Global Health Care Comparison PDF

CHAPTER 17 Global Health Care PHOTO 17.1 Bus on a London street during the COVID-19 pandemic. The pandemic is a signifcant reminder of the importance of global health. Source: Loveandrock/Shutterstock. DOI: 10.4324/9781003203872-21...

CHAPTER 17 Global Health Care PHOTO 17.1 Bus on a London street during the COVID-19 pandemic. The pandemic is a signifcant reminder of the importance of global health. Source: Loveandrock/Shutterstock. DOI: 10.4324/9781003203872-21 405 406 PART IV  Health Care Delivery Systems L E A R N ING O B JEC TIV ES Evaluate socialized medicine. Understand the reasons for the decline of socialist medicine. Explain decentralized national health care programs. All nations of the world are faced with the pressure of public demands for quality health care and the rising costs of providing that care. Diferent approaches to these problems have led to renewed interest in comparative or transnational studies of health care sys- tems in order to learn from the experiences of other countries (Amzat and Razum 2014; Hsieh 2015; Kikuzawa, Olafsdottir, and Pescosolido 2008; McCoy 2016; Olafsdottir and Beckfeld 2011; Stevens 2016). In this chapter, the focus is on modern forms of socialized health care common to Canada, the United Kingdom, and Sweden, followed by an examination of decentralized national health programs in Japan, Germany, and Mexico, and changes in the former socialist systems of Russia and China. Te value of studying the health care delivery systems of diferent countries is the insight provided into the norms, values, culture, and national outlook of those societ- ies, as well as the lessons learned from their experiences. Health care delivery systems worldwide are faced with the same problem of rising costs, aging populations, dealing with the COVID-19 pandemic, and the requirement to meet their nation’s health needs. However, they difer in the variety of their approach. Such systems do not evolve in a vacuum but refect the social and political philosophy of the country in which they exist. Terefore, social and political values underlie the choices made, the institutions formed, and the levels of funding provided. A nation’s approach to health care is based upon its historical experience, culture, economy, political ideology, social organization, level of education and standard of living, economic resources, and attitudes toward welfare and the role of the state. In Europe, the provision of health services became an important component of government policy in the second half of the nineteenth century. Behind this develop- ment was the desire of various European governments for a healthy population whose productivity could be translated into economic and military power. In some countries, providing national health insurance was also a means to reduce political discontent and the threat of revolution from the working class. Compulsory health insurance was usually part of a larger program of social insurance intended to protect the income of workers when sick, disabled, unemployed, or elderly. Initially, protection was provided only to wage earners below a certain income level, but gradually benefts were extended to all or most of the population. Germany established the frst national health insurance program in 1883, followed by Austria in 1888 and other European countries over the course of the twentieth century. Entitlements based on citizenship are aimed at providing people with welfare and health benefts regardless of their class position. Te social welfare systems of Europe are  CHAPTER 17  Global Health Care 407 more advanced in this direction than in the United States. Many Europeans receive comprehensive health insurance; protection of lost income due to illness, injury, or unemployment; and allowances to supplement family expenses for the maintenance of children, such as clothing and school lunches. Tese benefts are provided to all citizens, the afuent and the nonafuent alike. Te result is that European govern- ments are typically responsible for the delivery of health care and most of its fnanc- ing. For example, over 80 percent of all health costs in the European Union (EU) are fnanced from public sources, either through national health insurance programs or direct payments by the state. As Elyas Bakhtiari and his colleagues (Bakhtiari, Olaf- sdottir, and Beckfeld 2018:249) point out: “Te welfare state is arguably the most infuential and important institutional arrangement when it comes to understanding the causes and consequences of social inequality.” It was not until 1965 and the passage of Medicare and Medicaid that the United States provided health care benefts for some Americans: the aged and the poor. When European governments were introducing social insurance programs, the U.S. government was not deeply involved in regulating either the economy or health care. Although this has changed, Americans have historically been less com- mitted to government welfare programs and more in favor of private enterprise in dealing with economic and social problems. However, except for the elderly, participation in the welfare system is still not considered normative in the United States, and those Americans under the age of 65 who do receive welfare benefts tend to be stigmatized and have low social status. In Europe, providing welfare and social security for the general population, not just the poor and elderly, is a normal feature of the state’s role. Tis situation implies a fundamental difer- ence in the social values of Americans and Europeans, with Americans stressing individualism and Europeans viewing government in a more paternalistic and collective fashion. Te United States spends more on health than any other country in the world. Most advanced countries spend between 10 and 12 percent of their gross domestic product (GDP) on health; the United States, however, spent 17.7 percent of its GDP on health in 2019. Te United States clearly leads the world in health care spending because its costs for care are the most expensive anywhere. For example, in 2020, a hip replacement operation in the United States could cost $29,067; the same hip replacement in Spain would be $6,757. A month’s supply of the drug Avastin to fght certain cancers would cost $3,930, while in the UK it would cost $470. Americans or their insurance providers literally pay more for everything—doctors’ fees, labora- tory tests, childbirths, surgery, hospital charges, emergency room visits, prescription drugs, nursing care, and so on. Yet, on the two most common measures of a country’s overall level of health—infant mortality and life expectancy—the United States does not rank especially high. As shown in Table 17.1, Japan had the lowest infant mortality rate in the world at 2.0 deaths per 1,000 live births in 2018, which is the most recent year verifed comparative data are available as this book is being published. 408 PART IV  Health Care Delivery Systems TABLE 17.1 Infant Mortality Rates, Selected Countries, 1990 and 2018. Infant deaths per 1,000 live births Country 1990 2018 Japan 4.6 2.0 Finland 5.6 2.5 Norway 6.9 2.5 Sweden 6.0 2.6 Czech Republic 10.8 2.6 Italy 8.1 3.2 Greece 9.7 4.5 South Korea – 3.0 Austria 7.8 3.4 Spain 7.6 3.3 Germany 7.0 3.4 Australia 8.2 4.2 Portugal 10.9 2.6 France 7.3 3.2 Ireland 8.2 3.6 Israel 9.9 3.4 Switzerland 6.8 3.6 Netherlands 7.1 3.5 United Kingdom 7.9 4.2 New Zealand 8.4 4.4 Poland 19.4 4.4 Canada 6.8 4.5 Hungary 14.8. 4.8 Slovak Republic 12.0 5.0 United States 9.2 5.7 Chile 16.0 6.4 Russia 26.9 6.7 Mexico – 11.3 China 50.2* 11.8 Turkey 51.5 16.9 * Infant mortality rate for China is for 1991. Sources: Various (National Center for Health Statistics, U.S. Census, Statistics Canada, World Health Organization, and World Bank).  