The Australian government has introduced a number of reforms to care for older people aimed at improving financial sustainability, quality, and consumer choices. The independent Aged Care Quality and Safety Commission, established in early 2019, will bring together previously disparate functions of quality assurance, complaints, and regulation of the aged care sector. The government has also started conducting unannounced audits of aged-care (or nursing) homes for reaccreditation.
The Australian government is also investing more funding to help people remain in their own homes as they age. One example is the Community Visitor scheme, which supports the 70 percent of elderly people who receive aged care at home and experience loneliness.
In its 2018 budget, the federal government allocated AUD 102.5 million (USD 71.7 million) to services for older Australians, with AUD 82.5 million (USD 57.7 million) for residents of aged-care facilities and AUD 20.0 million (USD 14.0 million) for those in the community at risk of isolation.
The 2018 budget also included AUD 72.6 million (USD 50.8 million) for suicide prevention and follow-up care for the adult population and AUD 110 million (USD 77 million) for child and youth health care.
In 2017, the Australian government launched Head to Health, a one-stop electronic resource to direct people experiencing mental health issues to services and resources, supporting them in taking control of their health by reaching out to high-quality, reputable providers. The website was developed in partnership with people and families who have experienced a mental health issue, as well as those who provide care.
The author gratefully acknowledges the contributions of LSE research assistant Michael Woods.
Brazil’s ongoing political and economic crisis has affected financing for all public policies and programs, including SUS.32 Long-term fiscal austerity policies were implemented in 2016 and followed by rationing measures. In 2017, around 1,200 ministerial directives that regulate transfers of federal resources were unified under a unique consolidation ordinance.33 In addition, the federal government has promoted the unification of SUS financing for primary care, complex health services, pharmaceutical care, and health surveillance and management. The goal is to reduce bureaucracy and increase flexibility in how municipalities use financial resources at local levels. Despite the benefits of these measures, there are concerns about underfinancing in strategic areas, such as primary care and health surveillance, due to the concentration of financial resources in specialized and hospital care.34
After a political shift in 2019, the new Brazilian government maintained its fiscal austerity policy and introduced other social, educational, and environment policies that may threaten health.35 Nevertheless, the Ministry of Health has proposed new policies to strengthen and expand access to primary care, including the creation of a new secretary dedicated to primary care. These policies aim to increase access to family health units; to delineate a new efficiency-based funding model and a model for the training and provisioning of physicians in remote areas; and to expand the use of electronic medical records.36
As noted above, prescription drugs, outside of hospitals, are not universally covered. At the federal level, there are signs of renewed interest in a pan-Canadian system of drug coverage. In 2018, the Advisory Council on the Implementation of National Pharmacare was established, and an interim report was produced in 2019.46 If a national program moves forward, it will be the biggest expansion of public funding and coverage since Canadian Medicare was introduced.
Provinces and territories continue to implement structural reforms to improve efficiency. The latest example occurred in 2017 when Saskatchewan replaced its 12 regional health authorities with a single provincial health authority. This initiative reflects a national trend toward greater administrative centralization. Similarly, as part of an evolving reform effort, Manitoba established a single provincial organization — Shared Health — to centralize some clinical and administrative services. In 2019, the Ontario government announced its plans to consolidate several provincial arm’s-length agencies, along with the 14 subprovincial health authorities — Local Health Integration Networks — that administer and deliver health care for their local populations, into a single provincial agency.47
In March 2018, the 13th National People’s Congress unveiled a plan for restructuring its biggest cabinet (the State Council) in order to improve efficiency and public services (see above).
- A 2018 agreement with Norway will facilitate joint tenders for hospital drugs and information-sharing about new pharmaceuticals (see “How are costs contained?”).
- A new external reference pricing system for drugs will be implemented in 2020 (see “How are costs contained?”).
