health system will expand coverage for cost-effective services and give extra priority to those who are worse-off, while providing high financial risk protection - variation among nations and citizens with nations

Canda History

- one country, two histories ~ The English conducted the first exploration of Canada in 1497 ~ The French founded the first large-scale permanent European colony -The Seven Year war (1753-1763) -Treaty of Paris 1763 ~ Birth of 2 colonies/provinces- Quebec and Ontario

Social Ethic 1: Pure Egalitarianism

- the healthcare system should be financed and structured so that the entire health care experience a person has in response to a given illness should be the same regardless of that individual's socioeconomic status in society, and the financial burden of health insurances and out-of-pocket spending for health care should be at least proportional to income if not progressive - country examples: Canada, Japan, Taiwan, Korea - common characteristics: government-run, single-payer health insurance system with a common fee schedule

Dependence on India's private sector (public)

-25,778 hospitals -714,000 beds -36,000 ICUs -18,000 ventilators - -improvement in institutional deliveries- 22% increase from 2004-2014 7% population fall below poverty line every year due to catastrophic health expenditures nearly 10% HHs reported more than 40% of usual expenditure on health

Dependence on India's private sector (private)

-43,486 hospital beds -1.18 million beds -59,000 ICUs -29,000 ventilators -62% of India's health infrastructure (35% to 70%) -75% of OP visits and 55% IP visits (2014)

Doctors in China

-Based on the 2015 White Paper on Chinese doctors -Long working time: Around 50 hours per week and overtime is pervasive. -Low salary: 70,000-80,000 Yuan per year, while the average annual salary in 2015 for urban employees were 62,029 Yuan. -The majority is hospital employees. -Dangerous occupation: Violence against physicians is common. 66% of physicians reported to experience various conflicts with patients. And criminals benefit from the medical conflicts (Yinao, 医闹).

China Summary

-Chinese health care system is a centralized healthcare system, characterized as public financed and delivery system (Similar to NHS). -Chinese system showed advantages in -Curb the spread of pandemic -Achieve a definite goal within a short-term period

Burden of Disease

-Chronic and life-style related ~ cancer is the leading cause of death ~ heart disease -Risk factors ~metabolic- high BMI, HBP ~environmental ~behavioral - tobacco and alcohol use, drug use, dietary risks - Variation in prevalence by race and ethnicity ~ diabetes among Black Canadians is 2.1 times the rate for White Canadians ~ lower rates of tobacco and heavy alcohol use among Black Canadians

Russia: Payment

-Fee-for-service -Salary

As a patient in China

-Few waiting time: Same-day Online appointment and Registration -Crows of people in the tertiary hospitals -Lack of communication -Low cost for minor and common ailments

Russia: Financing

-General taxation -employer contributions -out-of-pocket

Canada Government and Political system

-Government structure ~ constitutional monarchy- system of government in which a monarch shares power with a constitutionally organized government -Style of government ~ parliamentary democracy with federal structure ~ prime minister heads the national government ~ parliament is a bicameral body ~ premiers head the 13 jurisdictions with unicameral assemblies -Essence of government ~"Peace, Order and Good Government"

Out-of-Pocket Model

-Health system in many low-income countries -Access to care is based on ability to pay ~Rich get medical care, and the poor stay sick or die -Example: rural regions of Africa, India, China, South America

Pre-World War 2: Public health development

-Infectious disease was the dominant public health concern - Canadian government directed efforts to standardize and coordinate public health initiatives of the provincial health ministries ~national hygiene grants program ~ public health laboratory ~ food and drug control programs and the care of children ~ vital statistics - First school of public health created to train workforce on infectious disease control - Creation of the first ministry of health - Provinces were divided into health districts-public health physicians, one or two nurses, and a public health inspector ~ health units were financially supported by the provinces ~ services provided: control contagious disease, community sanitation, and general monitoring

Evolution of the Canadian Health System

-Initial attempt at establishing a national health insurance program failed WHY IT FAILED: -Implementation of reforms at the provincial level ~Plan: The Hospital Services Plan ~Financing: Annual premiums ~Payment: initially per diem bur later changed to a global budget ~Incentivized unwarranted increase in utilization ~Global budget paid hospital monthly rate that was based on 90% occupancy rate -Benefits covered: all services provided at the facility Health care reform continued to be responsibility of provinces

Bismarck Model

-Insurance system "sickness fund" usually financed jointly by employers and employees through payroll deduction -Insurance plans have to cover everybody, and they don't make a profit -Delivery of health care is done through private hospitals and physicians -Tight government regulation to control cost -Examples: Germany, France, Belgium, Japan, Netherlands, Switzerland

Russia: Insurance

-Mandatory Health Insurance -Private Insurance

Social Ethics 2: two-tiered Health System

-Most of the citizenry should share the same health care experience in response to a given illness, although a small, wealthy elite can buy out of this social contract and have its own, more expensive health insurance and health care system - country examples: United Kingdom, Germany

Pre-World War 2: Financing and Delivery of clinical services

-Municipal Doctor Plans-recruit and retain physicians to provide rural health services -Local government paid for physicians' salaries -Resource pooling to fund hospital construction among rural towns ~led to the nation's modern health care system

Canada Size and Geography

-Second Largest nation in the world and largest one on the North American continent -Two-thirds of the population reside alone get southern border -Population density: 37 people per square kilometer ~ 80% reside in urban areas(2250 people/ square kilometer)

Pre World-War 2:Impact of the Great Depression

-Transformed the Canadian health care system -Physicians and hospitals were financially strained -Open to more government intervention ~Saskatchewan Medical Association endorses public health insurance program ~ The Cooperative Commonwealth Federation promoted "Socialized health service"

Beveridge Model

-health care provided and financed by government through tax payment -many hospitals and clinics are owned by the government -some doctors are government employees, but there are also private doctors -examples: Great Britain, Spain, New Zealand, and most of Scandinavia

Gross Domestic Product (GDP) of Canada per capita from 1960 to 2019 (in US dollars)

-total GDP-$1.736 Trillion USD -GDP/capita- >$45,000 -economy evolved from resource-driven origins to diverse market sectors -key industries- trade, health care, finance and insurance, natural gas, oil, mining and agriculture

Evolution of the Canadian Health System: Five principles of the Canada Health Act

1) Public Administration: plans administered and operated on a not-for-profit-basis by a public authority 2) Comprehensiveness: plans must cover all medically necessary health services provided by hospitals and physicians 3) Universality: covers all residents 4) Portability: coverage follows insured moving from one province to the next, waiting periods may not exceed three months 5) Accessibility: Insured must have uniformed and reasonable access to hospital, physician, and dental surgery services

Three basic goals of a health care system

1) keeping people healthy 2) treating the sick 3) protecting families against finical ruin from medical bills

What percentage of the population of both South Africa and Canada are living with HIV/AIDS?

13% of South Africa and 0.1% of Canada

What percentage of people in the UK are unable to complete their recovery program?

40%

What percent of Pacific Islanders are obese?

63%

Canada: Financing

70% ~province/government - block grant transfer ~government - First Nation and Inuit descent - veterans/Armed force/Royal Canadian Police 30% ~private ~out of pocket

What is Opioid Substitution Therapy?

A type of therapy endorsed by the UN to manage the dependence of opioids. Medications are prescribed rather than finding opioids in unauthorized settings.

Which of the following interventions does Brazil currently have to improve the prevalence of diabetes? o Nutritional standards o Evaluation plan o Free public gyms o Implementation plan o A & C

A&C

Why are waiting times for services increasing in NHS England?

ALL COVID-19 pandemic Provider shortages Declining NHS funding Mismatch between population needs and NHS resources

In the article, "Chaoulli v. Quebec: Cause or Symptom of Quebec Health System Privatization?", why didn't duplicate private insurance increase after Bill 33 implementation?

ALL Limited uptake of private health insurance by consumers Parallel efforts to impose wait time guarantees in the public sector Public sector assumes the administrative and cost burden of accommodating patients in a parallel sector

Evaluation of Russia's healthcare system (access)

Adequate access to primary care •Geographical access was not a barrier to access due to affordable transportation Disparities in access to high quality care exist •Elite members of society often have better access to high quality care •Widening gap among social groups Disparities in access to health care funds •Worsening distribution of funds between rural and urban areas •Wealthier urban households have better access

Why do you think the leading cause for death under 5 in India is lower respiratory infections, while here in the U.S. it isn't a top 5 cause of death?