CHAPTER 17  Global Health Care 409 Finland and Norway were next, with a rate of 2.5 infant deaths per 1,000 live births. Te United States was 25th among the 30 countries in Table 17.1, with an infant mor- tality in 2018 of 5.7 per 1,000 live births. Poland, Hungary, New Zealand, and the Slo- vak Republic all had lower rates of infant mortality than the United States. Te United States ranked 32nd in infant mortality that year among all countries with populations of over fve million and 52nd among all countries in the world. Te country with the highest infant mortality in the world was Afghanistan, at 108.5 deaths per 1,000 live births, followed by Somalia (93.0), South Sudan (90.4), and the Central African Republic (84.3). As for life expectancy, perhaps the best overall single measure of a nation’s health, Table 17.2 shows that Italy had the highest life expectancy for males at 81.7 years in 2018. Next are Singapore, Australia, and Iceland. Te United States ranked 27th in male life expectancy, at 76.3 years, among the 30 countries listed. Table 17.2 indicates that males in Chile, Costa Rica, and the Czech Republic lived longer on average than their American counterparts. For females, Table 17.2 shows Japan with the highest life expectancy at 87.5 years for 2018. Spain was next at 86.1 years, followed by Sin- gapore and South Korea. Te United States is shown in Table 17.2 to have a female life expectancy of 81.4 years, which is 30th. Tese rankings are all pre-pandemic, and life expectancies will be lower for most countries when the results of COVID-19 are factored into tabulations for 2020 and immediately thereafer. TABLE 17.2 Life Expectancy at Birth, According to Sex, Selected Countries, 2018. Males Females Country Life Expectancy in Years Country Life Expectancy in Years Italy 81.7 Japan 87.5 Singapore 81.5 Spain 86.1 Australia 81.3 Singapore 85.8 Iceland 81.3 South Korea 85.8 Israel 81.1 Italy 85.5 Japan 81.1 France 85.4 Switzerland 81.1 Switzerland 85.3 Sweden 80.9 Australia 85.3 Spain 80.7 Portugal 84.7 Ireland 80.4 Finland 84.6 Netherlands 80.4 Greece 84.5 New Zealand 80.4 Iceland 84.4 Canada 80.3 Israel 84.4 Norway 80.3 Sweden 84.4 (Continued) 410 PART IV  Health Care Delivery Systems TABLE 17.2 (Continued) Males Females Country Life Expectancy in Years Country Life Expectancy in Years South Korea 79.7 Canada 84.3 France 79.6 Norway 84.3 Greece 79.6 New Zealand 83.9 United Kingdom 79.5 Belgium 83.8 Belgium 79.1 Austria 83.8 Austria 79.0 Netherlands 83.8 Finland 78.9 Ireland 83.7 Germany 78.8 Germany 83.6 Portugal 78.8 United Kingdom 83.0 Denmark 77.8 Denmark 82.8 Chile 77.6 Estonia 82.8 Costa Rica 77.5 Costa Rica 82.7 Czech Republic 76.6 Chile 82.4 United States 76.3 Poland 82.4 Turkey 75.6 Czech Republic 81.8 Poland 74.6 United States 81.4 Source: United Nations Development Programme, 2019. Socialized Medicine: Canada, Britain, and Sweden A summary of the key features of fee-for-service, socialized medicine, decentralized national health, and socialist systems are shown in Table 17.3. Te fee-for-service model was examined in Chapter 16 on the United States. In this section, socialized medicine will be discussed. Socialized medicine refers to a system of health care delivery in which health care is provided in the form of a state-supported consumer service. Tat is, health care is purchased, but the buyer is the government, which makes the services available at little or no additional cost to the consumer. Tere are several diferent forms of socialized medicine, and the types that exist in Canada, Britain, and Sweden will be reviewed. Despite some diferences between countries, what is common to all systems of socialized medicine, as shown in Table 17.3, is that the government (1) directly controls the fnancing and organization of health service in a capitalist economy, (2) directly pays providers, (3) owns most of the facilities (Canada is an exception), (4) guarantees equal access to the general population, and (5) allows some private care for patients willing to be responsible for their own expenses.  CHAPTER 17  Global Health Care 411 TABLE 17.3 The Role of Government and Types of Health Care Delivery Systems. Types of Systems Role of Government Fee-for-Service Socialized Decentralized Socialist Medicine National Health Medicine Regulation Limited Direct Indirect Direct Payments to providers Limited Direct Indirect Direct Ownership of facilities Private and public Private and public Private and public Public Public access Not guaranteed Guaranteed Guaranteed Guaranteed Private care Dominant Limited Limited Unavailable Canada Te Canadian system of health care delivery is of particular interest to Americans because it is ofen discussed as a future model for the United States. Like the United States, physicians in Canada are generally private, self-employed, fee-for-service prac- titioners. Unlike the United States, doctors’ fees are paid by government-sponsored national health insurance, known as Medicare, according to a fee schedule negoti- ated between the provincial or territorial governments and the medical association. Most hospitals also operate on a budget negotiated with government ofcials at the provincial or territorial level. Tus, Canada does not have a single health care delivery system but ten provincial and three territorial ones. Te federal government, how- ever, infuences health policy and the delivery of care through fscal and budgetary mechanisms, so the Canadian system is not as decentralized as that of Germany or France, where central governments exercise little direct control over health matters. Canada essentially has a private system of health care delivery paid for almost entirely by public money. Te publicly fnanced health care system is supported by taxes and premiums collected by the federal and provincial/territorial governments. Responsibility for providing health care rests with each province or territory, with federal government supplementary funds. Virtually every Canadian has comprehensive insurance cover- age for hospital and doctor expenses. Dental care, prescription drugs for persons under age 65, ambulance services, private hospital rooms, and eyeglasses are not covered. Canada was late in adopting its version of socialized medicine. Universal hospital insurance was not provided until 1961, and coverage for physician fees was not passed until 1971, over the opposition of doctors. Prior to this period, Canadians paid their medical and hospital bills in a variety of ways: direct payments by patients, private health insurance, and municipal government payments. Te health profle of Canadi- ans with respect to infant mortality and life expectancy is better than for Americans. 412 PART IV  Health Care Delivery Systems Table 17.1 shows that Canadians had a lower rate of infant mortality than Americans in 2018 (4.5 as compared to 5.7 deaths in the United States per 1,000 live births). Table 17.2 shows that Canadian males had a life expectancy of 80.3 years in 2018 compared to 76.3 years for American males. Canadian females had a life expectancy of 84.3 years compared to 81.4 years for American females. Like the United States and virtually all other countries, Canada has a social gradient in health and life expectancy, with Canadians at the bottom of the class structure being less healthy and living less longer lives than those at the top (Bolaria and Dickinson 2009; Segall and Fries 2017). Universal health insurance coverage in Canada has reduced social disparities in health but has not eliminated them (Martin et al. 2018). Te major problem facing Canada with respect to health care delivery is, as in most other major countries, one of rising costs. Te percent of GDP spent on health in 2018 was 10.8 percent. In 1977, the federal government had realized it had no control over spending and enacted Bill C-37, which limited federal contributions to national health insurance and made them independent of provincial health spending. Federal income and corporate taxes were also reduced, thereby giving the provinces room to increase their taxes to balance spending without increasing the overall tax rate. Federal taxes went down, but provincial taxes went up, and taxation in general stayed at about the same level. Until 2004, the federal government paid about 24 percent of health care costs, the provinces/territories 44 percent, private spending 30 percent, local governments 1 percent, and worker’s compensation 1 percent. At that time, these levels changed under the Canada Health Transfer (CHT) program, with the federal government agreeing to send an additional $14 billion in federal money over the next six years to the provinces and territories for health care, with guarantees of 6 percent annual increases until 2015–2016 and 3 percent increases for 2017–2020. Tis agreement to increase federal contributions helped equalize the budget allotments for all levels of government by bringing more federal money into the health care system. Federal and provincial/territorial spending levels became similar, and now they represent over 70 percent of all health care funding combined. Te new monies were necessary to ofset the country’s growing problems in the health sector, including an increasing shortage of doctors and nurses, lengthy waits for cancer care and surgery, and mounting costs for drugs for an aging population. Te private market for health is also growing in Canada, with the emergence of private clinics that accept both public and private health insurance. Canada’s private health insurance, usually provided by employers, supplements public benefts with coverage for private or semiprivate hospital rooms, prescription drugs, dental and vision care, and other services. In 1984, the Canada Health Act was passed, reafrming the principle of universal access to health care, and imposed penalties on provinces that allowed physicians to charge patients fees above government limits. By 1987, all provinces had banned extra billing by doctors. However, while Canadian health care is essentially free at the point of service in that patients never see a bill, it is not free for the taxpayer. Canadians pay 15 to 20 percent more in income tax than Americans, with the result that some of the afuent pay over