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The provision of universal health care by the Portuguese NHS depends on the allocated government budget to health. Several reforms have been implemented over the last decades to improve access while ensuring the financial sustainability of the health care system. However, a practical and useable definition of public health sustainability is hard to find. We show that under two alternative definitions – both related to fiscal space and compliance with sound public finances – public health spending increase is limited. Our analysis indicates that public health spending growth levels below 3% can be financially sustainable.

Taking into account that financial sustainability is a function of economic growth and will depend on the level of control of other public spending, our forecast for long-run health spending growth is compatible with the financial sustainability targets defined.

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.

Purpose: We estimate national health expenditures on prevention using precise definitions, a transparent methodology, and a subdivision of the estimates into components to aid researchers in applying their own concepts of prevention activities.

Methodology/Approach: We supplemented the National Health Expenditure Accounts (NHEA) with additional data to identify national spending on primary and secondary prevention for each year from 1996 to 2004 across eight spending categories.

Findings: We estimate that NHEA expenditures devoted to prevention grew from $83.2 billion in 1996 to $159.8 billion in 2004, in current dollars. As a share of NHEA, this represents an increase from 7.8 percent in 1996 to 8.6 percent in 2004. This share peaked at 9 percent in 2002 and then declined due to reductions in public health spending as a percent of NHEA between 2002 and 2004. Primary prevention represents about half the expenditures, consisting largely of public health expenditures – the largest prevention element.

Originality/Value of Paper: Our 2004 estimate that 8.6 percent of NHEA goes to prevention is nearly three times as large as the commonly cited figure of 3 percent, but depends on the definitions used: our estimate falls to 8.1 percent when the research component is excluded, 5.1 percent when consideration is limited to primary prevention plus screening, 4.2 percent for primary prevention alone, and 2.8 percent if we count only public health expenditures. These findings should contribute to a more informed discussion of our nation's allocation of health care resources to prevention.

Objective – This chapter assesses the extent to which previous economic and financial crises had a negative impact on health outcomes and health financing. In addition, we review evidence related to the effectiveness of different policy measures undertaken in past crises to protect access to health services, especially for the poor and vulnerable. The current global crisis is unique both in terms of its scale and origins. Unlike most previous instances, the current crisis has its origins in developed countries, initially the United States, before it spread to middle- and lower-income countries. The current crisis is now affecting almost all countries at all levels of income. This chapter addresses several key questions aimed at helping inform possible policy responses to the current crisis from the perspective of the health sector: What is the nature of the current crisis and in what ways does it differ from previous experiences? What are some of the key lessons from previous crises? How have governments responded previously to protect health from such macroeconomic shocks? How can we improve the likelihood of positive action today?

Methodology/approach – The chapter reviews the literature on the impact of financial crises on health outcomes and health expenditures and on the effectiveness of past policy efforts to protect human development during periods of economic downturn. It also presents analysis of household surveys and health expenditure data to track health seeking behavior and out-of-pocket expenditures by households during times of financial crisis.

Findings – Evidence from previous crises indicates that health-related impacts during economic downturns can occur through various channels. The impact in households experiencing reductions in employment and income could be manifest in terms of poorer nutritional outcomes and lower levels of utilization of health care when needed. Households may become impoverished, reduce needed health services, and experience reductions in consumption as a result of health shocks occurring during a time when their economic vulnerability has increased. Women, children, the poor, and informal sector workers are likely to be most at risk of experiencing negative health-related consequences in a crisis. Real government spending per capita on health care could decline due to reduced revenues, currency devaluations, and potential reductions in external aid flows. Low-income countries with weak fiscal positions are likely to be the most vulnerable.

Implications for policy – Past crises can inform policy-making aimed at protecting health outcomes and reducing financial risk from health shocks. Evidence from previous crises indicates that broad-brush strategies that maintained overall levels of government health spending tended not to be successful, failing to protect access to quality health services especially for the poor. It is particularly vital to ensure access to essential health commodities, which in many low-income countries are imported, in the face of weakening exchange rates. Focused efforts to sustain the supply of lower-level basic services, combined with targeted demand-side approaches like conditional cash transfers may be more effective than broader sectoral approaches. Low-income countries may need specific short-term measures to ensure that health outcomes do not suffer.

The research analyzes good practices in health care “management experimentation models,” which fall within the broader range of the integrative public–private partnerships (PPPs). Introduced by the Italian National Healthcare System in 1991, the “management experimentation models” are based on a public governance system mixed with a private management approach, a patient-centric orientation, a shared financial risk, and payment mechanisms correlated with clinical outcomes, quality, and cost-savings. This model makes public hospitals more competitive and efficient without affecting the principles of universal coverage, solidarity, and equity of access, but requires higher financial responsibility for managers and more flexibility in operations.