Air pollution plays a large part. However, the inability to access medical care, or quality medical care, plays a large part in infections such as pneumonia getting out of hand. Medications and treatment options are not as accessible.

Which of the following are health disparities in Portugal? Age,Gender,Education,Income,All of the Above

All of the above

What is one disparity in Germany's maternal care system?

As an asylum seeker in Germany, you are not entitled to statutory health insurance until you have lived in Germany for at least 15 months. Until then, Asylum Seekers Benefits Act will cover you through health care vouchers until then.

Prominent Issues(access to care)

Availability - distance, travel times, wait times •Wait times - Supply and demand factors •Shifting demographics (population and workforce) •Increased demand and declining provider supply due to aging population •Intervention: integration of nurse practitioners Accessibility •PCP appointments can be difficult to get •Intervention: increase availability and accessibility of PCP •Gap in supply of physical infrastructure •Lag in hospital construction, long-term care beds, assisted living facilities

To solve the geographic maldistribution, one approach used by Chinese in 1960-1970s was:

Barefoot doctors

Based on the classification of basic health care model, Chinese healthcare system in 2020 should be:

Beveridge Model

Who commissions general practice?

Both National Health Service Clinically Commissioning Group

What are the three national cancer screening programs in the UK?

Bowel cancer screening, Breast cancer screening, Cervical cancer screening

China Structural Factors

Centralized government -Prompt action -Avoid any resistance from local government via strict punishments -Mobilize the whole society to combat the pandemic Public health system -Freely allocating resources (Staffing and equipment) -Discretion to design COVID-related benefit

Would you say that China's healthcare structure is more functional than the United States? Why?

China's healthcare structure overall seems to be more functional than the healthcare structure in the United States. China's healthcare structure ensures that the government pays for vaccines related to HPV and has many programs to monitor the HIV and HPV status of the country whereas the United States offers vaccines and programs but are funded individually and by private health insurance companies.

Description of Russia's health care system (medical technology)

Ct scan Machines/Million MRIs/million Canada 15 10 United Kingdom 45 40 America 35 35 Russia 13.4 5 •Significant disparities of technology between policlinics and hospitals •Rural areas experience the greatest shortage

Why is the prevalence of HPV so high in China?

Cultural stigmas and Lack of availability of screening in rural areas

William Beveridge (1879 - 1963)

Daring social reformer who designed Britian's National Health Service

Russia Demographics

Decline in fertility rate has led to rapid aging between 1959 and 1990 •Currently, 15.5% of population over 65 years •Largest population group is 25-54 years accounts for 43% Top five conditions contributing to total disability-adjusted life years are •Cardiovascular disease •Injuries •Digestive diseases •Neuropsychiatric conditions •Malignant neoplasms 3 major risk factors •High blood pressure •Tobacco •High BMI

Community-based services are provided by other health professionals (United Kingdom)

Dental, pharmacy, optometry, district nurses (home health nurses), midwives, health visitors

Prominent Issues(role of private sector)

Development of private health insurance for services covered under Medicare •Currently prohibited under the constitution •Supreme court struck down Quebec's statute •Ruled that "... government has the responsibility to provide services under Medicare in a timely fashion to prevent undue pain and risk of death. If the government fails to meet these obligations, the statutory prohibition of people going outside the public system to obtain care is unconstitutional under the laws of Quebec." Impact of a parallel private health insurance system is unclear •Exacerbate cost and equity concerns •Bolster infrastructure for delivery of high technology services •Violates the just, fair and equitable principles which are the hallmark of the Canada Health Act •"Free up" public capacity and make access better for all

Current and Emerging Issues and Challenges(Russia)

Emergence of TB and HIV/AIDS •TB has been an acute challenge for the health care system •Rising multiple drug resistance to TB •Increased growth rate of HIV infection •Achieved 98% success rate in preventing mother-to-child HIV transmission Noncommunicable diseases and injuries constituted 70% of top causes of death •Accounts for 70% of total mortality •3 leading risk factors - high blood pressure, cholesterol, and tobacco use Pharmaceutical shortages leading to high spending •Limited development of pharmaceutical industry •Old soviet union relied on communist countries •Western drug companies prefer to sell brand name medications rather than generics

Evolution of the Canadian Health System

Enactment of the Medical Care Insurance Act of 1962 -universal coverage of physician services -physicians were paid based on a fee-schedule ~23-day physician strike ~ allowed physicians to balance bill Other provinces soon adopted similar program

Decentralization of health care in Russia was largely successful because of better federal oversight into the financing, planning, and management of health care services at the territorial/municipal levels

False

Health care in East Germany was characterized by a highly decentralized health care system managed by the socialist unity party.

False

Medicare requires coverage for outpatient drugs.

False

Provident dispensaries in the United Kingdom have been referred to as the forerunners of prepaid health. These programs provided free health care for their members, covering primary care services, prescription drugs, and inpatient care.

False

The Cuban health care system funds some basic health care services covering preventive care, testing, and IP medications at no cost to individuals.

False

History of Russia Health Care System

Financing of the old Soviet system •General government revenues •Declining funds •6.6% in 1960 -5% in 1980 Emergence of an insurance-based system -Mandatory Health Insurance Fund •Not-for profit independent entities responsible for managing health care financing •Federal MHIF •Subsidize poorer territories •Non-working population - children, students, retired or unemployed, and individuals with disabilities •Territorial MHIF contribute towards coverage of services for non-working population Territorial MHIF •Covers services provided at the territorial and local health authorities

Description of the Current Health Care System (United Kingdom)

Financing: - general taxation - national insurance - user fees Payment: - capitation - fee-for-service Insurance: - Public Health Insurance (NHS) - Private Insurance Delivery: - Public and private hospitals - private physicians

Description of the Current Health Care System (Germany)

Financing: - wage contributions - supplementary contributions Payment: - fee-for-service - salary Insurance: - public health insurance - statutory health insurance (SHI) - statutory long-term care insurance (LTCI) Delivery: - Public and private hospitals - private physicians

Besides child mortality, what other health issues are prevalent in Russia?

HIV/AIDS, high BMI, cardiovascular disease, injuries, high male mortality

How does France compare to the US in regard to HPV vaccination rates?

HPV vaccination rates in France were extremely low at 19% compared to the HPV vaccination rates in the US at around 80%

Evolution of the Health Care System (Access)

Health care equality - cornerstone of the Canadian philosophy of health care •Most residents have access to Medicare •Medicare reduces the exposure to financial access barriers Barriers in access to health care •Other health care costs - transportation, uncovered services, etc. •Geography - rural vs urban •Wide expanse of rural areas resulting in travel times •Harsh winter weather •Social/cultural •Language issues Disparities in access to health care •Low-income population •Rural residents •Racial/ethnic groups

Description of the Health Care System(Human resources-Workforce)

Health care is the nation's largest source of employment Physicians ~ Distribution: 241 physicians per 100,000 population - family medicine physicians represent between 50% and 53% of the physician workforce - growing number of female practitioners particularly - 8% of physicians are located in rural areas and 92% are concentrated in urban areas ~ Challenge: perceived physician shortage - surge in part-time physicians (female and older physicians) - changes in patient demand for medical services Nurses ~ Distribution: 1222 nurses per 100,000 population - 4 groups of nursing professionals- Nurse practitioners, registered nurses, registered psychiatric nurses, and licensed practical nurses ~ Challenge: aging nursing workforce - aging nursing workforce amidst aging population and greater demands for health care

Canada: payment

Hospitals ~ Global budget Physicians ~ Fee schedule ~ Alternate Payment programs - Capitation - Salaries - Contract

History of Russia Health Care System

Household spending on health care •Prescription drugs - Largest portion of household spending •IP prescriptions - free •OP prescriptions - cost sharing •Led to unnecessary hospitalization •Prescription drugs account for 30% of health care spending Reliance on specialist treatment and hospitalization •Long length of inpatient stay •Two times more spending on IP care than OP care

Description of the Health Care System- Human Resources (United Kingdom)

Human Resources (workforce) •Health care is the nation's largest source of employment •Providers •150,000 Clinical staff (consultants, doctors-in-training, and GPs) •330,000 nurses and midwifes •Challenge: Physician shortage •Ratio of patients per GP practice has been deteriorating •6.4 thousand patients to each GP practice in 2008 and by 2017 this figure had climbed to over 7.6 thousand