half of their income in taxes. Quebec, for example, has the highest income tax, and persons in the highest tax bracket pay  CHAPTER 17  Global Health Care 413 58.7 percent of their income in taxes. Canadians also pay a sales tax (value added tax) of about 15 percent on their purchases. Canadian physicians, like their American counterparts, are part of a profession that has become subject to increased government regulation. In the mid-1980s, there were some protests and expressions of discontent among physicians about having their fees set by government agencies instead of themselves, but the government’s position remained unchanged. Since then, there has been little or no confict between the government and the medical profession. Most Canadian physicians today appear to have accepted the government’s payment system. Virtually all Canadian doctors participate in provincial health plans and have no other major source of payment for most medical procedures. A signifcant change in Canada’s public health care delivery system occurred when the Supreme Court ruled in 2005 that Quebec’s ban on private health insurance was unconstitutional. Te court held that the prohibition on private health insurance is not constitutional when the public system fails to deliver reason- able services. Quebec, for example, allows patients to be treated in private hospitals when they cannot be treated within six months in the public system. Canadians appear to prefer their health care system, especially in contrast to the American model. Major reasons for the greater satisfaction of Canadians with their health care delivery system are its quality and lower cost. Canadian patients pay virtu- ally nothing directly to doctors and hospitals. Rather, the provincial governments are the nation’s purchasers of health services, paying a set fee to doctors for patient care and providing a set budget for operating costs to hospitals. Canadian hospitals, unlike American hospitals, cannot make more money by providing more services. Te essen- tial diference between the United States and Canada in health spending is that the Canadian system combines universal comprehensive coverage for the population with cost controls. Since the government buys essentially all the care provided, it has the leverage to control the costs of that care. Drawbacks to the Canadian system include (1) long waits for elective procedures; (2) inequitable access to services, especially by indigenous (First Nation) populations such as the Inuit; and (3) health dispari- ties among indigenous people (Martin et al. 2018) Canada is also the only advanced country with a national health care system whose health coverage does not include prescription drugs. Also, Canada’s population is aging, so fewer people will be work- ing and paying taxes to support the health care system. At the same time, demands on the system will be increasing because older people need more care. Canada, like other countries, faces major challenges in maintaining the quality of its health care. Its health care system treated 1.4 million confrmed cases of COVID-19 by summer 2021 and the country experienced over 26,000 deaths. Britain Britain had inaugurated a national health insurance program between 1911 and 1913, but it provided limited benefts and covered only manual laborers. In 1948 the British government went much further and formed the National Health Service (NHS) by nationalizing and taking over the responsibility for the country’s health care. In such circumstances, the government becomes the employer for health workers, maintains 414 PART IV  Health Care Delivery Systems facilities, and purchases supplies and new equipment through the use of funds collected largely by taxation and allocated by Parliament. Health services are provided at no cost to those who use them. Te NHS is the world’s ffh largest employer with 1.2 million employees in 2019. It is also the largest publicly funded health service in the world. Although Germany was the frst country to enact national health insurance, Britain established the frst health care system in any Western society to ofer free medical care to the entire population. Prior to 1948, the quality of care one received in Britain clearly depended on one’s fnancial resources, with the poor sufering from a decidedly adverse situation. Te Labour Party, which was in power afer World War II, wanted to ensure that everyone would receive medical treatment free of charge. To accomplish this purpose, the government had to take over privately owned medical facilities. Te National Health Service Act of 1948 reorganized health care delivery in the United Kingdom under the single umbrella of the NHS. Tis organizational structure changed in 1999, with the political separation of the NHS into separate semi-autonomous health services for England, Wales, Scotland, and Northern Ireland (Gabe 2021; Hughes and Vincent-Jones 2008). Te frst line of medical care in Britain remains that of the general practitioner (GP), who works from an ofce or clinic as part of either a solo or group practice. GPs are paid an annual capitation fee for each patient on their patient list, as part of a contractual arrangement with their NHS. Te average number of patients on a GP’s list is about 2,000. With special permission, a GP who is a solo practitioner may have a list with up to 3,500 patients. Group practices can have even larger patient lists, depending on the number of doctors involved. Te GP is required to provide medical services free of charge. Te patient (if over the age of 16) has the right to select his or her doctor, and the doctor is free to accept or reject anyone as a full-time patient. But if a potential patient is rejected from joining a doctor’s list, the doctor must still provide treatment if the person is not on any other physician’s list or if the person’s physician is absent. A higher capitation fee is paid for patients who are 65 years of age or older, and additional sums are paid by the government to meet certain basic ofce expenses, to join a group practice, for additional training, for seniority, and for practicing medicine in areas that are underserved by physicians. Except for emergencies, if treatment by a specialist (called a “consultant” in the Brit- ish system) or hospitalization is warranted, the GP must refer the patient to a specialist. Generally, specialists are the only physicians who treat patients in hospitals, and they are paid a salary by the government. About 11 percent of the total funds to support the NHS are derived from payroll deductions and employer’s contributions, thus most of the revenue comes from general taxation. Te average worker pays about 9 percent of his or her earnings for national health insurance, which is matched by employers. Because of strong opposition from physicians when the NHS was frst organized, physicians are also allowed to treat private patients, and a certain number of hospital beds (“pay” beds) are reserved for this type of patient. Private patients are respon- sible for paying their own bills, and most of them have health insurance from private insurance companies. Te advantage of being a private patient is less time spent in waiting rooms and obtaining appointments and, of course, more privacy. In addition to the medical care provided by the NHS, the British have a sickness beneft fund to  CHAPTER 17  Global Health Care 415 supplement income while a person is sick or injured, death benefts paid to survivors, and maternity benefts. Te British Medical Association (BMA) had initially opposed both the enactment of national health insurance between 1911 and 1913 and the formation of the NHS afer World War II. However, each became law as the government was determined to institute the programs, and enough inducements were ofered to physicians to reduce the strength of their opposition. In the face of strong government determination and skillful politics by the prime ministers of that time (Herbert Asquith in 1911 and Clement Attlee in 1946), the BMA was rendered inefective. Both prime ministers managed to divide the loyalties of the BMA. Attlee, for example, refused to be drawn into lengthy negotiations with the BMA but provided concessions to teaching hospitals and consultants (specialists) and permitted the treatment of private patients in state hospitals to gain the support of many in the medical establishment. It also became increasingly clear to the medical profession that the government was going to turn the measure into law, either with or without the support of the BMA. In the end, the BMA became a partner with the government in instituting changes. Initially, the NHS was marked by controversy and subjected to criticism. Te mode of capitation payments to GPs meant that the more patients seen by a physician, the more money the physician was able to make. Hence, there was a serious concern and some evidence that medical care was being provided in quantity rather than quality. A measure was introduced to pay physicians less for