- The central government and the regions have entered an agreement to restructure the financing of the regions. The previous requirement of an annual 2 percent productivity increase for hospitals will be replaced by a funding scheme that holds regions accountable for addressing specific criteria related to coordination and integration of care. In addition, a minor portion of funding will be redistributed to technology development projects.
In October 2014, NHS bodies, led by NHS England, published the Five Year Forward View, which sets out the challenges facing the NHS and strategies to address them.51 These include pilot programs across England to test new models of care, among them:
- scaled-up multidisciplinary primary care
- enhanced health care in long-term care homes
- vertically integrated hospital and community care
- networks to improve emergency care.
Five-year strategies have also been published for improving cancer and mental health services, and better prevention, including a diabetes prevention initiative.52 The General Practice Forward View sets out strategies to reduce workforce shortages in primary care and to streamline GP workloads.53 These initiatives have recently been consolidated in the NHS Long Term Plan, published in early 2019. This 10-year plan sets out a vision for local integrated care systems to improve population health, new national strategies on cardiovascular and respiratory disease (in addition to cancer and mental health), and new primary care networks to better link together general practices.54
The authors would like to acknowledge Anthony Harrison, the author of earlier versions of this profile, as well as Sean Boyle of LSE, Claire Mundle and Sarah Gregory of the King's Fund, and Sandeepa Arora of the Nuffield Trust.
A controversial part of the 2015 Touraine law recommended making physician consultations totally free at the point of care: practitioners would be paid directly by social security and SHI for all visits. However, in view of the strong opposition from doctors, the extension of third-party payment to the entire patient population has been postponed indefinitely.
The mounting discontent over excessive balance billing revealed in the press, together with claims by private clinics of unfair competition, has prompted several public inquiries. The latest inquiry resulted in recommendations to increase public control over these activities.
Experiments with new payment mechanisms are in their early stages. These experiments are inspired by the creation of accountable care organizations. At the national level, bundled payments are to be tested in 2019–2020 for orthopedic and colorectal surgeries. In addition to the national program, regional initiatives are encouraged, with the objectives of integrating care and improving quality, relevance, efficiency, and prevention. These five criteria will be considered when decisions are made as to whether to allow regional pilots, which will run for a period of five years and benefit from funding of care not currently covered by SHI. Disease types selected are stroke, heart failure, and acute coronary syndromes. A total budget of EUR 20 million (USD 25.3 million) is earmarked for 2019 for the payment pilots.
After a period of active health reform in several areas between 2012 and 2016, new reform debates and proposals stagnated until spring 2018. One of the reasons is that after the federal elections in September 2017, it took six months of difficult talks and political insecurity to again form a grand coalition between political parties (Christian Democrats and Social Democrats). The first new bill introduced in 2018 (the SHI-Contribution Relief Law, or GKV-Versichertenentlastungsgesetz) aims to reduce the mandatory contributions that individuals in SHI pay every month.20 While the general contribution of 14.6 percent has been equally shared between employers and employees since 2015, the supplementary contribution is paid by employees only. The law plans to reinstate the equal split of general and supplementary contributions between employers and employees. Furthermore, the law stipulates halving the reference amount used to calculate the minimum contribution for the self-employed insured. Until now, independent of their actual income, the self-employed have paid a contribution based on expected minimum income of EUR 221 (USD 284) per month. This is unmanageable for a large proportion of small-business owners and increases their risk of having no health insurance.21
Furthermore, the Ministry of Health has recently issued a decree on minimum staffing requirements for nurses in hospitals. The maximum number of patients per nurse has been defined for hospital units where nursing staff is particularly needed — intensive care, geriatric, cardiology, and trauma surgery — to guarantee patient safety. The regulation went into effect January 2019. To further expand the capacities of nurses in hospitals and in long-term care and to reform salaries and working conditions for nurses, the Nursing Staff Strengthening Act was enacted in September 2018.22
India has initiated a number of reforms that could have far-reaching implications for the health sector and the broader economy. These include:
- Launching Ayushman Bharat, which encompasses the National Health Protection Scheme (Pradhan Mantri Jan Arogya Yojana), for coverage of tertiary care for vulnerable populations and Health and Wellness Centres initiative for the delivery of comprehensive and integrated primary care.
