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.
Brazil’s ongoing political and economic crisis has affected financing for all public policies and programs, including SUS. 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. 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.
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. If a national program moves forward, it will be the biggest expansion of public funding and coverage since Canadian Medicare was introduced.
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.
- 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. 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.
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.
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. 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.
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.
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.
- 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.
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 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.
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%).
The updated New Zealand Health Strategy, launched in 2016, consists of two parts: the Future Direction and the Roadmap of Actions 2016. 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.
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.
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.
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.
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.
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.
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 strategy 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.