treating more patients, but as the population increased, the doctors found it difcult to reduce their patient load. Also, the govern- ment and physicians have disputed the amount paid for capitation fees, with the physi- cians arguing that it is not enough. Disputes have likewise taken place between GPs and consultants (specialists). Consultants have higher prestige and draw higher incomes, and GPs have claimed that the NHS favors consultants, not only with regard to income but also to fringe benefts (vacations, retirement, and so on), while demanding that politi- cians and government administrators be more sensitive to their needs. Consequently, confict and problems concerning health care delivery in Britain are largely between health care providers and the government. Tere is little direct involvement by the public. It is the state’s role to act as the protector of patients’ rights and interests, but only in the last few years have there been channels for the public to voice its concerns directly. Te central problem faced by the NHS is its lack of fnan- cial resources. Although the British have a relatively high standard of living, there are large pockets of poverty. Moreover, the NHS has worked hard to hold down medical costs, with 9.8 percent of Britain’s GDP spent on health care in 2018. Tis matches the 2018 European Union average for health expenditures. Tough relatively successful in combating rising expenses, this policy has had its drawbacks. British doctors and nurses, on average, are not paid exceptionally high salaries. Occasionally they go on strike to bargain for more pay. Many doctors, especially consultants, do a considerable amount of private practice work to increase their income. British patients became increasingly dissatisfed with waiting for long periods of time in doctors’ ofces and for appointments to see them. Tere were also long delays in obtaining elective surgery and criticism about low stafng levels in hospitals. To improve the situation, the British government, led by Prime Minister Margaret 416 PART IV  Health Care Delivery Systems Tatcher, initiated reforms in the 1990s intended to create a competitive “internal market” within the nation’s health care delivery system. Hospital trusts were estab- lished that allowed large hospitals to be self-governing and to fnance themselves by contracting directly with local health districts (Gabe 2021). Additionally, GPs in group practices were allowed to establish primary care trusts to purchase services from hos- pitals for their patients. Tis arrangement changed, however, in 2013, when Prime Minister David Cam- eron initiated new reforms in which primary care trusts were abolished and replaced with local foundation trusts and clinical commissioning groups (CCGs) to make decisions about patient services and how to pay for them. Te Health and Social Care Act of 2012 invested Healthwatch England with statutory powers in its jurisdiction to monitor the quality of health care on behalf of consumers. It also authorized greater competition among providers based on their prices, allowed greater participation of private sector providers in health care delivery, and instituted legal requirements to reduce health inequalities. Additionally, the Equality Act of 2010 made it unlawful to discriminate within the NHS. Furthermore, hospitals providing services to private patients are allowed to make a proft from those services instead of providing them at cost. Hospitals are also allowed to market their services to make them more attractive to private patients, and NHS patients can be admitted by their doctors to the best hospitals available—not just those in their district. Tese measures were intended by the government to improve efciency, reduce delays in receiving treatment, and assist doctors and hospitals to increase their incomes by attracting more patients. Although these measures signi- fed the application of free-market methods to a state-fnanced system, the principle of state-sponsored health care remained in place. In addition to reforming the health care marketplace, a Patient’s Charter was provided that assured patients of ten basic rights, including the right to receive care; be referred to a consultant, if necessary; be given a clear explanation of treatment; have access to health records, and have the confdentiality of those records maintained; receive detailed information on local health services; be guaranteed admission to treatment by a specifc date; and have any complaints about the NHS investigated. Although reforms have been found necessary, the NHS has accomplished what it set out to do: provide free, comprehensive medical care to the residents of the United Kingdom. Te extent to which the NHS will be afected by Britain’s departure from the European Union at the end of 2020 is unknown at present. To date, the NHS has shown signifcant results. Te general health profle of Britain is among the best in the world. Tables 17.1 and 17.2 show, for example, that the infant mortality rates for the United Kingdom are lower than in the United States, while life expectancies for males and females are higher. On balance, health care is of a high quality despite problems, and particular success has been achieved against heart disease. Yet signifcant inequali- ties in health remain between social classes (Bartley 2017; Bradby 2012; Marmot 2004, 2015). Poor health among the lower classes in Britain, however, is due more to the unhealthy lifestyles and living environment associated with poverty rather than a lack of access to quality health care (Atkinson 2015). Te United Kingdom was particularly impacted by the COVID-19 pandemic. Te pandemic was a major challenge for the NHS, as hospitals in many parts of the country  CHAPTER 17  Global Health Care 417 were flled to overfowing. Figures available for summer 2021 show there were over 4.5 million cases in the UK, especially in England (2.9 million), with over 128,000 deaths for the country as a whole—the highest of any country in Europe. Making the situation worse was the emergence of a strain of the coronavirus in Britain that was not more deadly but exceedingly more contagious. Te UK went into additional lockdowns in 2021 and was the frst country to give emergency approval to the Oxford-AstraZeneca vaccine. Te strategy was to vaccinate as many people as quickly as possible with a frst dose to delay or stop the spread of the disease and wait for resupplies to give second doses 12 weeks later. Te UK was far more successful in rapidly vaccinating its popula- tion than the European Union, which was slow in ordering vaccines, keeping them in supply, and distributing them to member states. Sweden Sweden, along with Britain, has demonstrated that a socialized system of health care delivery can be efective in a capitalist country through the formation of a national health service. Te Swedish National Health Service is fnanced through taxation. Taxes in Sweden have typically been the highest in the world. Tax reform in 1991 reduced the highest income tax rate from 72 to 51 percent, but the top tax bracket was increased to 56 percent in 1995 and 61.4 in 1996. Swedish tax rates in 2020 show the lowest tax bracket is 51.1 percent and the highest remains at 61.4 percent of one’s income. Although taxes are high, welfare benefts are generous. In fact, Sweden is one of the world’s most egalitarian countries when it comes to the provision of welfare benefts to the general population, and inequities in living conditions have been reduced to a level that is more equal than in most other countries. Universal health insurance, old-age pensions, unemployment insurance, and job-retraining programs protect employed Swedes and their families from serious concern about being pushed into poverty by poor health, old age, and unemployment. Tere are social class diferences in health in Sweden, with the lower class showing a less positive health profle than more afuent Swedes, but the diference is much less pronounced than elsewhere (Burström 2012; Leopold 2016). Sweden, along with the other Nordic countries, has the lowest propor- tion of poor people in Europe. On virtually every measure, the Swedes must be considered one of the world’s healthiest populations overall. As shown in Table 17.1, Sweden has one of the lowest infant mortality rates in the world (2.6 deaths per 1,000 live births) in 2018. Table 17.2 shows that Sweden has high life expectancy for males (80.9 years) and females (84.4 years). Sweden spent 11.0 percent of its GDP on health in 2018. Te Swedish National Health Service is the responsibility of the Ministry of Health and Social Afairs. Only particularly important health issues are decided by the min- istry. Most decisions pertaining to health policy are made by the National Board of Health and Welfare. Tis board plans, supervises, and regulates the delivery of health services at the county level. Physicians are employed by county councils and are paid according to the number of hours worked rather than the number