Evolution of the Canadian Health System

Impact of the National Health and Diagnostic and Medical Care Act ~ increase utilization ~ rising health care costs Cost Control Measures: ~Enactment of the Program Financing Act - reduced federal matching to BLOCK GRANTS TRANSFERS - 25% of health care expenditures - provided stronger incentive for provinces to control cost and reduced the risk to federal govt. - Reduced federal taxes to create "tax room" for the provinces Utilization control measures ~Supply side interventions - reduce hospital beds - limit annual budgetary increases to hospitals to rates less than the rate of inflation - limit increases in physician fee schedules No reduction in the benefits covered or scope of services

Evolution of the Canadian Health System

In 1966, Federal Government Care Act also called "Medicare" ~financing: 50/50 Federal matching funds ~benefits covered: universal coverage for physician services administered by the provinces Provinces had the freedom to develop their health plans ~ attitude toward balance billing ~ accept gov fee schedule rate OR opt-out of the government-sponsored plan

Evolution of the Canadian Health System

In 1984, the Canadian Health Act was passed to integrate the three legislature: ~ National Hospital and Diagnostic Services Act ~ Medical Care Insurance "Medicare" ~ Program Financing Act National health insurance framework known as Medicare ~ Provincially administered ~ Federal guidance- Five Principles of the Canada Health Act

What are the most important disparities that contribute to mental and physical health in the UK?

Income and employment

Expansion of health care post-revolution in Cuba did all of the following except:

Increase access to imaging services

According to the current projections, by 2030 which will be the most populous country in the world?

India

How does India's healthcare system compare to the U.S.?

India's healthcare system is universal, with high quality urban hospitals vs very low-quality rural hospitals. Many Indians are unable to afford medical care. The US is a mix of public and private healthcare and differs significantly from India in accessibility. While many Americans are also unable to afford quality health insurance, the number is less than that of India.

What is one of the main causes of obesity in New Zealand?

It is widely believed that obesity rates are rising everywhere due to a modern lifestyle which promotes overeating and provides little encouragement to exercise.

Kerala Model

Kerala India U.S. Human Development 0.79 0.65 0.93 Index (HDI) Literacy rate 93.91% 74.4% 99% Life Expectancy 74.9 69.7 78.9 Infant mortality rate (per 12 40 5.7 1,000 births) Maternal mortality rate (per 46 130 17.4 Sex ratio (females per 1084 899 1000 males) GDP per capita (USD) 3,200 2,099 63,000 •Social and land reform movements in 1920s and 1930s •Was never part of the British rule •Govt. investment in social welfare •Remittance from a migrant population working abroad

How is maternal care paid for in Germany?

Maternal care is financed through individual sickness funds from wage contributions of the citizens in Germany.

What is a disparity seen in rural Canada?

Limited access to medical technology

To curb health care spending, physicians are reimbursed based on a predefined quarterly maximum number of patients, and beyond this number, reimbursements are limited or greatly reduced. What are the implications of this process?

Long wait times at the end of each quarter

History of Russia Health Care System

MHI Goals •Comprehensive medical care for all •Increased health care funding •Employer and territorial govt contributions •Decentralize health care •Shift away from central planning, financing, and management •Improve efficiency and quality •Introduce incentives to providers, insurers, and patients •Focus on primary care •Attract more doctors, encourage OP delivery, reduce hospital referrals

History of Russia Health Care System

MHI was created to facilitate market mechanisms and competition: •Private health insurance companies competed for contracts with MHIF •Incentive to select efficient and high-quality providers •Physicians and health care facilities competed for contracts with health insurers •Incentive to provide high-quality, low-cost health care service •Patients had the freedom of choice among health care providers and insurers

Canada: Delivery

Medicare ~ provides insurance to all provincial residents for both hospital and physician services ~variation among provinces with respect to generosity of coverage Private ~ covers services not covered by Medicare (dental care, residential care, and pharmaceutical)

Prominent Issues(outpatient pharmaceuticals)

Medicare does not require coverage for outpatient drugs •Fragmented system of insurance for Rx •Provincial variation in coverage for OP Rx services => Equity concerns •Provinces may cover Rx expenses for certain subpopulation OR, •Provinces may supplement insurance premiums Missed opportunity to negotiate better pricing •May address issues of cost and equity in OP Rx Cross-broader pharmaceutical sales •Traditional and internet sale of brand-name medication ($1.2B) => drug shortages •Withholding sale to Canadians •Increase in wholesale prices

The National Health Service in England is based on the following core principles except:

Meet the needs of some people

Studies state that Russians have adequate access to primary care, however, disparities still exist because

Members of society have access to elite medical institutions

Description of the Health Care System: Acute Care/ Impatient Care

Mostly public owned - Federal, provincial, municipal, regional •Declining number of hospitals and beds particularly in rural areas •Reflects transition to residential care facilities and long-term care

What is New Zealand ranked in terms of obesity compared to other countries?

New Zealand ranks third in OCED countries

What is the Nutriscore system which was implemented in Germany in 2018 and what is your opinion of it?

Nutriscore is a system introduced in Germany that ranks food on a scale from A to E based on how "healthy" or "unhealthy" the food is. This system however can be unfairly biased against foods containing high levels of saturated fats that are important and beneficial for a balanced diet (such as avocados or fish).

How does Opioid Substitution Therapy benefit countries that have it in place?

OST reduces the risk of HIV behaviors, overdoses, criminal activity, and stresses on users and family

Why do you think obesity rates are higher among the Pacific Islanders and Maori people in New Zealand?

Obesity rates are higher among the pacific islander and maori people because, in general people living in areas that are less socioeconomically developed have higher obesity rates, the native people live in more rural- less socioeconomically developed areas

In the article, "How can Canada improve worsening wait times?", the following are reasons why wait times are so bad in Canada except:

Outpatients drug are not covered under Medicare

Chinas COVID shortcomings

Overaction of governments Example1: Going back home in Spring Festive -Central government: Reduce travel in Spring Festive. -Province and city: Compulsively require employees to spend Spring Festive in their working locations. Example 2: Force the whole city to lockdown if one infected patient is reported. -Violation of human rights -Huge Resource Consumption paid by public funding

Which one of these is not an issue or challenge facing the NHS as discussed in class?

Patient choice restrictions

GPs and specialists are generally reimbursed on a uniform fee schedule that is negotiated between sickness funds and regional associations of physicians. This payment mechanism incentivizes physicians to do one of the following.

Physician-induced demand

Evaluation of Russia's healthcare system (quality)

Population clinical indicators •Life expectancy - 72 years •Infant mortality rate (2016) - 8 per 1000 live births •Improvement when compared with 19 per 1000 live births in 2000 •Maternal mortality rate decreased from 40 to 25 per 100000 Inadequate quality of care •Lack of modern technologies, facilities, and medication •Lack of evidence-based approaches in clinical decision making

Pre-World War II (United Kingdom)

Pre-World War II (United Kingdom) •Health care reform proposals •Extend the limited 1911 act into comprehensive national health insurance •Based on individual right to health care •Build up and universalize existing, locally funded and run public health services •Based on the idea that society has an obligation to look after the health of its people •Emergency Medical Service - coordinated all medical services •Social Insurance and Allied Health- the Beveridge report •Comprehensive health care promoting education, employment, housing, and social security

What is not covered under Canada's national healthcare plan, Medicare?

Prescription medication

Description of Russia's health care system ( Primary Care/ Outpatient Care)

Primary care is delivered in policlinics •Rural care primary care delivered in small primary care practices staffed by physician assistants Four categories of policlinics: •Adults, mothers and children, women, and people with disorders Policlinics are staffed by specialists and generalists •Assigned a geographically defined population •Provide only basic treatment •Limited gatekeeping or follow-up •Often bypassed for hospital care Provider reimbursement •Salaries

Description of the Health Care System: Primary Care/ Outpatient Care

Primary care services •First POC with the health care system -direct care and care coordination •Delivered in ambulatory clinics or community health centers •Private physician offices are the most common

Chinese reaction to COVID

Principle: All those in need have been tested, quarantined, hospitalized or treated 1. Trace every infected person and track every close contact for quarantine -High technology: Smart phone, big data, artificial intelligence etc. 2. Quarantine for close contract -Personal experience from my mom3. Treatment and hospitalization 3. Treatment and hospitalization -Everyone who tested positively were forced to hospitalization. -Hospitalized patients with light symptoms in 16 mobile cabin hospitals with 16,000 beds -Specific hospital to treat severe cases (Construct new hospitals with 1,000 beds in 10 days) -Treat every patient regardless of severity, age and cost 4. Increase equipment production 5. Staffing and equipment support for Hubei area from the rest of China -42,600 medical workers, 17,655 ventilators, 15,746 ECG monitors, 77,300 PPEs etc. 6. Cover all the cost resulted from treatment and test. -"As of May 31, the medical bills of 58,000 inpatients with confirmed infections had been settled by basic medical insurance, with a total expenditure of RMB1.35 billion, or RMB23,000 per person. The average cost for treating Covid-19 patients in severe condition surpassed RMB150,000, and in some critical cases the individual cost exceeded RMB1 million, all covered by the state."