- Setting up the National Health Authority to implement the PM-JAY.
- Initiating the provision of universal sanitation coverage and making the country open defecation–free through the Swachch Bharat Mission.
- Launching Intensified Mission Indradhanush 2.0 to achieve 90 percent vaccination coverage for children under 2.
- Providing clean cooking fuel under the Pradhan Mantri Ujjwala Yojana scheme.
- Providing nutritional and social support for all National Health Protection Scheme beneficiaries with tuberculosis.
- Replacing the Medical Council of India with the National Medical Commission and setting uniform standards for medical education.
- Creating a health technology assessment body (Health Technology Assessment in India) under the Department of Health Research to evaluate all medical technologies.
A number of innovations have been launched in recent years, including the following:
- Creating an environment to encourage healthy diets. The Ministry of Health has imposed measures such as mandatory food labelling and restrictions on advertising unhealthy food for children. It has been incentivizing food manufacturers to produce healthier products, and has been improving economic access to healthy food through the taxation of unhealthy food. In addition, the Ministry of Health is improving the nutritional value of food served in public institutions, and is including education on healthy diets in the school curriculum for young children.26
- Expanding the role of nurses in the community. In 2018, the Ministry of Health extended the responsibilities and scope of practice for specialist nurses in the community, to relieve some of the pressure on primary care physicians. Specialist nurses can now treat mild cases of acute diseases and cases that are urgent but simple to treat; treat and monitor patients with chronic diseases; provide preventive care and handle health promotion; and prescribe medications and contraceptives. Specialist nurses can also provide palliative care and refer patients for diagnostic tests, to specialists, and to EDs.27
- Improving continuity of care. Urgent care centers are required to report patient data (diagnosis, treatment, recommendations for future care) to the patient’s health plan and to the hospital if the patient is referred for acute care, bridging the information gap between community and inpatient care. Centers must also report cases of communicable or rare diseases and domestic violence to relevant authorities.28
- Further expanding dental care coverage. The 2018–2019 Ministry of Health budget funds the expansion of the health basket to include dental care for people aged 75+ during 2018, and for children up to 18 years old during 2019. This step concludes the “reform of dental care for children,” which started in 2010 with the inclusion of dental care for children up to 8 years of age to the health basket.29
- Increasing the scope, breadth, and depth of services for older people. To better meet the needs of Israel’s aging society, the Ministry of Health is broadening eligibility for long-term care.30
Because of the regionalization of the health system, most innovations in the delivery of care take place at the regional rather than the national level, with some regions viewed as leaders in innovation.
In 2017, Parliament introduced compulsory vaccinations for all infants and children up to age 16, following an increase in the number of deaths due to infectious diseases (mainly mumps) and the antivaccination movement. Children who do not comply with the prescribed vaccination are not allowed to attend kindergartens, nurseries, and schools.
In January 2017, the government approved an updated version of essential covered benefits, with significant changes in the outpatient specialist services that can be delivered by the National Health Service and a further shift of hospital care into outpatient settings. The government estimates an additional expenditure of EUR 800 million (USD 1.1 billion) per year for this reform.
The author would like to acknowledge Sarah Jane Reed and David Squires as contributing authors to earlier versions of this profile.
The Social Security Council set the following four objectives for the 2018 fee schedule revision:
- developing efficient and comprehensive care in the community
- developing safe, reliable, high-quality care and creating services tailored to emerging needs
- reducing the workload of health care workers
- making the health care system more efficient and sustainable.34
To proceed with these policy objectives, the government modified numerous incentives in the fee schedule. In addition to the Continuous Care Fees (see “What is being done to promote delivery system integration and care coordination?” above), hospital payments are now more differentiated, according to hospitals’ staff density, than those of the previous schedule.