of patients treated. Physicians are obligated to work a fxed number of hours per week, usually about 40 to 42. It is generally lef up to the doctor to decide what percentage of his or her time 418 PART IV  Health Care Delivery Systems is to be spent on treating patients, doing research, or teaching. Physicians’ salaries are standardized by specialty, place and region of work, and seniority. A major characteristic of the NHS in Sweden is that general hospitals are owned by county and municipal governments. Tese local governments are responsible for maintaining and providing services. Te state pays the general hospitals a relatively small amount of money from a health insurance fund, leaving the balance to be paid from local tax revenues. Enrollment in the government-sponsored health insurance program is mandatory for the entire population. Most of the money to support the insurance program comes from the contributions of employers and payroll deductions of employees. Tis insurance, a form of national health insurance, is used primarily to pay the salaries of physicians and other health workers. Tere are also some general practitioners in private practice whose fees are paid by the insurance fund and token payments from patients. Fees for all physicians, however, are set by the government and paid according to their schedule. Te Swedish health care system has some additional benefts other than generally free medical treatment. Beginning in 2010, Swedes were able to choose whether they wish to be treated in either a public or private medical facility at state expense. Tey can be treated almost anywhere in the country they wish. Sweden introduced a health guarantee in 2005 that patients would not have to wait more than seven days for a doc- tor’s appointment or 90 days to see a specialist or have an operation. Excessive travel expenses to visit physicians and hospitals are paid by the government, and there is a cash sickness fund designed to protect a person’s standard of living against losses of income because of illness or injury. Under this program, people may receive up to 80 percent of the income they would be earning if they were able to work at their job. BOX 17.1 National Health Insurance in Rwanda The African country of Rwanda, with a popula- and there are very few specialists such as neu- tion of 11.5 million people, is one of the poorest rosurgeons and cardiologists. The $6 annual fee countries in the world, but it has national health and co-payment cannot really cover the cost of insurance. The Rwandan health insurance pro- care, even in Rwanda, but over half of the cost gram covers 92 percent of the population and is paid by foreign donors, especially the United originally cost $2 a year. Recently the cost was States. The poorest of the poor have their pre- $6 annually, with a $10 per visit co-pay. Since the miums paid by organizations, such as the Global insurance program was established in 1999, life Fund to Fight AIDS, because many people cannot expectancy has risen for the country as a whole afford to pay even $6. A complaint, however, is from 48 years to 68.7 years in 2018. The plan that some people do not like to pay in advance provides basic coverage in a country where CT for something they may not use and want their scans and kidney dialysis are usually unavailable, $6 refunded if they don’t get sick.  CHAPTER 17  Global Health Care 419 Drugs are either free or inexpensive, and fnancial supplements are paid to each woman giving birth to a child and to families with children under the age of 16, regard- less of the family’s income. Tus, it would be somewhat misleading to consider the funding of Sweden’s health care delivery system as an example of national health insurance, because most of the revenues come from county councils. Te total health bill in Sweden is met by con- tributions of 71 percent from county taxes, 16 percent from the national government, 10 percent from the health insurance system and other sources, and 3 percent from patient fees. Te county councils introduced a fnancial system of payments to hos- pitals in 1994 based on the actual number of patients treated instead of a traditional fxed annual budget, and competition between hospitals was allowed with the goal of improving quality and lowering costs. Consequently, Sweden, like the United King- dom, has moved toward a purchaser-provider model within its own government-run health system and has maintained this approach. Sweden remains committed to universal and equal access to health services paid by public funding. County councils have been directed by the national legislature to remain responsible for health care delivery but pass the responsibility for nursing homes to municipalities and transfer part of their budgets to local health districts. Tis measure will allow the districts to purchase services from diferent primary care cen- ters and hospitals, a development intended to promote competition between providers and greater freedom of choice for patients. Tese changes in Sweden’s health services are not extreme. Instead, they are intended to improve a highly successful system by introducing limited aspects of a free market. Sweden took a diferent approach to the COVID-19 pandemic. It did not have a complete lockdown, as discussed in Chapter 3. Sweden closed its high schools and colleges, but not its elementary schools, bars, and restaurants. Te wearing of masks was not required. Sweden had a history of individual responsibility and adopted this approach, making recommendations to the public rather than issuing orders. Since there was a strong sense of individual responsibility, a trusting culture, and an institu- tional structure in which local and regional governments were relatively autonomous in providing health care, Sweden had a “sof” lockdown” (Pierre 2020). A surge of the virus in late fall, however, suggested fault with the strategy. Even though Sweden did not experience the intensity of the outbreaks seen in Italy, Spain, and Britain, it did have over 1 million cases and more than 14,000 deaths by summer 2021. Denmark had only 2,500 deaths, with Norway and Finland having just a few hundred. Consequently, Sweden’s mortality from COVID-19 was exceptionally high for Scandinavia but far less than Britain, France, Spain, Italy, and Germany. Decentralized National Health Programs: Japan, Germany, and Mexico Decentralized national health programs difer from systems of socialized medicine in that government control and management of health care delivery is more indirect. Te government acts primarily to regulate the system, not operate it. Ofen the government 420 PART IV  Health Care Delivery Systems functions in the role of a third party, mediating and coordinating health care delivery between providers and the organizations involved in the fnancing of services. In decentralized national health programs, the government (1) indirectly controls the fnancing and organization of health services in a capitalist economy, (2) regulates payments to providers, (3) owns some of the facilities, (4) guarantees equal access to the general population, and (5) allows some private care for patients willing to be responsible for their own expenses. In this section, the decentralized national health care systems in Japan, Germany, and Mexico will be discussed. Japan Japan spends 10.9 percent of its GDP on health care (more than half of that of the United States), but the Japanese have achieved striking results over the last 65 years. For example, in 1955, the average life expectancy of a Japanese person was more than four years less than that of an American. By 1967, Japan’s life expectancy had passed that of the United States and, as shown in Table 17.1, is one of the highest in the world for males (81.1 years) and females (85.5 years) as of 2018. Japanese rates for infant mortality (Table 17.2) are the lowest in the world (2.0 per 1,000 live births in 2018). Japan has a national health insurance plan, introduced in 1961, but its benefts are relatively low by Western standards. Japanese patients pay 30 percent of the cost of health services, with the national plan paying the remainder. However, patients are reimbursed by the plan for expenses over 80,100 yen (about $773) for medical care during any given month; low-income patients are reimbursed for amounts spent over 35,400 yen (about $342) monthly. People over 70 years of age have all of their costs covered. Patients are allowed to choose their own doctors and encouraged to visit them regularly, and these policies more than likely promote the longevity of the Japanese because health problems can be diagnosed during early stages. Under a national law efective in 2008, companies and local governments are required to have the waistlines measured of persons under their jurisdiction between the ages of 40 and 74 years dur- ing their annual physical. Persons exceeding Japanese government limits of 33.5 inch waists for men and 35.4 inches for women are given guidance for dieting and