Most of the health infrastructure in India is in which sector?

Private

Pre-World War 2: Provision of Services

Private practice- focused on provider- patient relationship ~Four main categories of treatment- medication, bloodletting, diet and (including starvation), and surgery Hospitals ~ negative view of hospitals- "lacked adequate care" and "associated with poor" ~ not seen as a place to practice medicine ~ hospital network developed more quickly in Canada than the US

What was a recommendation that we mentioned that would help Denmark improve their vaccination program?

Promoting HIV vaccination and addressing disparities seen in uninsured populations, like asylum seekers.

Description of Russia's health care system(Acute Care/Inpatient Care)

Provided by facilities managed by their regional or district administration •Service areas comprise between 15000 - 50000 people Central district hospital is responsible for all facilities in the region Few federally-owned tertiary level facilities •Substandard facilities •Outdated equipment •Limited internet access in rural areas

Canada: Insurance

Public ~ most hospital facilities are operated by the provincial government Private ~ physician and residential care facilities are mostly NGO ~ Not-for-profit hospitals

Description of the Health Care System: Public Health

Public health is distinct from the delivery of medical care •Focused on population health such as community health assessment, disease surveillance, disease and injury prevention, and health protection •Purview of the provincial and local governments •Federal government role is limited •Implementation of Quarantine Act and health protection legislation

How does China financially cover their citizens?

Public taxes used to cover lower and middle class and Co-payments used to cover upper class

Recent increase in infant mortality rate can be attributed to?

Recent Healthcare System + Economic Collapse that has resulted in physician shortages, lack of vaccines, and the lack of a public health minster. This has allowed for the return of infectious disease and malnutrition.

Ghana suffers from a chronic shortage of health workers not because there are insufficient numbers of medical professionals but because

Refusal to accept postings Employment freeze Ballooning physician wage bill All of them

Description of the Health Care System: Residential Care/Long-Term Care

Residential care facilities are mainly used for eldercare and mental health •~79% private-for-profit

History of Chinese system: Stage 2

STAGE II: THE INITIAL STAGE OF REFORM AND OPENING (改革开放，1979-2002) •In 1978 CCP ushered a transition from the planned economy to a socialist market economy. Reform in Healthcare system •Resource allocation relied on market mechanisms. •Allow private health providers to enter healthcare industry while some public health-care facilities were privatized. •Governments reduced health related expenditure and health providers needed to care for their own financial viability. •The basic of health insurances, the people's commune and state-owned enterprises, collapsed so that people had to pay health care by their own. Outcomes: •Health industry flourished •Medical expenditure rose rapidly along with rising incomes •Health facilities were increasingly profit-driven: Supply-driven demand; Corruptions (Red pockets, 红包)；Hospitals which provided low-quality or invalid treatment but overcharged (Putian System, 莆田系) •High out-of-pocket cost and low coverage of health insurance •Less investment in infection control program. 2003 SARS!

History of Chinese system: Stage 3

STAGE III: THE PERIOD OF DEEPENING OF REFORM AND OPENING (2003 TO TODAY) -Health insurance •Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) •Universe coverage: In 2019, 95% by public health insurance •Benefit can still be improved -Increased governmental investment. The growth rate of government spending on health should be higher than the growth rate of the government spending. -Health delivery system reform •Cost containment: Canceling of hospital drug price addition; the growth rate of cost was regulated below 10%; Lower the prices of prescriptions, services and co-pay. •Hierarchical medical system: Divert patients to community hospitals and reduces the flow into tertiary hospitals.

Health care delivery- Bottom-up approach (India)

SUBCENTER •Serves 3000 to 5000 population •Provide comprehensive primary care services, free essential medicines and basic diagnostics, nutritional support to pregnant women, TB patients etc. •Auxiliary nurse midwife/ female health worker/ male health worker/ ASHA (Hope)- Accredited Social Health Activist •931,000 ASHA workers PRIMARY HC •1st point of contact between a village community and a physician •Serves around 20,000 to 30,000 people (6 subcenters) •4-6 beds COMMUNITY HC •Referral center for 4 PHCs •Obstetric care and other specialist consultations as well •30 beds, lab + x-ray diagnostics •80k to 120k population HOSPITALS •District hospitals- terminal referral centers •Research and teaching hospitals- similar to University hospitals in the U.S. •Specialty hospitals like Regional Cancer Centers (RCCs)

Provide a name of one of the government programs OR the research program that was mentioned?

Seguro Popular, INSABI, System of Social Protection in Health, or Joven & Fuerte

Which populations are more vulnerable by AIDS/HIV in South Africa?

Sex workers, young women, men who have sex with men, transgender women, people who inject drugs, children/orphans

How have social factors decreased trust in vaccinations?

Social media and high-profile members of the government misinforming people can cause more people to not trust in the science and evidence that are used to inform immunizations.

Why are women who live in rural parts of Mexico and have a lower socioeconomic status more prone to have breast cancer?

Socioeconomic status (a lot of disparities), fragmented healthcare system, lack of information, cultural aspects, lack of professionals and technology in rural areas

History of Chinese system: Stage 1

Stage I: From the founding of new China to the reform and opening (1949-1978) •The health service delivery system was established and developed quickly. The institutional framework of the Chinese health service delivery system was essentially formed in this period. •Planned economy: Government controlled, planned and organized the health system. Three-tier system: Central government-Province-City/County •Health insurance: State-financed. Rural cooperative medical scheme (Rural residents), Free Health Services (Civil servants), and Labor medical insurance (Employees in state-owned enterprises). Low premium and reimbursement rates, but low OOP cost due to bartering and limited access to health services(20.43% in 1978) •Health delivery: State-owned. Severe shortages of doctors and drugs. Geographic maldistribution of health services (Hospitals and medical staffs concentrated in metropolitan and urban areas) •To solve the geographic maldistribution, Mao in 1968 encouraged rapidly trained primary health staffs to practice in rural areas, the so-called barefoot doctors (赤脚医生) . In 1970, there were around 1.5 million barefoot doctors, accounting for one-third of the rural medical staffs (4,779,280) and one-fifth of total medical workers (6,571,795).

Building Blocks of a health care system (United Kingdom)

System Resources: - human resources (workforce) - medical technology - health services financing Structures and Processes along the Continuum of Care: - Primary Care/Outpatient Care - Acute Care/Inpatient Care - Post-Acute Care/Long-term care System Outcomes: - Access - Quality - cost ==Health Policy & Reform

Description of the Health Care system: Medical technology

Technology Ct scan Machines/Million MRIs/million Canada 14.7 8.8 United Kingdom 7.9 6.1 America 43.5 35.5 Growth in free-standing imaging centers ~ 5% of CT machines and 21% of MRI scanners in 2013 ~ Funded through private insurance and out-of-pocket payments Challenge: Accessibility ~ Funded through private insurance and out-of-pocket payments ~ Access is concentrated in urban areas

What are the two causes of low vaccination rates in the Democratic Republic of the Congo?

The DRC government decentralized in 2015, giving unprecedented decision-making authority to newly appointed provincial government officials. Decentralization has put into place new leaders who are not familiar with health policies and planning documents, particularly those for immunization.A: Health workers conducting routine vaccinations do not have access to adequate equipment to protect themselves, caregivers, and children from the coronavirus.

What was one campaign or initiative to address low vaccination rates in the Democratic Republic of the Congo?

The Expanded Program on Immunization (EPI) program.

Evolution of health care system continued

The National Hospital and Diagnostic Service Act was enacted in 1957 -Financing: 50/50 funding scheme that was contingent on: ~ universal coverage ~ portability of services from province to province ~ insurance for all medically necessary services ~ publicly administrated not-for-profit program -benefits covered: all hospital services Provision of federal fund enabled implementation in other provinces All provinces participated by 1961 - adopted the Hospital Services Plan as the template for hospital payment - did not cover physicians services. why? Established the constitutionality of federal role in health care

What could the US learn from Denmark's approach to vaccinations?

