Health care

Overview
Health care, or healthcare, is the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the medical, nursing, and allied health professions. Health care embraces all the goods and services designed to promote health, including “preventive, curative and palliative interventions, whether directed to individuals or to populations”. The organised provision of such services may constitute a health care system. This can include specific governmental organizations such as, in the UK, the National Health Service or a cooperation across the National Health Service and Social Services as in Shared Care. Before the term "health care" became popular, English-speakers referred to medicine or to the health sector and spoke of the treatment and prevention of illness and disease.

In most developed countries and many developing countries health care is provided to everyone regardless of their ability to pay. The National Health Service, established in 1948 by Clement Atlee's Labour government in the United Kingdom, were the world's first universal health care system provided by government and paid for from general taxation. Alternatively, compulsory government funded health insurance with nominal fees can be provided, as in Italy. Other examples are Medicare in Australia, established in the 1970s by the Labor government, and by the same name Medicare was established in Canada between 1966 and 1984. Universal health care contrasts to the systems like health care in the United States or South Africa, though South Africa is one of the many countries attempting health care reform. The United States is the only wealthy, industrialized nation that does not provide universal health care.

Industry
The health care industry is considered an industry or profession which includes peoples' exercise of skill or judgment or the providing of a service related to the preservation or improvement of the health of individuals or the treatment or care of individuals who are injured, sick, disabled, or infirm. The delivery of modern health care depends on an expanding group of trained professionals coming together as an interdisciplinary team.

Consuming over 10 percent of gross domestic product of most developed nations, health care can form an enormous part of a country's economy. In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed 16.3 percent of the GDP of the United States, the largest of any country in the world. For the United States, the health share of gross domestic product (GDP) is expected to hold steady in 2006 before resuming its historical upward trend, reaching 19.5 percent of GDP by 2016. In 2001, for the OECD countries the average was 8.4 percent with the United States (13.9%), Switzerland (10.9%), and Germany (10.7%) being the top three.

Systems
Purely private enterprise health care systems are comparatively rare. Where they exist, it is usually for a comparatively well-off subpopulation in a poorer country with a poorer standard of health care–for instance, private clinics for a small, wealthy expatriate population in an otherwise poor country. But there are countries with a majority-private health care system with residual public service (see Medicare, Medicaid). The other major models are public insurance systems. A Social security health care model is where workers and their families are insured by the State. A publicly funded health care model is where the residents of the country are insured by the State. Within this branch is Single-payer health care, which describes a type of financing system in which a single entity, typically a government run organisation, acts as the administrator (or "payer") to collect all health care fees, and pay out all health care costs. Some advocates of universal health care assert that single-payer systems save money that could be used directly towards health care by reducing administrative waste. In practice this means that the government collects taxes from the public, businesses, etc., creates an entity to administer the supply of health care and then pays health care professionals. A single-payer universal health care system will actually save money through reduced bureaucratic administration costs. Social health insurance is where the whole population or most of the population is a member of a sickness insurance company. Most health services are provided by private enterprises which act as contractors, billing the government for patient care. In almost every country with a government health care system a parallel private system is allowed to operate. This is sometimes referred to as two-tier health care. The scale, extent, and funding of these private systems is very variable.

A traditional view is that improvements in health result from advancements in medical science. The medical model of health focuses on the eradication of illness through diagnosis and effective treatment. In contrast, the social model of health places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier. It defines illness from the point of view of the individual's functioning within their society rather than by monitoring for changes in biological or physiological signs.

World Health Organization
The World Health Organization (WHO) is a specialised United Nations agency which acts as a coordinator and researcher for public health around the world. Established on 7 April 1948, and headquartered in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health Organization, which had been an agency of the League of Nations. The WHO's constitution states that its mission "is the attainment by all peoples of the highest possible level of health." Its major task is to combat disease, especially key infectious diseases, and to promote the general health of the peoples of the world. Examples of its work include years of fighting smallpox. In 1979 the WHO declared that the disease had been eradicated - the first disease in history to be completely eliminated by deliberate human design. The WHO is nearing success in developing vaccines against malaria and schistosomiasis and aims to eradicate polio within the next few years. The organization has already endorsed the world's first official HIV/AIDS Toolkit for Zimbabwe from October 3 2006, making it an international standard.

