• The greatest density of high-technology services of any country in the world.
• More health workers are employed per hospital bed than in any other country.
• Medical education and medical research productivity are among the world's best.
• Roughly 15% of the population (40-45 million) who are uninsured have uncertain access to basic services and even less opportunity for high-technology health care.
• Additional large numbers of people, estimated at 50 million, are underinsured; they do not have enough insurance to cover serious illness or must pay very high deductibles.
• The largest number of citizens are uninsured at this point in time since the initiation of Medicare and Medicaid in 1965.
• Long-term care costs are growing as the population ages. Long-term care consumed 7.9% of all health care spending in 1995.
• Hospital and insurers regularly shift uninsured patients' hospital costs to paying clients and deliberately avoid high-risk patients altogether if possible.
• National opinion polls indicate 75% of Americans support health are reform and want some form of a national health care program, even if it means an increase in taxes.
• There are extensive accreditation and inspection requirements, both federal and state, that require enormous investment in both systems and manpower. Tacking and reporting requirements are the most extensive in the world.
• There is a more sophisticated quality control function in health care compared to other countries.  Extensive reporting requirements for state inspection, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), and certification organizations have created a need for substantial investment in information systems. Major quarterly indicators are tracked and reported.

PRIMARY FEATURES OF THE CANADIAN HEALTH CARE SYSTEM

• Hospital and physician services are covered by provincial health insurance, without significant co-payments at the point of service after a deductible amount.
• The provincial health plan is the only payer for "core" services.  Funds are derived from personal, sales, and corporate taxes. Approximately 75% of all health care costs are pad from public sources. Private insurance is not allowed for basic services.
• Citizens are free to choose their doctor and hospital.
• Physician practices are largely private and independent. The fee-for-service payment system is based on rates negotiated by physician organizations and provincial governments. A standard billing form is used by all physicians.
• Hospitals are largely public and non-profit.  Financing is based on an annual global budget. Virtually all major surgery and high-technology diagnostic tests are provided in hospitals, with few recent exceptions.
• Essentially all high-technology available in other advanced countries is also accessible in Canada.
• Provincial planning process limits the distribution of high-cost technologies (CT & MRI) to regional hospitals
• Health care administrators control major policy and decision responsibilities.
• Accepted practice patterns among health care providers are rarely questioned. The College of Family Physicians of Canada has its own board, but all other specialties are under the Royal College of Physicians and Surgeons.  There exist no formal criteria for assessment of medical practice or accepted indications for a host of medical and surgical testing (guidelines or outcomes).  The local standard of care has given way to a national standard for performance since the 1970s.

MEDICAL EDUCATION

• Quality standards are fully comparable to other developed countries.
• Focus is on training generalists and family practitioners. Less emphasis is placed on specialist training and students are encouraged to practice in a less aggressive style.  Fewer high-technology procedures are used and intensive care is not emphasized.
• There are more medical schools and graduates than needed to fulfill national needs.  This has resulted in an increased outmigration to the United States.

NURSING

• Nursing careers are constrained by limited opportunites for advancement.  The differential pay for advanced education is minimal.
• Nurses have little political power over physicians.
• Nurses tend to have a low degree of job satisfaction.
• The Canadian Nursing Association (CNA) is encouraging nurses be required to have a university degree by the year 2000.
• The roles of nurse-practitioners and midwives are increasing.

FEATURES OF THE JAPANESE HEALTH CARE SYSTEM

• Japanese are a relatively health population that live longer and are more rapidly aging than any other nation in the world.
• The proportion of the Gross Domestic Product (GDP) devoted to health care is the lowest among the advanced industrial nations, at 6.9% (in 1992), with among the lowest per capita expenditure of $1376.
• An efficient and unusually powerful federal health services bureaucracy oversees both public and private health care.
• Most hospitals and clinics are owned by physicians, who also serve as both prescribers and dispensers of medication.
• Japan leads the world in the per capita consumption of pharmaceuticals that represent approximately 19% of health care costs (1988).
• Japan has the highest number of hospital beds per capita of any nation.
• The world's highest proportion of CT scanners and MRI instruments per million population is found in Japan.
• The Japanese have a proclivity toward self-care and health maintenance.
• Japan places a special emphasis on preparing female physicians.  The Tokyo Women's Medical College is possibly the only all-female medical school in the world.
• There are no national standards for care or hospital accreditation and nor surveys. Common perception among the population is that outpatient hospital care is of a higher quality than outpatient clinic care.  The Ministry of International Trade and Industry establishes equipment standards under Japanese industrial standards. Permissible exposure limits on toxicants are set by the Japanese Association of Industrial Health.