The US could expand vaccination access through universal healthcare, as Denmark has.

How has the type of Canada's healthcare system impacted how efficient and effective they have been with addressing the HIV/AIDS epidemic? Can you identify areas of weakness or strengths?

The form of Canada's universal healthcare system has ensured that thousands of Canadians who have HIV/AIDS are provided coverage for both hospital and physician services, so they can get access to the care and treatment they need. This is a major strength of the Canadian healthcare system; however, this comes with some weaknesses including the struggle of longer waiting times.

Why do you think the HPV vaccination rate is so low in France? Is it because the vaccine isn't completely covered by insurance, geographic maldistribution, or something else?

The main reason for low vaccination rate is being against vaccines in general, more of a parental decision for their kids, lack of education, and belief the vaccine is not okay. Overall, comes down to what people believe is right for them and their children.

The following feature does not depict physicians in China nowadays:

The majority practices in free-standing clinics

Why do new strains of COVID-19 pose a risk to vaccination efforts?

The vaccines are not effective against new strains coming from the Amazon region, posing a new threat to the populations. A new vaccine would have to be developed and those who were already vaccinated.

Are there traits they could draw from another country's type of healthcare system in order to improve any of the weaknesses you found?

They could utilize a single-entry model which has been implemented in Australia. In this model the patients enter a single wait list for a specific specialty or procedure. If the patients were distributed to the first provider available, rather than having to wait for a different provider, they could gain some efficiency.

Evolution of the Health Care System (Quality)

Three quality measures of the Canadian health care system: Population health (clinical indicators) •Infant mortality - 4.8 deaths/1000 live births •3-4 times higher among the indigenous population •Life expectancy - 82.1 years •Aboriginal men live 7 years less than national average •Vaccination rates - high rates of vaccination across the population System efficiency •Longer waiting times •45% were able to obtain same day or next day appointments •33% report an average wait time of 6 days to see a physician •41% report an average wait time of 1 month to see a specialist •32-55 days median wait time for MRI Patient perception/satisfaction •84% very satisfied/somewhat satisfied

What are the main disparities of sexual health in China? What can be done to address these disparities?

Two of the biggest disparities in China's sexual health is the rate of HIV related sexual behaviors among the sexually active youth and the lack of condom use. To address these disparities, the government should bring sexual health classes into schools and make condoms widely available at no cost. This would educate the youth and give them resources to be smarter when they are sexually active.

Which country in Europe has the highest substance dependency?

United Kingdom

What kind of healthcare system does New Zealand have?

Universal health care

How is Venezuela's transparency in their healthcare status?

Venezuela has not been transparent in reporting health statistics as they have not posted a health report since the firing of the health minister in 2017.

s the NHS being privatized? (reading)

What's the issue? - The involvement of the private sector in the NHS is a hotly contested topic. Private companies have always played a role in the NHS, but critics claim that their involvement has increased and is evidence of a privatization of care that is undermining the service's core values. How much does the NHS spend on the private sector? - This is because central bodies do not hold detailed information on individual contracts with service providers, especially where these contracts may cover small amounts of activity and spending. Information on private sector spending is available from the annual accounts of the Department of Health and Social Care but also requires judgement and interpretation. - The Department of Health and Social Care accounts also record how much the NHS spends on services provided by the voluntary and not-for-profit sectors and local authorities. - The Department of Health and Social Care's accounts also show that NHS providers spent £1.5 billion[2] on services from non-NHS organizations in 2019/20. What's behind this? - The extent of private sector-commissioned services varies between different areas of care. For example, evidence suggests that spending on private providers increased more quickly in community services and mental health than in other services. This may be, for example, because of contracts being more frequently retendered in these services and because more non-NHS providers are operating in these service areas. - The NHS and the private sector have also established partnerships for the delivery of clinical services such as radiology and pathology and non-clinical services such as car parking and management of buildings and the estate. The King's Fund view: - Detailed data on individual contracts is not available, and judgements must be made on what is included as spending on the private sector. For example, if spending on GP services and voluntary sector organizations delivering health care services were included, the total spending on the private sector would be higher than the figures contained in the Department of Health and Social Care accounts.

How can public health officials inform Russian citizens about the benefits of folic acid to avoid mass resistance?

answers vary; Could run informational campaigns in the form of direct outreach (TV Ads, newspaper/Magazine Ads, Billboards). Public health officials could also incentive physicians to discuss the benefits of folic acid with patients to decrease resistance if a policy change occurs.

Prussian Chanceller Otto von Bismarck

invented the welfare state as part of the unification of Germany in the 19th century

Description of Russia's health care system(Human resources-workforce)

• Physicians •Distribution - 3.75 physicians/1,000 population in 2015 •Increased effort to increase and strengthen primary care •Retraining specialist in primary care medicine Nurses •Shortage •Rural and urban disparity •99% of nurses are women

Demographics (United Kingdom)

•2021 population estimate is 66 million people •0-14 years: 17.63% •15-24 years: 11.49% 25-54 years: 39.67% •55-64 years: 12.73% •65 years and over: 18.48%

Demographics (Germany)

•2021 population estimate is 80 million people •Low birth rate and aging population •Decline in proportions of working-age •Fewer workers paying into social security system •Increased old-age dependency ratio •% of people 65+ per 100 people in labor force •Reflects economic burden due to rising health and pension expenditure

India COVID

•21 days lockdown on 24thMarch 2020 •Implemented within 4 hours of announcement •450 million internal migrants

Government and Political System (United Kingdom)

•3rd largest economy in Europe •Total GDP - $2.82T •GDP/capita - $46,659 •Key industries - financial services, manufacturing, aircraft/aerospace, natural gas

Population of India

•By 2027, India is expected to overtake China and become the most populous country in the world

Evaluation of the Healthcare System- Quality (United Kingdom)

•Care Quality Commission (CQC) regulates health and social care •Applies national quality standards •Investigates consumer complaints •National Institute for Health and Clinical Excellence (NICE) •Develops treatment guidelines •Determines approved pharmaceuticals •NHS Choices •Publishes quality data at the organizational, department and physician levels •Population clinical indicators •Life expectancy - 80.7 years•Infant mortality rate - 5 per 1000 live births •Maternal mortality rate - 8 per 100000 live births •Vaccination rate is high •Patient Satisfaction•Broad support among citizens

Hitler's Third Reich and World War II (Germany)

•Centralized leadership - Hitler's leader principle •Appointed a director of sickness funds •Funds, community health services, NGOs, health professional organizations •Negative implications of centralized leadership •Creation of a master race •Extermination of Jewish people and stigmatized minorities •Misuse of private health information •Medical professions in Nazi party •Positive implication •Extended public insurance to pensioners •Covered all wage earners •Unlimited health •12 weeks maternity leave

Russia Macroeconomics

•Characterized by many large companies •High density of extraction and heavy industry •For 20 years, economic policy oriented toward economic stabilization, liberalization of prices, and integration into the global economy •GDP equivalent to $4 Trillion in 2019 •Major industries are machinery; extractive industries such as coal, oil, gas; defense; shipbuilding; road and rail transportation

Ghana Government and Political system

•Composed of 10 administrative regions and 216 administrative districts •National level is responsible for policy and strategy development •Regional level is intermediate level responsible for translating national policy into regional strategies and coordinating actions •The district is the level at which all government policies •District assemblies are very important in the implementation and sustainability of a multisectoral response to healthcare systems

Conclusion (United Kingdom)

•Continues as a stable health system •Political upheaval and budget pressure affecting the health system's stability •Significant pressure on the government to erase a budget deficit and control spending •Budget restraint is for NHS trusts and foundation trusts •Health outcomes some of the best in the world •Aging population remains a major challenge

Evaluation of Ghana's healthcare system

•Cost -Finance •Central government •NGOs •Global funds •Private donors •Quality •Access

Current and Emerging Issues and Challenges (Germany)

•Cost Containment •Challenge: •Contributions increase more slowly than health expenditures •Opportunities: •Ambulatory global budgets and regional prescription caps •Aging population •Challenges: •Shrinking and shifting population •Increase prevalence of chronic diseases •Greater demand for health care resources •Unsustainable public finances •Opportunities: •Immigration •Pension reform •Refugee crisis •Challenge: •More than 476,000 asylum seekers in Germany •Refugees arrive with infectious and chronic diseases •Lack of public support •Opportunities: Passage of the integration law •Involvement and commitment from international communities