time periods for weight loss. Employers whose employees fail to meet weight-reduction goals are required to pay nearly 10 percent higher payments into the national health insurance program. Tis can be the equivalent of millions of dollars for large corpora- tions. Tere is no penalty for individuals. About one-third of Japanese doctors are in private practice and are paid on a fee- for-service basis. All the rest are full-time salaried employees of hospitals. Physicians not on a hospital staf cannot treat their patients once they are hospitalized. Physi- cian fees for ofce visits and examinations are low because the government sets fees. Regardless of seniority or geographical area, all Japanese doctors in private practice are paid the same amount for the same procedures, according to the government’s uniform fee schedule. Fee revisions are negotiated by the Central Social Medical Care Council in the Ministry of Health and Welfare, comprising eight providers (doctors, dentists, and a pharmacist), eight payers (four insurers, two from the government, and two from management and labor), and four who represent public interests (three  CHAPTER 17  Global Health Care 421 economists and a lawyer). However, any changes in fees are ultimately decided by the Ministry of Finance because government subsidies must be kept within general budgetary limits. In efect, the government virtually determines fees for doctors and hospitals. Hospital costs tend to be low because the government refuses to pay high costs in that area as well. Te government fee schedule is the primary mechanism for cost containment. Pro- viders are prohibited by law from charging more than the schedule allows. Japanese doctors do receive a substantial supplementary income from the drugs they prescribe (25 percent or more of the price of the drug). Not surprisingly, the Japanese have a high rate of prescription drug use. Private practitioners in Japan earn signifcantly more (about four times as much) than hospital-based doctors. Te Japanese national health insurance plan does not cover all Japanese. Instead, the government encouraged private organizations to keep government involvement at a minimum by setting up their own welfare benefts. Part of the normative structure of the Japanese business world is that companies are responsible for taking care of their employees. In Japan, this responsibility includes providing retirement plans, helping retired employees fnd postretirement work, arranging vacations, ofering low-cost loans for housing, and providing medical care. Consequently, there are separate pro- grams of health services for employees of large companies, small and medium-sized companies, and public and quasi-public institutions. Some large companies employ doctors and own hospitals. Tere is also a program for citizens who are not covered under other plans. Consequently, the entire Japanese population is covered by some type of health insurance plan (Anesaki and Munakata 2005; Ikegami et al. 2011). Te concept of having a decentralized system of health care based largely on occu- pation is supported by Japanese businessmen, who generally provide more benefts than are required by law. Business leaders oppose a heavy welfare burden for the gov- ernment, as they want to pay less in taxes and avoid the governmental administrative overhead required for a large public welfare system. Te tax burdens in welfare states such as Sweden and Britain are undesirable, as is the income-based welfare system in the United States. Also important is the desire of Japanese businesses to provide security to their employees in exchange for employee loyalty and productivity. Tis policy gives large Japanese corporations an advantage in attracting workers because of the greater beneft packages they can ofer. As a result, some Japanese have better health care benefts than others, although the overall provision of health benefts in Japan is highly equitable. Japanese lifestyles and the country’s high standard of living have undoubtedly contributed to the overall level of good health and longevity, while the provision of universal health insurance coverage without rationing care is a major achievement. While no health system can be perfect because demands can easily exceed resources, the Japanese have established one of the most efcient health care systems in the world: it is relatively low-cost, efective, and equitable. However, there are problems. About 80 percent of all Japanese hospitals are privately owned by physicians, but many facilities are old and lack space. Because the Japanese government limits how much they can charge, Japanese hospitals are ofen required to admit more and more patients in order to meet their expenses. Overcrowding has 422 PART IV  Health Care Delivery Systems therefore become common in most hospitals. Te average length of hospitalization in Japan is also longer than in the West. Hospital administrators complain that it is difcult to fnance updated facilities or hire additional personnel without increases in the amounts charged to patients. Tere are typically long waits at doctors’ ofces and clinics as well because Japanese physicians do not use an appointment system. Basically, it is a case of frst come, frst served, and some patients begin lining up outside the doctor’s ofce before it opens. Furthermore, relationships between doctors and patients in Japan tend to be more impersonal than in the United States. Patients may be told few details about their diagnosis, the reason for the treatment prescribed, or the types of drugs being admin- istered. Te doctor–patient relationship is based on trust and the traditional Japanese cultural value of deference to authority. Informed consent by the individual patient, common in the United States, is seen in Japan as “unrealistic” in a society that values making choices together with others as part of a group (Sullivan 2017:164). Being presented with options and then being asked by the physician to make a choice is something that is unfamiliar in the typical doctor–patient relationship. Physicians do not want to abandon patients to making their own choices about treatments, while a patient requesting information directly would be seen as questioning the physician’s authority, judgment, and knowledge. Terefore, patients are to rely on what doctors tell them. Te Japanese medical profession is highly self-regulated and averse to public scrutiny. Tere are also changes in disease patterns. Heart disease is on the rise and is now the second leading cause of death afer cancer. Historically, Japan has had low mortal- ity rates from heart disease in comparison to Western countries. Tis trend undoubt- edly infuences higher levels of life expectancy among the Japanese, especially among males. Te traditional low-fat, low-protein, and high-carbohydrate Japanese diet of fsh, rice, and green vegetables is a major factor in this situation (Cockerham, Hat- tori, and Yamori 2000). Also, the stress-reducing aspects of Japanese culture, such as strong group solidarity and cooperation in dealing with problems and afer-work socializing by males on a regular basis with close friends in bars or noodle shops, may be important. Tese drinking places are ofen designed to encourage relaxation and allow a temporary escape from tension. Afer-work socializing with co-workers seems to have become a routine activity in the lifestyles of many men in contemporary Japan. Nevertheless, a more Westernized lifestyle and increase in the consumption of animal fats and proteins—associated with Western diets—have promoted more heart disease, along with the stresses of living in a dynamic, hardworking, and densely populated society (Anesaki and Munakata 2005). Research examining socioeconomic diferences in risk behavior for coronary heart disease shows that persons with lower socioeconomic status smoke signifcantly more than those with higher status (Hanibu- chi, Nakaya, and Honjo 2016; Nishi et al. 2004). Alcohol consumption, however, was widespread at both the top and bottom of the social scale. Te shif toward higher fat in Japanese diets has also contributed to a rise in colon and pancreatic cancers, and heavy smoking among Japanese males has led to an increase in mortality rates from lung cancer. Te Japanese also have the highest rates of stomach cancer in the world. Increases in death rates from cancer and heart disease, as well as the highest mortality  CHAPTER 17  Global Health Care 423 rates from stroke of any advanced country, suggest that increases in life expectancy for the Japanese may be slowing down and perhaps reaching a limit. Tese changes, combined with the rapid growth of Japan’s elderly population, are likely to place tremendous pressure on Japan’s health care delivery system in the future. Te proportion of people living to old age is increasing in Japanese society faster than in any other country in the world, and this situation is going to require a signifcant response from Japan’s system of health care delivery. A recent