The WHO is financed by contributions from member states and from donors. In recent years the WHO's work has involved more collaboration, currently around 80 such partnerships, with NGOs and the pharmaceutical industry, as well as with foundations such as the Bill and Melinda Gates Foundation and the Rockefeller Foundation. Voluntary contributions to the WHO from national and local governments, foundations and NGOs, other UN organizations, and the private sector (including pharmaceutical companies), now exceed that of assessed contributions (dues) from its 193 member nations.

Oceania
Australia and New Zealand both have publicly funded universal health care systems, alongside ancillary private health care and insurance.

Australia
Medicare was introduced by the Whitlam Labor Government on 1 July 1975 through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. Yet Medicare has been supported by subsequent governments and became a key feature of Australia’s public policy landscape. The exact structure of Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medicare program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medicare was originally funded from general taxation. In October 1976, the Fraser Government introduced a 2.5% levy. The program is now nominally funded by an income tax surcharge known as the Medicare levy, which is currently set at 1.5% with exemptions for low income earners. In practice the levy raises only a fraction of the money required to pay for the scheme. If the levy was to fully pay for the services provided under the medicare banner then it would need to be set at about 8%. There is an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($50,000) who do not have private patient hospital coverage. This policy was instituted by the former Coalition Federal Government in an attempt to encourage people to take up private health insurance.

Europe
All of Europe has publicly sponsored and regulated health care. Countries include Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Slovakia, Slovenia, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Spain, Sweden and the United Kingdom.

Ireland
The Irish health care system is a socialized, universal, public health care system and is governed by the Health Act 2004, which established a new body to be responsible for providing health and personal social services to everyone living in Ireland - the Health Service Executive. The new national health service came into being officially on 1 January, 2005; however the new structures are currently in the process of being established as the reform programme continues.

Slovenia
The Health Insurance Institute of Slovenia (the Institute) was founded on March 1, 1992, according to the Law on health care and health insurance, after declaring independence from Yugoslavia. The Institute conducts its business as a public institute, bound by statute to provide compulsory health insurance. In the field of compulsory health insurance, the Institute's principal task is to provide effective collection (mobilisation) and distribution (allocation) of public funds, in order to ensure the insured persons quality rights arising from the said funds. The rights arising from compulsory health insurance, furnished by the funds collected by means of compulsory insurance contributions, comprise the rights to health care services and rights to several financial benefits (sick leave pay, reimbursement of travel costs and funeral costs, and insurance money paid in case of death). The Institute comprises 10 regional units and 45 branch offices distributed around the territory of Slovenia. The functional unit the Information Centre and the Directorate complete the Institute structure. At the end of 2005, the Institute staff numbered regular 929 employees. The Institute is governed by an Assembly, whose members are the (elected) representatives of employers (including the representatives of the Government of the Republic of Slovenia) and employees. The executive body of the Assembly is the Institute Board of Directors. The Slovene health insurance card system was introduced, at the national scale, in the year 1999. The system provided the insured persons with a smart card and set up data links between the health care service providers and health insurance providers (the Health Insurance Institute and the two voluntary health insurance providers).

Switzerland
Healthcare in Switzerland is regulated by the Federal Health Insurance Act. Health insurance is compulsory for all persons resident in Switzerland (within three months of taking up residence or being born in the country). International civil servants, members of permanent missions and their familiy members are exempted from compulsory health insurance. They can, however, apply to join the Swiss health insurance system, within six months of taking up residence in the country. Health insurance covers the costs of medical treatment and hospitalisation of the insured. However, the insured person pays part of the cost of treatment. This is done (a) by means of an annual excess (or deductible, called the franchise), which ranges from CHF 300 to a maximum of CHF 2,500 as chosen by the insured person (premiums are adjusted accordingly) and (b) by a charge of 10% of the costs over and above the excess.

United Kingdom
Each of the countries of the United Kingdom has a public health service that provides healthcare to all UK permanent residents that is free at the point of need and paid for from general taxation. However, since Health is a devolved matter, considerable differences are developing between the systems in the different countries. Though commonly referred to as the NHS across the UK, in fact the National Health Service just covers England with separate 'National Health Services' in the other parts of the UK. For details of public healthcare in each country, see:


 * England

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services.