Current and Emerging Issues and Challenges(Russia)

•Decentralization of healthcare regulation •Variation and inefficient resource allocation and spending among local authorities typically based on political motivations •Source of funds to finance health care •Low employer contribution •Regional MHIF director call for an increase in employer contribution to 8% •Population decline •High male mortality

Description of the Health Care System- Medical Technology (United Kingdom)

•Diagnostic technology are commissioned by the CCG •381 MRIs and 506 CT scanners •Does not include privately operated diagnostic technology

Post-War Period and Two German States (Germany)

•East Germany •National socialist, state-financed system •Option to purchase private insurance •Established a single sickness fund •Nationalized hospitals •Discouraged independent physician practices •West Germany •Re-established the Basic Law •Highly decentralized health care system managed by 3 main bodies: •Federal ministry of health •Federal states •Corporate bodies

Ghana Conclusion

•Emerging African country with natural resources and stable economy •Two-tiered health care system with basic health-care services •Social and environmental issues impact quality of life and health of the population

History of the System and Distribution of Stakeholders and Resources (Cuba)

•Expansion of health care services post-revolution •Increased access to health care in rural areas •Health care became a constitutional right •Proliferation of emergency services, medical training, and primary care •Cuban have access to a wide range of comprehensive health services

Current and Emerging Issues and Challenges

•Factors such as cultural and religious beliefs, poor physical infrastructure, and limited resources all work together to hamper the provision of equitable healthcare services •Malaria is major cause of high morbidity as well as mortality •Poor sanitation and the apparent unpreparedness of the healthcare system to prevent or management potential epidemics creates challenges for planners and policymakers •Unequal distribution of healthcare delivery across the country •Many ingrained cultural and religious practices have adverse impact on health •Early marriage is common •Chronic shortage of health workers and inequities in distribution and skills mix •Rural areas are particularly poorly served with access to health care

Government and Political System (Germany)

•Federal republic composed of 16 states •Federal constitution - Basic Law •Parliamentary democracy with separation of powers and 3 branches •Executive, legislative, and judicial •Head of state - federal president •Legislative functions - federal assembly and federal council

Russia Government and Political System

•Federative state with republican government •Three branches: executive, legislative, and judicial •Head of the state is the president •Two chambers: State Duma & Federation Council •President elected by universal and direct suffrage for a six-year term; max terms: 2 •77 political parties

Evaluation of the Healthcare System- Access (Germany)

•Free choice of providers •Access to all levels of care •Inequitable access may exist for: •Legal immigrants - SHI •Refugees - social security •Asylum seekers - Asylum Seekers' Benefit Act •Privately insured v. publicly insured •Uninsured population •0.2% of employed •Self-employed

Description of the Health Care System- Primary Care/Outpatient Care (United Kingdom)

•General Medical Services Contract (GMS) •National standard GP contract •Negotiated nationally every year between NHS and trade union representative of GPs in England (British Medical Association) •Used by NHS and/or CCGs to contract local general practices in an area •~70% of general practices •Personal Medical Services Contract (PMS) •Negotiated and agreed locally by CCGs and NHS with a general practice or practices •Provides more flexibility to address local need within national guidelines •Being phased out •~40% of GPs operate under this contract type •Alternative Provider Medical Services (APMS) •Provides even greater flexibility •Negotiated contracts with organizations to provide primary care services •Contract to provide care to the homeless or asylum seekers

Pre-World War II (United Kingdom)

•General practice •Provided by apothecaries and physicians •Apothecaries •Originally herb merchants •Forefathers of modern GP •Prescribe and dispense medicine •Apothecaries were given statutory authority to administer examinations and license doctors •Apothecaries and physicians provided home services and baby deliveries

Description of the Health Care System- Primary Care/Outpatient Care (United Kingdom)

•General practices are the first POC with the health care system and act as gate-keepers for more specialized care (secondary care) •What are general practices? •Small to medium sized 'businesses' whose services are contracted by NHS •Provide generalist medical services in a geographical or population areas •Could be either a solo practice or a GP partnership (group of general practitioners) •GP partnerships may consist of 2 or more practitioners, nurse, manager(s), etc. •Who commissions general practice? •NHS is formally responsible, but CCGs are taking on full or partial responsibilities •What is a GP contract? •Mandatory requirements and services for all general practices, as well as provisions for several types of other services that practices may also provide, if they so choose. There are 3 types of GP contracts: General Medical Services, Personal Medical Service, Alternative Provider Medical Services

Solidarity and Subsidiarity: The Basis for the German Health Care System (Germany)

•German health care system is rooted in 2 assumptions: •Assumption 1: Long and stable connections to jobs •Assumption 2: : Wage income will grow as quickly as health care costs•Recent changes have made these assumptions invalid •What remains? The fundamental principle of solidarity and subsidiarity •Solidarity - shared commitment among the German society toward respect and mutual care •Subsidiarity - common understanding that social action should transferred to the most appropriate level •What does this mean in the context of health care? •Agreement to share health risks •Contributions based on ability to pay •Less government intervention •Modern German health care system has achieved: •High degree of equity and justice •Health care is regarded as a right - reflects universal coverage, comprehensive benefits, and redistributive approach in health care financing

Size and Geography (Germany)

•Germany has a population of 82.2M •Largest country (by population) •Highest population growth since 1992 •High net immigration •Population density is 7 times higher than in the U.S •Population is not evenly distributed

Different stakeholders and their roles (state)

•Health care delivery •Mgmt/ monitoring of healthcare workforce •Health data •Food and drug quality •Managing private entities in the state

System Affordability (Cuba)

•Health care financing - tax-based government financing (11.2% GDP, 2018) •Basic health services are prepaid - preventive services, testing, and inpatients drugs •Government subsidies durable medical equipment (DME) - hearing aids, glasses, devices, etc.

Healthcare Quality (Cuba)

•Health care outcomes in upward trend: •Polio - first country to eliminate polio •Measles - eliminated in 1996 •Life expectancy - steady increase over the past decade •A child born in Cuba can expect to live 5 years longer than child in U.S. •Free or highly subsidized preventive and routine health services •Prenatal care - 95% of women received care •Child vaccination rate - 98% of children •Maternal mortality rate - 38/100000 births

Pre-World War II (United Kingdom)

•Health care services was paid for mostly out-of-pocket by those who could afford •Voluntary and public hospitals - free for the poor or what patients can afford •General practice or GPs - mostly out-of-pocket •Provident dispensaries - free medical care for members and sometimes families of trade unions, fraternal societies, and other groups •Services •Covered primary care services and prescription drugs•Inpatient services were not covered •Financing •Member contributions •Participation was initially voluntary but later became compulsory for all members •Provident dispensaries became the forerunner for prepaid health plans

Health Outcomes (Cuba)

•Health care system focuses on prevention and early detection: •National efforts to control chronic diseases - diabetes and cancer •National Cancer Control Unit •Prevention and attention •Annual screening - blood pressure •High doctor-patient ratio - 6.7physicians/1000 people •Community-level health behavior and illness prevention •Patients organized into health risks •Testing and treatment policies •Lowest prevalence of HIV •Questionable methods - sanatoriums for HIV-positive patients •Unabated tobacco crisis •One of the highest rates of smoking •Lung cancer accounts for 30% of all deaths

Description of the Health Care System- Human resources (workforce) (Germany)

•Health sector accounts for 11.2% of all employment in 2011 •Physicians •Steady increase since 1990 •Due to increase in foreign doctors •Steady decline in general practitioners due to variation in earning potential •Specialist earn 5 times more •Nurses •May work autonomously or in health care teams •Growing concern of nursing shortage •Efforts to increase retention and training of new nurses

Evaluation of the Healthcare System-Cost (United Kingdom)

•Health spending has grown rapidly since NHS inception •1950-2019: 3.6% spending growth rate •Health accounts for 17.9% of all public spending and 7% of GDP •Planned spending for the Department of Health and Social Care in England was £201.7B in 2020/21, up from £148.8B in 2019/20 •35% increase in spending from previous period •Includes > £50B funds for COVID-19•44.9% spent on staff salaries

Ghana current healthcare system

•Hierarchical structure •Facilities -National -Regional -District -Subdistrict •Workforce •Technology and equipment

Different stakeholders and their roles (private sectors)