concern is the COVID- 19 pandemic that infected 772,000 persons by summer 2021 and caused over 14,000 deaths. Compared to other advanced countries, the number of deaths in Japan from the coronavirus is relatively low. Germany Te structure of health care delivery in the Federal Republic of Germany has not changed signifcantly since 1883 and the reforms instituted by Bismarck’s administra- tion in imperial Germany. Te program established at that time was based on three principal components: (1) compulsory insurance, (2) free health services, and (3) sick benefts. Employees, self-employed, unemployed, old-age pensioners, and certain cat- egories of domestic workers providing infant and child care, home help, and so on are all required to be insured by one of Germany’s public health insurance organizations (known as sickness funds). Tere are 113 not-for-proft, self-governing sickness funds. Membership in a particular health plan was once determined by occupation or place of employment, but the Health Care Structure Act of 1993 ended this “century-old” classifcation system, equalized benefts between white-collar and blue-collar workers, and authorized competition between the funds (Busse et al. 2018:887). Te Health Care Structure Act was described by Reinhard Busse et al. (2018:887) as “the most important paradigm shif in the history of [Germany’s] statutory health insurance.” Today, anyone can join any plan who can now advertise for members. Germany’s larg- est public health insurance organization is the Allgemeine Ortskrankenkassen (AOK), which insures about half the population. Te AOK originally insured only blue-collar workers but broadened its membership base to include the general population. Bismarck’s welfare measures in the late nineteenth century were both a response to democratization and an attempt to suppress it. Tat is, Bismarck wanted to defuse the demands for political rights from an increasingly well-organized and lefist- oriented working class by providing them with social rights that linked workers to the state rather than to labor unions or socialist political parties. Included in Bismarck’s plan was the frst national health insurance program ever. Regardless of his political motives, Bismarck’s health insurance scheme proved to be durable and efective. Following Germany’s defeat in World War II and the incorporation of its eastern lands into a separate communist state, West Germany became a multiparty republic in 1949. Te Federal Republic’s constitution, the Basic Law, guarantees the social welfare of its citizens, continues the comprehensive social welfare system developed by Bismarck, and now includes the former East Germans afer reunifcation in 1990. Te program that currently exists includes health insurance, old-age pensions, sick- ness benefts for income lost to illness or injury, unemployment insurance, and family 424 PART IV  Health Care Delivery Systems assistance in the form of allowances for children, rent support (especially for the elderly), and public funds for the construction of low-income housing. Te country’s extensive welfare benefts have been found to be protective of the population’s general health (Lersch, Jacob, and Hank 2018). Approximately 88 percent of all Germans participate, involuntarily or voluntarily, in the nation’s public health insurance program. Others (11 percent) are mainly civil servants, who have their own insurance plan, and those who are self-employed or higher-income earners who can choose to take out substitute private insurance or stay in a state plan. Te remaining 1 percent are soldiers, police, and refugees who have special government-sponsored insurance. In the state plan, health care is free to the individual except for small co-payments and covers medical and dental treatment, drugs and medicines, and hospital care as needed. In the event of illness, the employer must continue to pay the employee’s full wages for six weeks, and then the health insur- ance fund provides the individual with his or her approximate take-home pay for up to 78 weeks. If the illness is more protracted, benefts are continued under a welfare plan unless the person is permanently incapacitated and is entitled to a disability pension. About 14.6 percent of a worker’s monthly gross earnings is deducted for health insur- ance, with half paid by the employee and half by the employer. Public health insurance plans are coordinated by the National Federation of Health Insurance. Te insurance plan issues a medical certifcate to members and their depen- dents periodically. Tis certifcate is presented to a physician when services are ren- dered. Te physician then submits the certifcate to his or her association of registered doctors, which all physicians are required to join. Payment is made to the physician through the doctors’ association, according to a fee schedule agreed upon by the asso- ciation and the public health insurance plans. Hospital fees and payments are handled in the same manner. Te Health Care Fund was introduced in 2009 that reallocates revenues to insurance plans according to a risk compensation formula in which funds with higher proportions of elderly, women, and sick persons obtain additional money. As the preceding discussion indicates, the German government does not play a major role in the fnancing of health services. Te government’s primary function is one of administration and regulation. Te Federal Ministry of Labor and Social Afairs exercises general supervision of the health care delivery system through state minis- tries and local health boards. Tis form of health service organization represents a unique contribution by Germany to the provision of health care consisting of (1) com- pulsory membership on the part of the population in a national health plan and (2) a set of institutions situated between the government and its citizens with the authority to manage health care under government auspices (Busse et al. 2018). Approximately 42 percent of Germany’s physicians are general practitioners, which is a high percentage compared to the United States, where GPs are about 12 percent of all physicians. Most German doctors practice medicine in private ofces or clinics on a solo basis. Few work in a group practice, but that may change as outpatient medi- cal centers are expanding throughout the country. German physicians are well paid, earning somewhat more, on average, than American doctors. Te Health Care Reform Act of 1989 helped limit costs by increasing the amounts paid by persons insured vol- untarily in the public health plan, adding a small co-payment for prescription drugs,  CHAPTER 17  Global Health Care 425 establishing price ceilings for most drugs, and other measures. Te Health Structure Act of 1993 mandated price cuts for drugs, lower incomes for doctors and dentists (along with compulsory retirement at age 68), increased co-payments for patients, and limits on hospital budgets. Germans have been able to choose their own public health insurance plan since 1997. Te 2007 Strengthening of Competition in Legal Health Insurance Law made having health insurance mandatory for all Germans and extended insurance options. Since 1995, approximately 10 percent of GDP has been spent on health, and cost containment remains a major policy objective for the government. Te current level of spending on health is 11.2 percent of GDP, which shows the policy has been some- what successful. Te German population, however, is also aging, which signals higher expenses in the future. Over 20 percent (or one in fve) of the German people were age 65 and over in 2018. Tis situation is complicated by the fact that Germany has had the lowest birth rate in Europe for several years, although it rose slightly from 8.5 births per 1,000 persons in 2013 to 9.5 births in 2018. Some 75.6 percent of births are by mothers with German citizenship and the remaining to women with citizenships from other countries. Since German death rates have exceeded birth rates since 1972 (9.5 births versus 11.5 deaths per 1,000 persons in 2018, for example), immigration is helping maintain Germany’s population, which now stands at 83.2 million inhabit- ants. Large numbers of immigrants from Eastern Europe, Turkey, and the Middle East have settled in Germany, causing some anti-migrant sentiment. About 79 percent of Germany’s population are ethnic Germans and the next largest groups are Turkish and Polish. Berlin has the largest Turkish population of any city outside of Turkey. Fewer younger adults of working age in relation to the number of elderly persons means fewer potential tax revenues to support health care and the social welfare sys- tem. To generate more income without raising taxes, health ordinances have increased co-payments by patients for prescription drugs, hospitalization, physical therapy, and other services. Future changes in health policy are inevitable as Germany continues to provide generous benefts to its citizens and permanent residents. Lower-educated German men tend to have