The author would like to acknowledge David Squires as a contributing author to earlier versions of this profile.
Long-term care, including home care, was under separate legislation (the Exceptional Medical Expenses Act) until 2015. In 2015, the major reform placed residential long-term care under the newly created Long-Term Care Act, and transferred home care to the Health Insurance Act (medical home care and home nursing care) and Social Support Act (ancillary home services). The reform program’s main goals were to guarantee fiscal sustainability and universal access in the future and to stimulate greater individual and social responsibility by expanding home-based care and social support as an alternative to institutional long-term care. To that end, the municipalities assumed responsibility for providing home care and social services based on the individual needs of the patient. The devolution of services to the municipalities as a result of the 2015 Long-Term Care Act was accompanied by substantial cuts to the available budgets (on average, almost 10%).
In 2015–2016, initial budget reductions were retracted, and future budget increases of EUR 2.1 billion (USD 2.7 billion) were set aside by the government to alleviate fiscal stress in nursing homes.43
In curative health care, market reform and regulated competition remain somewhat controversial. The government, determined to stimulate competition, has, among other measures, required insurers and providers to assume greater financial risk. The affordability and accessibility of expensive drugs have rapidly become prominent issues.44
As of the date of this report, the Health Insurance Act of 2006 has undergone two evaluations.45 The latest evaluation pointed to an imbalance of power, with providers having an advantage over insurers.
The current government has emphasized providing the right care in the right place, focusing on care networks and cooperation and on strengthening primary care. In 2018, a landmark agreement was reached with more than 70 organizations on a set of preventive measures, including smoking cessation. Other recent policy initiatives are focused on reducing labor shortages in the health sector, addressing loneliness among the elderly, and promoting participation in sports.46 The government is also developing policies to improve the long-term sustainability of health care financing.47
The updated New Zealand Health Strategy, launched in 2016, consists of two parts: the Future Direction15 and the Roadmap of Actions 2016.16 The former lays out some of the challenges and opportunities the health system faces and describes the desired future, including the underpinning culture and values. In addition, it identifies five strategic themes for driving change:
- improving patient literacy and empowerment
- emphasizing prevention, early intervention, and community care
- improving system performance
- delivering integrated and collaborative health care delivery
- pursuing technological innovation.
The Roadmap of Actions 2016 identifies 27 action areas to implement by 2021. These actions, organized under the five themes listed above, will ultimately contribute to the stated goal that “all New Zealanders live well, stay well, get well, in a system that is people-powered, provides services closer to home, is designed for value and high performance, and works as one team.”17
The 2017 election produced a new coalition government, introducing some new priorities. These include the following:
- a renewed focus on reducing inequalities
- reducing care access barriers and unmet needs
- improving primary care
- the launch of an inquiry into mental health and addictions.
The new government has also pledged an additional NZD 8.0 billion (USD 5.4 billion) in health funding over the next four years. In May 2018, the new government announced a wide-ranging review of the health system. Recommendations on how to improve the system’s structure are due by early 2020. Particular attention is being given to primary and community care and the capacity to deliver on equity-related goals.
The author would like to acknowledge the New Zealand Ministry of Health for its comments and for providing updated information for this profile.
In 2016, the government published a strategy for an “age-friendly society.” The goal is active, healthy aging through participation in and contribution to society. The government is also rolling out several other strategies through 2022, including a youth mental health and well-being program, an antibiotic-resistance initiative, and a mental health program aimed at adults.
The National Health Data Program, launched in 2018, aims to make health data available for government agencies, researchers, managers, health professionals, and residents.24
In 2017, municipalities and GPs were invited to participate in a primary care pilot project, which promotes the use of interdisciplinary teams as a primary tool for change. GPs are now responsible for the teams, under the leadership of each municipality. The project began in spring 2018 and will run until April 2021. The pilot includes testing of two new payment models: a fee-based model, similar to the existing funding model for GPs, and an operating grant based on the number and demographic characteristics of a GP’s patients. GPs also receive pay-for-performance bonuses and out-of-pocket payments.