NURSING

• Nurses provide the major part of public, primary, secondary, and tertiary health care in Japan.
• Nursing education has advanced very little with almost no opportunity for specialized training.
• There are four general categories of nurses in Japan:
• Public Health Nurse has the most advanced training. They complete the clinical nurse training and a graduate program in public health nursing. The smallest category of nurses is the Public Health Nurse. They provide child health are, check-ups, preventive care, and home nursing care.
• Clinical Nurses receive three years of training past high school, which is completed in a hospital setting. All Clinical Nurses must pass a national examination. Approximately 80% work in hospitals and 15% in clinics.
• Nurse Midwives also receive the same training as clinical nurses plus one year of midwife training. Approximately 50% work in hospitals and one-third own or practice in maternity or OBGYN clinics. Nurse Midwives function under the supervison of physicians.
• Assistant Nurse is comparable to the LPN in the United States.  They must be graduates of a junior high school before entering a two year training program.

HEALTH PROFESSIONALS

• Training programs for health professionals are directly associated with medical schools but with a lower status.
• The growth of health professionals has been slow to develop because physicians are trained in these fields and tend to dominate.
• Large focus is on traditional therapies such as massage, acupuncture, chiropractics, and herbal medicine.  These traditional practices are not covered routinely covered by health insurance.

FEATURES OF THE GERMAN HEALTH CARE SYSTEM

• Germans have near-universal insurance coverage with access to services based on health care needs.
• Private non-profit public "sickness funds" are governed by consumers and providers.
• Financing of health care is mandated through payroll deductions from employers, with equal employee contributions, based on an individual's ability to pay.
• Benefits include medical, dental, eye, inpatient hospital, home health, rehabilitative treatment at health spas, and full maternity care as well as income replacement when sick.
• Health services are administered through private practice and relatively autonomous primary care physicians who provide care under negotiated fee-for-service payment agreements with sickness funds, with no point-of-service charge to the consumer.
• Public and private non-profit hospital care is available in which salaried physician specialists assume full responsibility for patients.
• Government at the national, state, and local levels do not directly manage any part of the system, but maintains considerable control over health care policy, regulations, and capital investment in hospitals.
• Citizens have full access to comprehensive health care services with modest co-payments and with relatively free choice of both physicians and hospitals.
• Insurance companies bear the responsibility for quality. It is more an economic than a clinical evaluation. The statutory requirement for certain hospital quality functions is negotiated by the sickness funds with hospitals.

PHYSICIANS

• Physicians are divided into two categories: Hospital Physicians and Ambulatory Care Physicians
• Fierce competition exists between the two groups resulting in duplication of equipment, repetitive diagnostic tests, and complicated referral patterns.

NURSES

• There is a severe shortage of nurses in Germany probably due to the considerably lower pay and status than physicians.
• In the past, nurses were nuns and the profession is viewed as one which women work for very low pay with little professional status.

NATURAL HEALTH MOVEMENT

• Natural health movement is very strong in Germany.
• Approximately 30-40% of patients consult homeopaths, naturopaths, hydrotherapists, and other natural healers.
• The use of non-biomedical practitioners is generally acceptable as a complement to biomedicine.

