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This chapter provides an assessment of the sustainability of Ireland's health care system. It starts by describing the historical development of the Irish system and identifying key features of the current system that raise potential challenges for sustainability. It then provides an analysis of recently compiled and up-to-date data on trends in health care expenditures. A number of specific demand and supply side challenges to sustainability are then described and discussed. This is followed by an examination of recent and current reforms to the health care system, focussing on their likely impact on sustainability, as well as a discussion of how health economics has and can inform policy, practice and debate. We also discuss the potential implications of the COVID-19 pandemic for the Irish system.

This chapter sheds light on long-term trends in the level and structural dynamics of investments in Russian human capital formation from government, corporations, and households. It contributes to the literature discussing theoretical issues and empirical patterns of modernization, human development, as well as the transition from a centralized to a market economy. The empirical evidence is based on extensive utilization of the dataset introduced in Didenko, Földvári, and Van Leeuwen (2013). Our findings provide support for the view expressed in Gerschenkron (1962) that in late industrializers the government tended to substitute for the lack of capital and infrastructure by direct interventions. At least from the late nineteenth century the central government's and local authorities' budgets played the primary role. However, the role of nongovernment sources increased significantly since the mid-1950s, i.e., after the crucial breakthrough to an industrial society had been made. During the transition to a market economy in the 1990s and 2000s the level of government contributions decreased somewhat in education, and more significantly in research and development, but its share in overall financing expanded. In education corporate funds were largely replaced by those from households. In health care, Russia is characterized by an increasing share of out-of-pocket payments of households and slow development of organized forms of nonstate financing. These trends reinforce obstacles to Russia's future transition, as regards institutional change toward a more significant and sound role of the corporate sector in such branches as R&D, health care, and, to a lesser extent, education.

Little is known about perceptions of medical expenditure risks despite their presumed relevance to the demand for health insurance. This is the first study to examine households’ beliefs about their future spending on health care. The study made a unique elicitation of subjective probabilities of medical expenditures from rural Ethiopians participating in a panel survey and offered the opportunity to enrol in a health insurance programme. The vast majority of respondents give logically consistent responses to the subjective probability questions. The data indicate that the cross-sectional variance of realized expenditures, which is often used to proxy risk exposure, greatly overestimate the risk faced by any single household. Consistent with the serial correlation observed in realized expenditures, expectations are positively correlated with past expenses. They are revised upward in response to an increase in realized expenditure and, to some extent, they predict expenditure incurred in the year ahead. Despite containing information on future medical expenditures, there is no evidence that expectations influence the decision to take out health insurance, although plans to insure are positively related to the perceived volatility of expenses.

These results suggest that adverse selection may not threaten the viability of voluntary health insurance. A caveat is that measurement error in the reported probabilities may weaken the test for adverse selection. Notwithstanding this limitation, measurement of household-specific distributions of future medical expenses is feasible and avoids relying on the cross-sectional variance, which provides an upwardly biased estimate of medical expenditure risk.

This paper offers an overview of the defining traits of the Spanish National Health Service (Sistema Nacional de Salud, in Spanish), as well as an account of its current trends in both spending and organisational changes. Beyond a thorough description of the Spanish public health-care system and its main quantitative indicators, we offer a critical review of the ongoing decentralisation process of health-care provision and its recent trends in pharmaceutical spending.

The text is organised in the following two parts. Part 1 provides an overview of the Spanish health-care system, structured in several sections. It starts by placing Spain within a classification of international health-care systems and is followed by an account of the importance of public provision in the Spanish case. A relation of the guiding principles of the Spanish public system concludes the first part. The second part focuses on two key developments that have shaped the evolution of the Spanish health-care system in the recent decades. The first is the process of decentralisation of health-care; the section explains the challenges arising with the transference of health-care provision responsibilities from the central to regional governments. The second section critically reviews the recent expansion of drug-related spending in the Spanish health-care system, and the policy responses to attempt to contain health-care costs.

Objective – Measurement of the incidence of health financing contributions across socio-economic groups has proven valuable in informing health care financing reforms. However, there is little evidence as to how to carry out financing incidence analysis (FIA) in lower income settings. We outline some of the challenges faced when carrying out a FIA in Ghana, Tanzania and South Africa and illustrate how innovative techniques were used to overcome data weaknesses in these settings.

Methodology – FIA was carried out for tax, insurance and out-of-pocket (OOP) payments. The primary data sources were Living Standards Measurement Surveys (LSMS) and household surveys conducted in each of the countries; tax authorities and insurance funds also provided information. Consumption expenditure and a composite index of socio-economic status (SES) were used to assess financing equity. Where possible conventional methods of FIA were applied. Numerous challenges were documented and solution strategies devised.