In 2018, the government also introduced activity-based funding for specialized mental health services in combination with block grant financing.
In addition, a commission has been appointed to give advice on a new financing model for specialty care. The commission must consider the RHAs’ responsibilities for providing specialist care for the population, conducting research, and educating health personnel. The commission’s findings were set to be published in late 2019.
The government has started a process to decriminalize drug use as well as possession of minor quantities of drugs. The aim is to transfer the societal responsibility for handling minor drug offenses from the jurisdictional sector to the health care sector.
The author would like to acknowledge Anne Karin Lindahl, David Squires, and Ånen Ringard as contributing authors to earlier versions of this profile.
In late 2017, the Ministry of Health launched its Beyond Healthcare 2020 strategy to move more care to the community, encourage health promotion, and ensure value.64
In 2018, the ministry launched the Licensing Experimentation and Adaptation Program, a regulatory “sandbox” for identifying and understanding new health care innovations, such as telemedicine and mobile medicine, through industry partnerships. The program seeks to develop an appropriate regulatory approach to facilitate such innovations while prioritizing patient safety and welfare.65
To provide better protection against long-term care costs, the ministry will launch CareShield Life in 2020 to replace ElderShield. The new scheme will have higher cash payouts, starting at SGD 600 (USD 438) and increasing over time. There is no cap on payout for as long as the policyholder remains severely disabled.66 CareShield Life will be mandatory for citizens and permanent residents born in or after 1980. In addition, people with severe disabilities can withdraw up to SGD 2,400 (USD 1,752) per year, or SGD 200 (USD 146) per month, from their own and their spouse’s MediSave account for their long-term care needs, after setting aside a minimum amount for other health care needs.
The Ministry of Health will also be launching ElderFund in 2020, to provide discretionary assistance, up to SGD 250 (USD 183) per month, for severely disabled and needy citizens who require further help with their long-term care costs.
In addition, the ministry and public hospitals are working on value-driven outcomes with inter- and intra-hospital benchmarking to minimize unnecessary variation and to encourage the adoption of best practices. The ministry has also started to bundle payments to facilitate care transformation and reward efficiency. And it has implemented a pay-for-performance framework to reward the three public health care clusters that do well on key priorities, such as reducing hospital-acquired infections, managing length of stay, and minimizing waiting time for specialist appointments.
The author would like to acknowledge Chang Liu and Ruru Ping of ACCESS Health International as contributing authors to earlier versions of this profile.
Important policy areas that have been under scrutiny at both the local and the national level during the past few years include the quality and equity of care, wait times, coordination of care for the elderly, and investment in e-health.
The 2015 Patient Act sought to strengthen the rights of patients and encourage shared decision-making. It clarifies and expands providers’ responsibilities in conveying information to patients, guarantees patients the right to a second opinion, and ensures choice of provider in outpatient specialty care. It also strengthens the wait-time guarantee by clarifying patients’ right to seek care in any region.
Accurate reporting and monitoring to measure quality, equity, and efficiency remain important challenges in Swedish primary care and are a concern for policymakers. A new quality register for primary care was set up in 2017, coordinated by SALAR.
To improve the continuity and coordination of care, in 2014 the government launched a four-year national initiative for people with chronic diseases. Its three areas of focus are patient-centered care, evidence-based care, and prevention and early detection of disease. Regional implementation of various initiatives began in 2017–2018, among them, a team-based care program for frail elderly patients.
In the area of specialized care, there have been recent efforts to foster greater equity. The government has committed to providing SEK 500 million (USD 55 million) per year from 2015 to 2018 to reduce wait times in cancer care and to reduce regional disparities. The initiative has led to the development of standardized care processes and reduced wait times in some cancer areas, but not in all regions. The learnings from this work are being applied in additional areas in 2018.