FEATURES OF THE FRENCH HEALTH CARE SYSTEM

• In France, a highly sophisticated and professional federal bureaucracy manages national health care policy.  The government is viewed by citizens as having the prime responsibility to assure health care at reasonable out-of-pocket cost.
• Benefits include the full range of health services, including preventive checkups at regular interals.
• Results of tests and procedures are inscribed on health insurance "smart" cards and carried by the insured individual.
• Insurance coverage is not dependent on employment, although financing is primarily through employer payroll deduction.
• The working population is expected to subsidize older and dependent citizens.
• A comprehensive public/private mix of services is available but services are fragmented and complicated, with responsibility dispersed at local and national levels.
• Physicians have freedom of choice about location and mode of practice, with minimal hassles, but operate on tightly regulated fees negotiated by professional associations with nations insurance funds.
• Fee-for-service physicians provide most ambulatory care, and salaried public or fee-for-service private hospital physicians provide varying types of competing outpatient services as well as specialized care.
• Public hospitals are financed under "global budgets".
• Private hospitals operate on a per diem fee basis and have considerably greater freedom to expand services.
• The Minister of Health has an inspection team that visits most hospitals on a regular basis and reports on their status.  The Social Security Administration has "Praticiens conseils de la Securite Sociale," a 4000 member group that examines large-ticket items and prolonged stays. Its main thrust is for cost savings and not for quality of medicine.  Administrative hospital quality is accomplished by a random audit by the Cour des Comptes.  Standard care conformity within hospitals is monitored and supervised by the "medicins inspecteurs de la sante," who number approximately 300, are poorly paid, and report to the Directeur Departemental des Affaires Sanitaires et Sociales (DDASS). A yearly report on health care in a given area is prepared by the Inspection General des Affaires Sociales (IGAS).  This national body of high-ranking officials, mainly administrators and not physicians, gives expert opinion on matters pertaining to health care. Since the health care law of 1991, the Office for the Evaluation of Health Care Organizations in the Division of Hospitals in the Ministry of Health is responsible for overseeing hospital evaluation policies.

FEATURES OF THE SWEDISH HEALTH CARE SYSTEM

• Sweden has a long history of public and decentralized primary health care. Counties are responsible for financing and providing services.  Approximately 75-80% of county budgets are for health care.
• Sweden has been a pioneer in comprehensive public health promotion and prevention, environmental protection, and other measures to protect health.
• The design and management of local health care is controlled by full participation of physicians, health service administrators, health professionals, and political leaders.
• There is a strong emphasis on democratic control of services through decisions by elected county council officials.
• A very high value is placed on specialist care in hospitals.
• Tertiary care services are regionally planned and coordinated among groups of hospitals and counties.
• Sweden has the highest ratio of nurses to the population of any country in the world.  Nurses have a relatively high status and good compensation. They have a major responsibility in primary care of patients.
• There is a high proportion of elderly in the population compared to any other country (18%) and a very low infant mortality rate.

FEATURES OF THE RUSSIAN HEALTH CARE SYSTEM

• The number of physicians per capita is the largest in the world, approximately one physician for every 350 people.  Approximately 77% of the physicians are women.
• Essentially all administrators of health facilities are also physicians.
• Much of the health care in rural and remote areas is provided by feldshers, minimally trained providers who offer very basic health care services.
• Hospitals are modest in their capacity to cure ailments.  The rate of hospitalization is very high by world standards, which may be related to the fact that private housing is inadequate for care of illness.
• Nurses have relatively little patient contact and are responsible for maintenance and cleaning functions.
• Patients are expected to keep their own medical records and must have them available if needed at ambulatory care visits or in the hospital.  These records also include X-rays.
• Physicians are poorly paid and have very limited technology and facilities for practice, except for a few prestigious institutions.
• There is a chronic shortage of all medical supplies which include equipment and medication. Existing equipment is often inoperable due to lack of spare parts.
• A system of more advanced medicine and relatively modern hospitals is available only to the domestic and foreign elite.  These institutions have priority for equipment and supplies.

FEATURES OF THE CHINESE HEALTH CARE SYSTEM

• The Chinese health care system is controlled by the centralized communist party.
• There is a mix of modern Western medicine and traditional Chinese medicine.
• The "Doctor" designation is awarded for completion of a wide range of professional health care training and skill levels, which sees a predominance of women in this field.
• There is a minimal difference in status and salary between physicians, nurses, pharmacists, and other health professionals.
• A heavy reliance exists on mid- and lower-level practitioners, such as assistant doctors and health aides, for primary health care.
• Major disparities exist between rural and urban regions in quality and access to care and insurance.
• Schools place a strong emphasis on health and wellness through a socialization, education, and fitness process.
• The Chinese have the lowest incidence of heart disease than any other country probably due to their low fat diet, vigorous exercise, and healthy life style, although smoking is very widespread.

Return to Syllabus

References:

Lassey, M.L., Lassey, W.R., & Jinks, M.J. (1997). Health Care Systems Around the World. Prentice Hall.

Mendoza, E.M. & Henderson, B.J. (1995). International Health Care. American College of Physician Executives.