Results – LSMS are likely to underestimate financial contributions to health care by individuals. For tax incidence analysis, reported income tax payments from secondary sources were severely under-reported. Income tax payers and shareholders could not be reliably identified. The use of income or consumption expenditure to estimate income tax contributions was found to be a more reliable method of estimating income tax incidence. Assumptions regarding corporate tax incidence had a huge effect on the progressivity of corporate tax and on overall tax progressivity. LSMS consumption categories did not always coincide with tax categories for goods subject to excise tax (e.g. wine and spirits were combined, despite differing tax rates). Tobacco companies, alcohol distributors and advertising agencies were used to provide more detailed information on consumption patterns for goods subject to excise tax by income category. There was little guidance on how to allocate fuel levies associated with ‘public transport’ use. Hence, calculations of fuel tax on public transport were based on individual expenditure on public transport, the average cost per kilometre and average rates of fuel consumption for each form of transport. For insurance contributions, employees will not report on employer contributions unless specifically requested to and are frequently unsure of their contributions. Therefore, we collected information on total health insurance contributions from individual schemes and regulatory authorities. OOP payments are likely to be under-reported due to long recall periods; linking OOP expenditure and illness incidence questions – omitting preventive care; and focusing on the last service used when people may have used multiple services during an illness episode. To derive more robust estimates of financing incidence, we collected additional primary data on OOP expenditures together with insurance enrolment rates and associated payments. To link primary data to the LSMS, a composite index of SES was used in Ghana and Tanzania and non-durable expenditure was used in South Africa.

Policy implications – We show how data constraints can be overcome for FIA in lower income countries and provide recommendations for future studies.

The search for more effective policies, choice of optimal implementation strategies for achieving defined policy targets (e.g., cost-containment, improved access, and quality healthcare outcomes), and selection among the metrics relevant for assessing health system policy change performance simultaneously pose continuing healthcare sector challenges for many countries of the world. Meanwhile, research on the core drivers of healthcare costs across the health systems of the many countries continues to gain increased momentum as these countries learn among themselves. Consequently, cross-country comparison studies largely focus their interests on the relationship among health expenditures (HCE), GDP, aging demographics, and technology. Using more recent 1980–2014 annual data panel on 34 OECD countries and the panel ARDL (Autoregressive Distributed Lag) framework, this study investigates the long- and short-run relationships among aggregate healthcare expenditure, income (GDP per capita or per capita GDP^_HCE), age dependency ratio, and “international co-operation patents” (for capturing the technology effects). Results from the panel ARDL approach and Granger causality tests suggest a long-run relationship among healthcare expenditure and the three major determinants. Findings from the Westerlund test with bootstrapping further corroborate the existence of a long-run relationship among healthcare expenditure and the three core determinants. Interestingly, GDP less health expenditure (GDP^_HCE) is the only short-run driver of HCE. The income elasticity estimates, falling in the 1.16–1.46 range, suggest that the behavior of aggregate healthcare in the 34 OECD countries tends toward those for luxury goods. Finally, through cross-country technology spillover effects, these OECD countries benefit significantly from international investments through technology cooperations resulting in jointly owned patents.

The 30 MOCHA (Models of Child Health Appraised) countries are diverse socially, culturally and economically, and differences exist in their healthcare systems and in the scope and role of primary care. An economic analysis was undertaken that sought to explain differences in child health outcomes between countries. The conceptual framework was that of a production function for health, whereby health outputs (or outcomes) are assumed affected by several ‘inputs’. In the case of health, inputs include personal (genes, health behaviours) and socio-economic (income, living standards) factors and the structure, organisation and workforce of the healthcare system. Random effects regression modelling was used, based on countries as the unit of analysis, with data from 2004 to 2016 from international sources and published categorisations of healthcare system. The chapter describes the data deficiencies and measurement conundrums faced, and how these were addressed. In the absence of consistent indicators of child health outcomes across countries, five mortality measures were used: neonatal, infant, under five years, diabetes (0–19 years) and epilepsy (0–19 years). Factors found associated with reductions in mortality were as follows: gross domestic product per capita growth (neonatal, infant, under five years), higher density of paediatricians (neonatal, infant, under five years), less out-of-pocket expenditure (neonatal, diabetes 0–19), state-based service provision (epilepsy 0–19) and lower proportions of children in the population, a proxy for family size (all outcomes). Findings should be interpreted with caution due to the ecological nature of the analysis and the limitations presented by the data and measures employed.

Purpose – This chapter examines how drug prescribing behavior in Taiwanese hospitals changed after the government changed reimbursement systems. In 2002, Taiwan instituted a system in which hospitals are reimbursed for drug expenditures at full price from a fixed global budget before the remaining budget is allocated to reimburse all other expenditures, often at discounted prices. Providers are thus given a financial incentive to increase prescriptions.

Methodology – We isolate the effect of this system from that of other confounding factors by estimating a difference-in-difference model to analyze monthly drug expenditures of hospital departments for outpatients during the years 1999–2006.

Findings – Our results suggest that hospital departments which use drugs more heavily as part of their regular medical care increased their drug prescription expenditures after the implementation of the global budget system. In addition, we find that the response was stronger among for-profit than not-for-profit and public hospitals.

Implications – Hospital doctors responded to the financial incentive created by the particular global budgeting system adopted in Taiwan by increasing expenditures on drug treatments for outpatients.

This chapter explores the contribution of health care expenditure to basic needs satisfaction. It focuses on Nuevo Lugar, a shanty town of Lima with access to modern health care services and infrastructures. The research follows a three-step approach beginning with the investigation of what is understood as basic needs through people's concepts of the “good life”. It then identifies basic needs satisfiers in the slum – those goods and services people consume motivated by meeting their valued needs. Finally, it explores the case of expenditure on consultation fees, medicines and vitamin supplements. It finds that they might not make a significant contribution to people's physical health due to the lack of information on illnesses and treatments tailored to the local population, together with the high costs of medicines.