 * Northern Ireland


 * Scotland

NHS Scotland was founded by the National Health Service (Scotland) Act 1947 (since repealed by the National Health Service (Scotland) Act 1978) which came into effect on the same day as the NHS in England and Wales but has always been a separate organisation.


 * Wales

NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969.

Latin America
Most countries in Latin America have public health care provided. Mexico is planning to launch its own universal health care network though at the moment the standards of health care in Mexico are seriously lacking with large divides between rich and poor. Puerto Rico is planning its own health reform for the poorest of the population. Health care in Venezuela is probably the most extensive and given the country's fortunes in oil wealth, expenditure has recently increased greatly, starting with mass vaccinations under the Plan Bolivar 2000. Trinidad and Tobago has universal healthcare, but there are shortages of equipment, supplies, space and staff.

Cuba
The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of its citizens. Following the Revolution, the new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled "On Revolutionary Medicine", stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices." These aims were hampered almost immediately by an exodus of almost half of Cuba’s physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in University of Havana’s medical college. Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services. In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states

"'Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations.'"

Like the rest of the Cuban economy, Cuban medical care has suffered from severe material shortages following the end of Soviet subsidies and the ongoing United States embargo against Cuba that began after the Cuban Missile Crisis. The effects of the U.S. embargo on medicines in Cuba have been studied in numerous reports. • R Garfield and S Santana. Columbia University, School of Nursing, New York; "The impact of the economic crisis and the US embargo on health in Cuba" "this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services" • American Association for World Health; Online. American Association for World Health Report. March 1997. Accessed 6 October 2006. Supplementary source: American Public Health Association website "After a year-long investigation, the American Association for World Health has determined that the U.S. embargo of Cuba has dramatically harmed the health and nutrition of large numbers of ordinary Cuban citizens." • Felipe Eduardo Sixto; An evaluation of Four decades of Cuban Healthcare. "The lack of supplies accompanied by a deterioration of basic infastructure (potable water and sanitation) resulted in a setback of many of the previous accomplishments. The strengthening of the U.S. embargo contributed to these problems." • Pan American Health organization; Health Situation Analysis and Trends Summary "The two determining factors underlying the crisis are well known. One is the dissolution of the Soviet Union and the socialist bloc, and the other is the economic embargo the Government of the United States." • Harvard Public Health; Review/Summer 2002 : The Cuban Paradox "Because its access to traditional sources of financing is seriously hindered by the sanctions, which until recently included all food and medicine, Cuba has received little foreign and humanitarian aid to maintain the vitality of its national programs" • The Lancet medical journal; Role of USA in shortage of food and medicine. "The resultant lack of food and medicines to Cuba contributed to the worst epidemic of neurological disease this century." Data for 2004 show that Cuba has one of the highest life expectancy rates in Latin America. Costa Rica, Chile, Virgin Islands, Guadeloupe, and Martinique now have a higher life expectancy for combined sexes from birth.

Canada
The federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility." The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises, private corporations. Most of all doctors do not receive an annual salary, but receive a fee per visit or service. About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and optometry. Many Canadians have private health insurance, often through their employers, that cover these expenses. In Canada, some services are permitted and some are not. The Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that private services must be allowed to compete with the public program, thus opening the door to a dual system of private and public healthcare. Quebec has been the fastest to adopt this system and has the most private healthcare available of all the Canadian provinces.

United States
In the United States, certain publicly funded health care programs help to provide for the elderly, disabled, military service families and veterans, children, and the poor, and federal law ensures public access to emergency services regardless of ability to pay; however, a system of universal health care has not been implemented. The Commonwealth of Massachusetts is attempting to implement a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007. California, Maine, Pennsylvania, and Vermont also are attempting universal systems at the state level, with some smaller locations such as San Francisco also attempting this at the citywide level. Some government health care systems allow private practitioners to provide services, and some do not.