•Hospitals •Diagnostics •Out-patient clinics •Private medical colleges and other healthcare workforce training

Pre-World War II (United Kingdom)

•Hospitals•Established to provide medical care for sick and poor people and services were provided in either: •Private voluntary hospitals - acute health care or services that required short-stay and treatment and surgery •Tax supported public hospitals - chronically ill and elderly •Cottage hospitals - primary and specialty care in rural are and small communities •Funded by charitable groups and endowments, and voluntary self-pay • Services were initially free but financial constraints led hospitals to ask for voluntary payment and patients were asked to pay what they could•Services were provided by physicians and surgeons •Providers were not well paid•Supplemented income by providing private services and/or medical student training services

Current and Emerging Issues and Challenges (United Kingdom)

•Increase in private sector participation •Waiting times •Increasing costs and budget restraints

Demographics (Germany)

•Increasing life expectancy •Shifting population distribution: •0-14 years: 12.9% •15-24 years: 9.8% •25-54 years: 38.6% •55-64 years: 15.7% •65 years and over: 23% •Five leading causes of death: •Cardiovascular disease •Cancer •Respiratory illnesses •Digestive illnesses •Mental health and behavioral disorders

Conclusion (Cuba)

•Lancet recently noted, "Cuba's health system has been able to solve some issues that other countries have not" •System is seemingly well adjusted, well organized, and well attuned to the general needs of its current population •Populations are never static; policies often change when leadership does

Russia Size and Geography

•World's largest country •One-eighth of the Earth's land area •Located in two continents: Europe and Asia•8% of the country's land is arable •Population: 142 million; world's 9th largest

Technology and the Future of Health Care (Cuba)

•Limited use of technology •Pencil and paper charting is common •CT scanners are uncommon •Medical students have limited, dialup Internet access •Use of natural remedies •Center for stem-cell related clinical trials •Consequence of the removal of US embargo on medical technology •Increase access to medical technology •Environmental challenges •Medical tourism

Description of the Health Care System- Post Acute Care/Long-term care (United Kingdom)

•Long-term care services•Illness, disability or accident, and end-of-life care •Provided at home or in residential care facilities•Delivery •Private (for-profit and not-for-profit) sector •78% residential care •86% nursing home •Public sector (NHS) provides end-of-life care •Hospices are usually run by charitable organizations •Payment •NHS pays for nursing home services •Out-of-pocket payment for other long-term care services and support •Local authority may provide partial or full support on a sliding scale

Different stakeholders and their roles (federal)

•Major health policy decisions •Dept. of Health & Family Welfare •Dept. of Health Research

Health care in India

•Medical care- free outpatient and inpatient care at government facilities for those who are living below poverty level. •Cost sharing (very nominal in government facilities) depending on economic status. •Federalism- Central and State governments •Decentralized approach •Health care delivery (like education and other social welfare programs) is a state responsibility

Prominent Issues(equity in system performance)

•Medical tourism as a result of increased waiting times •Migration of patients to the United States to receive health care services •Estimated expenditures of ~ $1B per year •Reflects the capacity of the wealthy to obtain care •Influences from the U.S. including academic studies, media coverage, and advocacy positions

Russia History

•Modern Russians are descendants of the Slavic tribes •Russian empire was proclaimed in the 18thcentury under Peter the Great •The Revolution of 1905 resulted in some constitutional reform •War with Nazi Germany was a major theatre for WWII •Went through a period of economic stagnation •In 1991, official name changed to the Russian Federation

Evaluation of the Healthcare System-Innovation(United Kingdom)

•NHS introduced a new care delivery model - the vanguard site •Goals are to integrate services and improve care coordination •Integrating primary and acute care systems •Linking hospitals to improve clinical and financial viability •Reduce variation in care and improve efficiency •Improving access to primary care •Increasing the number of doctors •Increase funding for infrastructure •Renovate and replace GPs •Invest in technology

Evaluation of the Healthcare System- Access (United Kingdom)

•NHS sets target waiting periods for a variety of conditions •Non-urgent referrals - 18 weeks •52% were to get same day appointment •69% reported ease of access for after-hours care •7% reported waiting > 2 months for specialist •Urgent cancer referrals - 2 weeks •94.7% patients were seen within target for cancer •Waiting times increasing for other services •Why? •Declining NHS funds •Provider shortages •COVID

Ghana History

•Named after medieval Ghana Empire of West Africa in Ancient Ghana -First African nation to gain independence •The Europeans arrived on the Gold Coast in the late 15th century -Early struggle between Dutch and Portuguese -Short-lived ventures by Swedes and Prussians •Known to the world as the Gold Coast

Pre-World War II (United Kingdom)

•National Health Insurance Act of 1911 •Established government payment of health care services •Financing •Employee, employer, government contributions •Services Provided payment for workers' medical care •GP services and prescription drugs •Service not covered - dental and hospital services •Reimbursement •GPs chose to be paid under capitation

National Health Protection Scheme (India)

•One of the most ambitious public insurance programs •Target: 100 million poor and vulnerable families •2 mn beneficiaries covered for IP admissions •32 mn families enrolled •Auto enrolled (based on income & caste) •Coverage of USD 7,007 per family per year to cover secondary and tertiary health services •How is it financed? •40% states, 60% central government •Partly tax funded

German Industrialization and the National Health Insurance Act of 1883 (Germany)

•Otto von Bismarck, introduced legislation that created the Health Insurance Act •Motivations for implementing the Bismarck system •Non-altruistic motives •Gain political support from blue-collar workers •Weaken socialism

Palliative care in Kerala

•Pain and palliative care society: 1993 •Palliative care policy in the state: 2008 •Joint effort of the state government and community-based organizations •1,550 palliative care units •Neighborhood networks in palliative care •Access to palliative care •India: 2% •Global average: 14% •Kerala: 26%

Description of the Health Care System- Primary Care/Outpatient Care (United Kingdom)

•Payment •GPs receive a global sum payment/capitation for services provided •Based patient workload and any additional cost for providing care in a rural or remote area •Performance-based payment for providing enhanced services under the Quality and Outcomes Framework (QOF) •QOF is a voluntary program that practices can opt-in •Based on patient workload and enhanced services provided •Accounts for 10 - 25 percent of practice income •95% of practices participated in 2019 •Salary •PMS contracts allow option for salaried GPs or other health care professionals •Provides assured income •Incentivizes GPs to operate and practice in rural/remote areas

Description of the Health Care System--Acute Care/Inpatient Care (United Kingdom)

•Payment (Hospitals) •Diagnosis-related group rates (DRGs) •Classifies patients of similar clinical characteristics and comparable costs and pays hospitals a flat fee for each DRG that reflects national average treatment costs of patients in that grouping •NHS and NHS improvement set DRG rates •Bundled payment •Total annual cost of care for health care services (e.g., care for diabetic patient) •Payment (Specialists) •Salary •Negotiated and agreed

What about health insurance coverage? (India)

•Percentage of population insured: 1% in 2004 to 15.2% in 2014 to 37% in 2019 •Some form of government insurance: 12.8% •Employer sponsored insurance: 1.2% (133 million) •Private insurance by HH: 1.2% •Inequities •Any health insurance: 36.4% of richer quintile compared to 9.7% of poorest quintile •Even government insurance: 15.1% (rich) to 8.6% (poor) Govt. health expenditure: 1.4% of GDP

Description of the Health Care System- Primary Care/ Outpatient Care (Germany)

•Physicians (129000 in 2017) •GPs have no formal gatekeeping function •Sickness funds required to offer option of family physician model •Work in their own private practices •56% in solo practice and 33% in dual practice •In 2017, 45% self-employed, SHI contracted and 55% specialists •Payment •Fee schedule - what are the incentives? •Negotiated between sickness fund and regional association •Physician payments are limited to predefined number of patients •Limited payment per patient beyond threshold •What are the implications? Positive? Negative? •Salaries •Multispecialty clinic physicians •Fee for service •Higher taxes

Summary of Canada

•Political and financial decisions negatively impacted the development of physical infrastructure •Waiting times for services such as imaging services, continue to be an issue •Canadians are satisfied and proud of their health care system despite obvious challenges •Solutions to system challenges will be driven by and played out in the provinces

Prominent Issues(financial sustainability)

•Political will to continue to accept and bear the cost of universal coverage •Bending the cost curve •Maintain access to high quality health care •Challenge: Federal government dissociation from responsibilities of the health care system •Opportunities: Greater reliance on provincial government •Provinces as incubators for innovation

