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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.

The objective of this study is to examine the sociodemographic factors that are associated with health care expenditure among households in Malaysia.

This study examines health care participation decision and amount of expenditure using the exponential Type 2 Tobit model. A dataset of a large sample (n = 14,838) that is nationally representative is used.

The results suggest that household size, location of residence as well as age, education and marital status of the household heads are significantly associated with household expenditure on health care. Health care expenditure increases with the age and educational attainment of household heads, whereas those who are being employed and residing in rural areas have lower health care expenditure. Although larger households are more likely to consume health care than smaller households, they spend less on health care. Furthermore, marital status does not affect the participation decision of health care expenditure, but the variable is associated with the decision on the amount of the expenditure.

The results provide insights into groups of population that can be targeted for healthcare intervention programmes and policy design.

This study is the first to our knowledge to use a microeconometric approach to analyse the health care participation as well as its level of expenditure among households in Malaysia.

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.

In 2010 the Patient Protection and Affordable Care Act boosted the expansion of community health centers (CHCs) with $11 billion in mandatory funding from 2011 to 2015. This study used data from the Medical Expenditure Panel Survey (MEPS) and the North Carolina Behavioral Risk Factor Surveillance System (BRFSS) to assess the cost savings associated with the use of community health centers compared to other primary care providers. After controlling for various demographic, socioeconomic characteristics and health conditions, we found savings at an average of $3,437 in total expenditures and $1,211 in ambulatory care expenditures. These results suggest that continuing investment in health centers are important during times of budget cuts in order to improve access to care and to generate cost savings to the healthcare system.

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.

When the factors affecting health expenditures are examined in the literature, it is seen that one of the most important factors is income. In this context, the purpose of this study is to investigate the relationship between out-of-pocket health expenditures and disposable personal income and revealing the income elasticity of health expenditures.

Therefore, short/long-term coefficients were obtained by analyzing Westerlund (2007) co-integration analysis and pooled mean group (PMG) regression methods for 22 European Union (EU) member states during the period 2003–2017. In addition, a comparison of the long-term coefficients for each country was obtained with augmented mean group (AMG) estimator.

The results of the AMG and PMG tests show that the long-term coefficients between disposable personal income and health expenditures are 0.83 and 0.97, respectively. These results imply that there is a significant relationship between the variables, and that health care should be categorized in the group of normal goods. However, the fact that the long-term coefficient is very close to 1, despite being classified in the category of necessity goods, requires more care to be taken in evaluating whether health services are luxury goods or necessity goods.

The use of second generation econometric tests on both cross-sectional dependence and heterogeneity demonstrates the value of the study. On the other hand, obtaining similar results by investigating the relationship between variables using different appropriate econometric models reveals the importance of the methodology used in this study. It reveals important details in terms of the literature regarding the long-term and short-term results obtained in this study.

The purpose of this paper is to explore the manner in which the degree of substitutability between public and private health expenditures contributes towards the distribution of wealth and political economy outcomes in the long run.

An overlapping generations model with heterogeneous agents where a person’s probability of survival into old age is determined by a variable elasticity of substitution (VES) health production function with public and private expenditures as inputs is developed. Public expenditure on health is determined through a political economy process.

Analytical and numerical results reveal that higher substitutability between private and public expenditures at the aggregate level and a higher share of public spending in the production of health lead to higher long run wealth levels and lower inequality. In the political equilibrium, higher aggregate substitutability between public and private health expenditures is associated with more tax revenue allocated towards public health. For most parameter combinations, the political economy and welfare maximising proportions of tax revenue allocated towards public health care converge in the long run.

The paper is a theoretical investigation of how substitutability between public and private health expenditures affect transitional and long run macroeconomic outcomes. These results are amenable to further empirical investigation.

The findings indicate that policies to improve institutional aspects that yield higher substitutability between public and private health expenditures and returns to public health spending could lead to better long run economic outcomes.

The results provide a political economy explanation for the low investments in public health care in developing countries, where aggregate substitutability between public and private health expenditures is likely to be lower. Furthermore, comparing the political economy and welfare maximising paradigms broadens the scope of the framework developed herein to provide potential explanations for cross-country differences in health outcomes.

This paper adopts an innovative approach to exploring this issue of substitutability in health expenditures by introducing a VES health production function. In an environment where agents have heterogeneous wealth endowments, this specification enables a distinction to be made between substitutability of these expenditures at the aggregate and individual levels, which introduces a rich set of dynamics that feeds into long run outcomes and political economy results.

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.