Asia
Israel, South Korea, Seychelles and Taiwan have universal health care. Thailand plans to. Health care in India is guaranteed to "improve" for all under the constitution, although the reality does not live up to the vague wording of the article. In Sri Lanka, drugs are provided by a government owned drug manufacturer called the State Pharmaceuticals Corporation of Sri Lanka. In the Philippines, the Department of Health (Philippines) organises public health for the country, and was established at the initiative of the American governors, before independence. Saudi Arabia has a publicly funded health system, although its levels are lower than the regional average.

China
Since the founding of the People's Republic of China, the goal of healthcare programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.

The current health insurance system in China provides virtually free coverage for people employed in urban state enterprises and relatively inexpensive coverage for their families. The situation for workers in the rural areas or in urban employment outside the state sector is far more varied. There are some cooperative health care programs, but their voluntary nature produced a decline in membership from the late 1970s.

The severest limitation on the availability of health services, however, appears to be the serious lack of resources, rather than discrimination in access on the basis of the ability of individuals to pay. An extensive system of paramedical care has been fostered as the major medical resource available to most of the rural population, but the care has been of uneven quality. The paramedical system feeds patients into the more sophisticated commune-level and county-level hospitals when they are available.

China is undertaking a reform on its universal health care system. The New Rural Co-operative Medical Care System (NRCMCS) is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical cover is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70-80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.

Japan
In Japan, payment for personal medical services is offered through a universal insurance system that provides relative equality of access, with fees set by a government committee. People without insurance through employers can participate in a national health insurance program administered by local governments. Since 1973, all elderly persons have been covered by government-sponsored insurance. Patients are free to select physicians or facilities of their choice. In the early 1990s, there were more than 1,000 mental hospitals, 8,700 general hospitals, and 1,000 comprehensive hospitals with a total capacity of 1.5 million beds. Hospitals provided both out-patient and in-patient care. In addition, 79,000 clinics offered primarily out-patient services, and there were 48,000 dental clinics. Most hospitals sell medicine directly to patients, but there are 36,000 pharmacies where patients could purchase synthetic or herbal medication.

National health expenditures rose from about 1 trillion Yen in 1965 to nearly 20 trillion Yen in 1989, or from slightly more than 5% to more than 6% of Japan's national income. However, this rise was in accordance with Japan's post-war economic boom (GDP had increased four times between 1965 and 1989 ). In addition to cost-control problems, the system was troubled with excessive paperwork, long waits to see physicians, assembly-line care for out-patients (because few facilities made appointments), over medication, and abuse of the system because of low out-of-pocket costs to patients. Another problem is an uneven distribution of health personnel, with cities favored over rural areas.

Africa
Health care in Africa is usually non existent or highly limited and under resourced. The outbreak and spread of HIV/AIDS in Africa has crippled many populations and sent life expectancies plummeting. However, some countries have been able to tackle the challenges, for instance health care in Uganda as well as education has reduced HIV/AIDS infections from 13% to 4.1% from 1990 to 2003. This contrasts to some governments' approach, especially that of the South African Health Ministry who until recently denied the link between HIV/AIDS.

Nigeria
Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals, while the state government manages the various general hospitals and the local government focus on dispensaries. The total expenditure on health care as % of GDP is 4.6, while the percentage of federal government expenditure on health care is about 1.5%. A long run indicator of the ability of the country to provide food sustenance and avoid malnutrition is the rate of growth of per capita food production; from 1970-1990, the rate for Nigeria was 0.25%. Though small, the positive rate of per capita may be due to Nigeria's importation of food products.

Historically, health insurance in Nigeria can be applied to a few instances: free health care provided and financed for all citizens, health care provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers. However, there are few people who fall within the three instances. In May 1999, the government created the National Health Insurance Scheme, the scheme encompasses government employees, the organized private sector and the informal sector. Legislative wise, the scheme also covers children under five, permanently disabled persons and prison inmates. In 2004, the administration of Obasanjo further gave more legislative powers to the scheme with positive amendments to the original 1999 legislative act.