Macroeconomics (Germany)

•Poor in raw materials •Focuses on industrial manufacturing and services •Total GDP - $3.3T in 2015 •3rd largest exporter in the world

Conclusion (Germany)

•Population aging and the increasing prevalence of lifestyle-related chronic diseases expected to boost health care demand •Plans underway to implement health care cost containment and process optimization •Value-based pricing models and •Pay-for-performance mechanisms

Evaluation of the Healthcare System- Quality (Germany)

•Population clinical indicators •Life expectancy - 80.7 years •Infant mortality rate (2016) - 3.4 per 1000 live births •On par with other EU countries but higher than Scandinavian countries •Mortality rate for children under five is lower than U.S. •85% - 95% vaccination rate for all common childhood diseases •Measles outbreak concern •Unmet WHO progress indicator •Quality perception of privately insured patients •Preferential treatment due to higher reimbursements •More services provided •More likely to see specialists, admitted, and have nonemergency surgery •Does not compromise quality of care in SHI

Ghana Demographics

•Population: 269 million -52% are female; 48% are male -Life expectancy: 666 years; M =641; F=691 -Illiteracy rate is 766% -More than half live in rural settings •English is language of business and instruction •Christian population is 712%

Brief History of the Ghana Healthcare System

•Pre-World War II -During European occupation -Traditional medicine •Since World War II -After independence •Government involvement •Financial crisis and reforms -Two-tiered system

Post-World War II (United Kingdom)

•Proposed plan to nationalize all hospitals•Financing •National taxes •Physician opposition generous negotiated term of agreement •Lifetime salary for senior specialists (consultants) •Right to continue their private practices •Control of private beds NHS hospitals •NHS established by Act of Parliament based on three core principles: •Met the needs of everyone •Free at the point of delivery •Based on clinical need, not ability to pay

The Fall of the Berlin Wall and Reunified Germany (Germany)

•Reunification of two health care systems: •Expansion of health care benefits through the sickness funds •Focus on quality assurance, evidence-based medicine, and technology assessment •Integration of inpatient and ambulatory services •Uniform premium contribution across all sickness funds •Mandatory health insurance coverage •Expanded long-term care services

Russia conclusion

•Russia's healthcare challenges are rooted in previous political past and economic situation •Despite large number of hospitals and doctors, still unable to provide acceptable health care services •Ineffective organization and oversight of health services •Quality of services and access remains quite low •Experiences more CVD, alcohol abuse and smoke more than most countries

Placing India in a context

•Second most populous country in the world •1858-1947: British colonization Post independence •1.3 billion people •28 states and 8 Union Territories •30 languages- each spoken by over a million people

Description of the Health Care System--Acute Care/Inpatient Care (United Kingdom)

•Secondary Care (Hospitals) •Publicly owned since the establishment of NHS •Organized as either NHS trusts or foundation trusts •Secondary Care (Private Hospitals) •For-profit and not-for-profit •Provide services not covered in NHS •Bariatric surgery, fertility treatment, etc. •Secondary Care (Specialists) •NHS hospitals employs most specialty physicians and surgeons •Allowed to engage in private practice

History: (United Kingdom)

•Sovereign nation with 4 constituents - England, Scotland, Wales, and Northern Ireland •European Union (EU) membership •Brexit referendum of 2016 - UK is prepared to exit the EU •No foreseen impact on the health care system •Constitutional reform •Scottish independence referendum •Magna Carta of 1215 •Outlined and protected certain individual rights •Evolved democratic nation • Individual freedoms •Government expectations - Universal health care for all citizens

Description of the Health Care System- Post-Acute Care/Long-Term Care (Germany)

•Statutory LTCI is mandatory •Entitled dependent on eligibility •Contributed at least 2 years •Assessment of care needs •Limited services•Benefits •LTCI benefits cover 50%institutional cost •Patients are advised to buy supplementary insurance •Providers •Private not-for-profit and for-profit providers •Hospice •Partly covered by LTCI upon approval

Evolution of the German Health Care System (Germany)

•Statutory sickness funds •Core component of the German health care system •Established by guilds, trade associations, industries, societies, etc. •Private relief funds to help pay for health care, funerals, other related expenses •Maintained hospitals for members, members' widows and orphans •Expansion of sickness funds •Local municipality authority •Passage of formal relief fund law •Imperial and parliament recognition •Act on Health Insurance for Blue-Collar Workers •Set the stage for social health insurance system

Description of the Health Care System- Acute Care/Inpatient Care (Germany)

•Steady increase in hospital closures due to increased competition •Declining average LOS •Hospital ownership •Publicly owned - 48% hospital beds •Private not-for-profit - 34% •Private for-profit - 18%•4 categories of hospitals: •Basic service •Regular service •Central service •Maximum care •Payment •Salary - hospital staff •DRGs - •Rehabilitation centers

Ghana Economy

•Strengthened by a quarter century of: -Relatively sound management -Competitive business environment -Sustained reductions in poverty levels •Recategorized as lower middle-income country •Well endowed with natural resources -Agriculture accounts for roughly 25% of GDP •Services sector accounts for 50% of GDP •Gold and cocoa production are major sources of foreign exchange •Oil production is producing close to targets •Faces consequences of two years of loose fiscal policy, high budget, deficits, and depreciating currency

Social Conflict and the Strengthening of the Medical Profession (Germany)

•Tensions between sickness funds and the medical profession •Bismarck system did not clearly define relationship between sickness funds and physicians •Bismarck system did not address provider qualifications •Sickness funds had full authority •Physician backlash •Physician strikes and lobbying •Established the Hartman Union - medical profession association •Berlin Treaty changed sickness fund and physician relationship •Established procedure for negotiating conflicts •Stipulated physician-to-population ratio

Cuba Health Care System - Overview (Cuba)

•The Cuban advantage - economic disadvantage and political isolation •Development of unique, low-cost, high-efficiency, low-technology healthcare system •More success contingent on some shifting variables •Large working-age population •High doctor-patient ratio

Post-World War II (United Kingdom)

•The Health and Social Care Act instituted changes to the organization of the NHS •Clinical commissioning groups (CCG) - Plan and commission health care services for their local areas •Assess local needs, decide priorities and strategies, buy services from providers •Responsible for the health their entire population •Performance is measured by improvements in health outcomes •CCGs are comprised of GPs, other clinicians including a nurse and a secondary care consultant (specialist), and community members •HSCA Goals •Extend market-based approaches •Diversify provider market •Increase competition •Increase patient choice •UK Parliament funds the department of health •NHS and CCG commission services •NHS commissions: •Primary care services •Low-volume, specialized health care •Ambulance and emergency •Mental health •CCG commissions: •Emergency care •Hospital care •Community health services •Maternity and newborn •Mental health •Learning disabilities •Majority of hospital services are provided by foundation and NHS trusts

Post-World War II (United Kingdom)

•The NHS Constitution - seven key principles •Provides a comprehensive service available to all •Access is based on clinical need not ability to pay •Aspires to highest standards of excellence and professionalism'•Puts patients at the heart of everything it does •Works across organizational boundaries and in partnership with other organizations in the interest of the patient, local communities, and the wider population •Committed to providing the best value for taxpayers' money and the most effective, fair, and sustainable use of finite resources •Accountable to the public, communities, and patients that it serves

Evaluation of the Healthcare System- Cost (Germany)

•Total health expenditures 2017 -11.5 % GDP •SHI - 57% spending •Private health insurance - 8.4% of THE •Out-of-pocket spending -13.5% of THE

Evaluation of Russia's healthcare system (Cost)

•Total health expenditures 2018 -5.3 % GDP •Territorial health care accounts for 45% of health financing •MHIF account for 51% of THE in 2015

Maternal mortality ratio (india)

•U.S : 14 deaths per 100,000 live births •India: 174 deaths per 100,000 live births

Government and Political System (United Kingdom)

•UK government is a Constitutional Monarch •Queen - Chief of State •Prime Minister - Head of Government •Legislative branch •House of Lords •House of Commons •Judicial BranchSupreme court •Power devolution to Scotland, Wales, and Northern Ireland •Each country has its own structure for planning, monitoring, and delivering health care services within its boundaries

History (Germany)

•World War I and II •Weimar Republic •"Sort-off" democracy •New Constitution •Contentious political and economic environment •Rise of national socialism and Adolf Hitler •Promised better social and political life •World War II •Rebuilding and East and West Germany reunification •EU leader