General discussions about how governance, including reimbursement systems, can promote innovation and trust are also taking place. The government aims to promote governance models that put greater trust in public-sector professionals to provide high-quality care to citizens. In part, this approach may be a response to pushback on past reforms aimed at increasing competition and the monitoring of providers based on performance indicators.
As discussed throughout this profile, the Health2020 strategy outlines national priorities, objectives, and 36 different measures aimed at:
- improving the quality of life
- promoting equal opportunity and self-responsibility
- ensuring and enhancing the quality of care
- creating more transparency, better governance, and closer coordination.
Recent reforms focus mainly on cost containment (see above).
The author would like to acknowledge Paul Camenzind and David Squires as contributors to earlier versions of this profile.28
Since June 2016, the NHIA has stepped up efforts aimed at strengthening primary care through delivery system integration and the establishment of a referral system. The six components of this new strategy38 are:
- Enhancing the capacity of primary care
- Incentivizing the public to use the referral system through adjustments to the copayment system
- Raising payments to hospitals for critical care to incentivize hospitals to reduce services related to treating minor illnesses
- Strengthening cooperation between hospitals and clinics to provide continuous care
- Strengthening the public's capabilities in self-care
- Strengthening the governance of hospitals.
Medicare and Medicaid Innovations. The Affordable Care Act ushered in sweeping insurance and health system reforms aimed at expanding coverage, addressing affordability, improving quality and efficiency, lowering costs, and strengthening primary and preventive care and public health. The most important engine for innovation is the new Center for Medicare and Medicaid Innovation. The ACA allocated $10 billion over 10 years to the agency with the mandate to conduct research and development that can improve the quality of Medicare and Medicaid services, reduce their costs, or both.
If initiatives undertaken by the Center for Medicare and Medicaid Innovation are certified by federal actuaries as improving quality of care at the same cost—or maintaining quality while reducing health care costs—the U.S. Secretary of Health and Human Services has the authority to spread these initiatives, without congressional approval, throughout the Medicare and Medicaid programs.
The Trump administration has rolled out several other changes to the Medicare and Medicaid programs. These include the 2019 announcement of Primary Care First, a new voluntary payment model intended for launch in 2021 that aims to simplify primary care physician payments. In addition, since 2018, several states have instated a requirement for able-bodied individuals to document that they are meeting minimum work requirements to qualify for or keep their Medicaid coverage.
Changes to the Affordable Care Act. As of 2020, most of the ACA’s provisions remain the law of the land. However the Trump administration has canceled some consumer protections through regulatory and executive actions. For example, in 2019, the individual mandate, the financial penalty for not having health insurance, was removed. In addition, through executive orders enacted in 2017 and 2018, the administration allowed states to offer alternative, lower-cost, minimally regulated insurance plans in their marketplaces that do not meet the minimum requirements of the ACA.
Cost Control Initiatives. The administration has also announced efforts to address high health care prices, especially concerning prescription drugs. Two bills passed in 2018 banned so-called “gag clauses” in contracts between pharmacies and pharmacy benefit managers. These clauses prevented pharmacists from informing customers when the cash price (without billing insurance) for a drug is lower than the insurance-negotiated price. In addition, to address hospital price transparency, federal rules require all hospitals to post their charges for medical procedures online and update the list at least once a year.
The past few years have also seen employers, which provide health insurance for approximately half of Americans, taking strides to lower health care costs by eliminating “middleman” agents—such as insurance companies and pharmaceutical benefit managers—from the health care financing chain. Some larger employers have joined with others to form their own nonprofit health care corporations, with the joint venture between Amazon, Berkshire Hathaway, and J.P. Morgan being one prominent example.45 Other firms, such as Apple, are hiring providers directly to deliver care to their employees at on-site health clinics.46