Economics
Health care economics consists of a complicated relationship between a number of participants; the consumer, insurance companies, employers, medical professionals, and various government entities. An essential feature of health care economics is the spreading of risk, since the cost of health care for catastrophic illness can be prohibitive. This risk may be spread by private insurance companies, or by government involvement in the health care market. The health care market can suffer from a number of problems which are so severe as to be characterized by some as market failure


 * Adverse selection in insurance markets occurs because those providing insurance have limited information with which to estimate the risks their clients wish to insure against. In simple terms, those with poor health will apply for insurance, raising the cost of providing insurance; those with good health will find the cost of insurance too expensive, raising costs further. Private insurers are economically incentivized to spend substantial sums on investigating the health history of prospective clients, charging higher premiums for unhealthy individuals, which they may not be able to afford.


 * Moral hazard in insurance markets occurs when the insured behave in a riskier manner than they would if they were not insured. This problem is made worse when the individual is paying only a fraction of the true cost of coverage.

Among the potential solutions posited by economists are:


 * Various forms of universal health insurance, such as requiring all citizens to purchase insurance, limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals. Compulsory universal health insurance is a common thread, although there is no requirement that the insurance or medical services be provided by government.


 * Decreased government regulation: Conservative Republican US Senator Bill Frist argued that the free market will keep costs down, because individuals who have to pay for their own health care will make wiser decisions and not spend money on unneeded or inefficient care. A deregulated free market, Frist argues, will also encourage efficiency and innovation. The US currently (2007) has the most expensive health care of any OECD country and also has the highest percentage of costs paid privately.

Most European systems are financed through a mix of public and private contributions. The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal ). Some nations, such as Germany, France and Japan employ a multi-payer system in which health care is funded by private and public contributions. In 2001 Canadians paid $2,163 per capita versus $4,887 U.S., according to the Los Angeles Times (also, see table above). According to Dr. Stephen Bezruchka, a senior lecturer in the School of Public Health at the University of Washington in Seattle, Canadians do better by every health care measure. According to a World Health Organization report published in 2003, life expectancy at birth in Canada is 79.8 years, versus 77.3 in the U.S.

A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency. No entirely private health care system exists, although the reform bill in Massachusetts attempts to make private health care more affordable.

Politics
The politics of health care depends largely on which country one is in. Current concerns in England, for instance, revolve around the use of private finance initiatives to build hospitals or the excessive use of targets in cutting waiting lists. In Germany and France, concerns are more based on the rising cost of drugs to the governments. In Brazil, an important political issue is the breach of intellectual property rights, or patents, for the domestic manufacture of antiretroviral drugs used in the treatment of HIV/AIDS. The South African government, whose population sets the record for HIV infections, came under pressure for its refusal to admit there is any connection with AIDS because of the cost it would have involved. In the United States, which has some of the most sophisticated, technologically advanced health care in the world, 12% to 16% of the citizens are still unable to afford complete health insurance.

Opponents of universal health care in the United States often argue that it will require higher taxes and a great likelihood of poorly performing health care facilities and physicians. The absence of a market mechanism may slow innovation in treatment and research leading to rationing of care through waiting lists. A statistical comparison shows that it is not universal health care that leads to a doctor shortage, but the payment system to doctors that causes a doctors shortage. In Italy, doctors are paid a fee per patient per year, a per capita salary, and Italy does not have a doctor shortage but has one of the highest doctor per patient ratios, 5.8 doctors per 1,000 patients. In Italy though, it should be noted that most physicians subsequently have very limited hours; many only maintaining patient hours 2 days per week. Canada, whose universal health care system pays its doctors a "fee per visit", creates a real market condition, where doctors' salaries are protected, and even increased, by decreasing the supply of doctors. Canada has a low doctor per patient ratio of 2.1 doctors per 1,000 patients. A comparative analysis shows that a salaried doctor system, while not perfect, results in more doctors; however, they work substantially fewer hours, while the fee per visit system creates economic pressures to reduce the number of doctors, who subsequently work more hours.

Providers
A health care provider or health professional is an organization or person who delivers proper health care in a systematic way professionally to any individual in need of health care services. A health care provider could be a government, Health care industry, health care equipment, institution such as a hospital or medical laboratory, physicians, support staff, nurses, therapists, psychologists, chiropractors, veterinarians, dentists, optometrists, paramedics, pharmacists, or even a health insurance company.