In Italy the experience of such experimental models is limited but successful. The study adopts the case study methodology and refers to the international collaboration started in 1997 between two Italian hospitals and the University of Pittsburgh Medical Center (UPMC – Pennsylvania, USA) in the field of organ transplants and biomedical advanced therapies.

The research allows identifying what constitutes good management practices and factors associated with higher clinical performance. Thus, it allows to understand whether and how the management experimentation model can be implemented on a broader basis, both nationwide and internationally. However, the implementation of integrative PPPs requires strategic, cultural, and managerial changes in the way in which a hospital operates; these transformations are not always sustainable.

The recognition of ISMETT’s good management practices is useful for competitive benchmarking among hospitals specialized in organ transplants and for its insights on the strategies concerning the governance reorganization in the hospital setting. Findings can be used in the future for analyzing the cross-country differences in productivity among well-managed public hospitals.

In large parts of the world, income inequality has been rising in recent decades. Other regions have experienced declining trends in income inequality. This raises the question of which mechanisms underlie contrasting observed trends in income inequality around the globe. To address this research question in an empirical analysis at the aggregate level, we examine a global sample of 73 countries between 1981 and 2010, studying a broad set of drivers to investigate their interaction and influence on income inequality. Within this broad approach, we are interested in the heterogeneity of income inequality determinants across world regions and along the income distribution. Our findings indicate the existence of a small set of systematic drivers across the global sample of countries. Declining labour income shares and increasing imports from high-income countries significantly contribute to increasing income inequality, while taxation and imports from low-income countries exert countervailing effects. Our study reveals the region-specific impacts of technological change, financial globalisation, domestic financial deepening and public social spending. Most importantly, we do not find systematic evidence of education’s equalising effect across high- and low-income countries. Our results are largely robust to changing the underlying sources of income Ginis, but looking at different segments of income distribution reveals heterogeneous effects.

Objective – The aim of the paper is to bring evidence and lessons from two low- and middle-income countries (LMIs) of the former USSR into the global debate on health financing in poor countries. In particular, we analyze the introduction of social health insurance (SHI) in Kyrgyzstan and Moldova. To some extent, the intent of SHI introduction in these countries was similar to that in LMIs elsewhere: increase prepaid revenues for health and incorporate the entire population into the new system. But the approach taken to universality was different. In particular, the SHI fund in each country was used as the key instrument in a comprehensive reform of the health financing system, with the new revenues from payroll taxation used in an explicitly complementary manner to general budget revenues. From a functional perspective, the reforms in these countries involved not only the introduction of a new source of funds, but also the centralization of pooling, a shift from input- to output-based provider payment methods, specification of a benefit package, and greater autonomy for public sector health care providers. Hence, their reforms were not simply the introduction of an SHI scheme, but rather the use of an SHI fund as an instrument to transform the entire system of health financing.

Methodology/approach – The study uses administrative and household data to demonstrate the impact of the reforms on regional inequality and household financial burden.

Findings – The approach used in these two countries led to improved equity in the geographic distribution of government health spending, improved financial protection, and reduced informal payments.

Implications for policy – The comprehensive approach taken to reform in these two countries, and particularly the redirection of general budget revenues to the new SHI funds, explain much of the success that was achieved. This experience offers potentially useful lessons for LMIs elsewhere in the world, and for shifting the global debate away from what we see as a false dichotomy between SHI and general revenue-funded systems. By demonstrating that sources are not systems, these cases illustrate how, in particular by careful design of pooling and coverage arrangements, the introduction of SHI in an LMI context can avoid the fragmentation problem often associated with this reform instrument.

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 purpose of this study is to examine the effect of local government spending on local government financial performance. Furthermore, this study also investigates the moderating role of re-election on the relationship between local government spending and the financial performance for all local government and dynastic local government. The hypotheses are analyzed using multiple regression with fixed effect using two groups of samples: all local governments and dynastic local governments from 2010 to 2015. The result shows that local government spending positively affects local government financial performance, but in dynastic local government, spending has negative effect on financial performance. Moreover, this study proves that re-election strengthens the positive effect of local government spending on local government financial performance in all sample and weaken the negative effect of spending on financial performance in dynastic local government. The finding of this study is very useful for the central government in terms of policy formulation and mechanisms to limit the practice of political dynasty.