worsening health (the cumulative disadvantage hypothesis) over the life course in Germany but not women (Leopold and Leopold 2018). Te general level of health of the German population, however, is good. Table 17.1 shows that in 2018 Germany had a lower infant mortality rate than the United States. Te U.S. infant mortality rate was 5.7 per 1,000 compared to 3.4 for Germany. Table 17.2 indicates that both German men and women had a higher life expectancy than Americans. For men, the Germans showed a life expectancy of 78.8 years in 2018, and American men were listed at 76.3 years. For women, the German fgures were 83.6 years versus 81.4 years for Americans. Almost half of all deaths are due to diseases of the heart and circulatory system. Te prevalence of heart disease in eastern Germany is higher than in the west- ern part of the country; men in the east have higher levels of cigarette smoking, hypertension, cholesterol, and obesity (Knesebeck and Siegrist 2005; Nolte et al. 2002). Since reunifcation, however, smoking among women in eastern Germany has increased dramatically, likely reversing their former mortality advantage as largely non-smokers in the past (Vogt et al. 2017). Tis outcome was credited to a weakening 426 PART IV  Health Care Delivery Systems PHOTO 17.2 COVID-19 checkpoint on the German-Polish border. Source: Matthias Wehnert/Shutterstock. of anti-smoking policies and changing norms of behavior. Nevertheless, the change in the health care delivery system and improved living conditions in eastern Germany are improving life expectancy. Relatively recent data show men in eastern Germany have gained 6.2 years and women 4.2 years in life expectancy since reunifcation (Vogt 2014; Vogt et al. 2017). During the COVID-19 pandemic, Germany was praised in containing the virus by taking decisive action early with a tight lockdown and initiating a strong testing-and- tracing program backed up by swif responses from its health care system. Te virus resurfaced in late 2020 and early 2021, and Germany once again went into a partial and then full lockdown as a surge in new cases and deaths occurred. As of summer 2021, Germany had over 3.7 million cases and 90,000 deaths. Mexico Mexico has a decentralized national health system that now covers about 98 percent of the general population through a variety of programs that fall into one of three broad categories. First, there are the public social security organizations that provide both health insurance and old-age benefts for specifc groups of private and government employees. Second, there is the health care provided through the government’s Sec- retariat of Health and Welfare (Secretaria de Salubridad y Asistencia [SSA]), which is the primary source of care for the majority of persons not covered by a social security organization, especially the urban poor. Tird, there is the private health care system,  CHAPTER 17  Global Health Care 427 which consists of various private practitioners, hospitals and clinics, and charitable organizations. What allowed Mexico to have near universal health insurance coverage today was the passage in 2003 of legislation establishing the System of Social Protection in Health (SSPH). Te major feature of the SSPH is Seguro Popular, a public insurance program that ofers comprehensive health benefts, including protection against being unable to aford coverage by guaranteeing health care as a right recognized by the Mexican Constitution of 1983 (Knaul et al. 2012). For low-income persons without employer contributions, health benefts are paid by federal and state governments out of taxes, with the states responsible for 50 percent of the funding. About 50 million Mexicans— nearly half of the population—are insured by Seguro Popular. Te next largest health plan in Mexico covers salaried workers in the private sec- tor and is administered by the Mexican Social Insurance Institute (Instituto Mexi- cano de Seguro Social [IMSS]). Te IMSS was established in 1943 as a compulsory government-sponsored social security program for salaried workers in Mexico City and surrounding areas, fnanced by contributions from workers, employers, and the state. Te program was extended to other metropolitan areas during 1943–1945. Sala- ried agricultural workers were added in 1954 and, in 1973, legislation was enacted that provided for the extension of IMSS social insurance to everyone with jobs in the private sector. Despite eforts to expand into rural areas, most of the IMSS member- ship is urban. Another health plan, which provides the most extensive and generous benefts of any social security program, was established in 1960 for government workers and is administered by the Social Insurance Institute of State Employees (Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado [ISSSTE]). Other social security programs with health insurance are available to members of the armed forces (ISSSFAM) and the state-run oil industry (PEMEX). Approximately 50 percent of Mexico’s population is covered by the IMSS, ISSSTE, ISSSFAM, and PEMEX. Mexico has a serious maldistribution of services. More than 35 percent of all doc- tors are located in the Mexico City area, which has 20 percent of the population. Con- sequently, Mexico City has a surplus of physicians, while other parts of the country have a shortage. Even though health clinics are established throughout the country, rural areas are likely to be served by a nurse. For the country as a whole, there are approximately 20 physicians per 10,000 people, and most doctors are employed in some type of government-sponsored health program, although some have both public and private practices. Te remaining doctors are private fee-for-service practitioners. In border areas near the United States, afuent Mexicans and others covered by some type of U.S. health insurance visit American doctors. Some Americans, in turn, seek the services of less expensive Mexican physicians and buy drugs at cheaper prices in Mexican pharmacies. Many drugs in the United States requiring prescriptions, includ- ing some antibiotics and painkillers, are sold over the counter in Mexico. Crossing the U.S.–Mexico border from one side or the other to obtain health services is common for both Mexicans and Americans (Raudenbush 2021). Te overall health of the Mexican population is improving. Life expectancy in 2018 was 72.1 years for males and 77.8 years for females. Infant mortality was 11.3 deaths 428 PART IV  Health Care Delivery Systems per 1,000 births in 2018 compared with 80 per 1,000 in 1965. About 5.5 percent of Mexico’s GDP was spent on health in 2018. Health care delivery in major urban cen- ters in Mexico is ofen of high quality, especially in the national medical institutes in Mexico City. In rural areas, however, access to modern medicine is limited and difcult to obtain. When physicians, clinics, or nurses are not available locally, people turn to a variety of sources, such as nuns or folk healers, or they rely on self-treatment (Nigenda et al. 2001). Overall, Mexico has established a generally efective national system of health care delivery, despite being a developing nation and having an ofen troubled economy that has afected public spending on health care. But signifcant problems remain. Mexican health care is oriented toward curative rather than preventive medicine. Hence, there has not been a large-scale efort to pre- vent illness through public health programs intended to improve nutrition, water, sew- age systems, and training in hygiene. In addition, the various social health insurance plans difer in the levels of benefts provided, and the decentralized system of health care delivery promotes a lack of coordination, planning, and fscal control in a country that lacks great national wealth. Most importantly, as noted, a signifcant segment of the population in rural areas lacks access to modern health services. However, health care coverage has at least been extended to large segments of the population, including both blue- and white-collar workers and low-income persons. Mexico’s health policy emphasizes continued improvement in the health of the general population, with a particular focus on meeting the basic health needs of the under- privileged and extending health insurance coverage. Health care for the urban poor seems to be Mexico’s highest priority at this point in the development of its health care delivery system, but rural residents have witnessed improvement as well (Knaul et al. 2012). According to Mexican medical sociologist Roberto Castro (2005), health conditions in Mexico have changed signifcantly since the last century, but deep health disparities remain across social classes and regions in the country. Tese disparities quickly became even more apparent during the COVID-19 pan- demic, for which Mexico was woefully unprepared (Bautista-González et al. 2021). Te country was slow in responding to the pandemic as its health care system strug- gled to contain the virus (Semple 2020). By early 2021, Mexico had over 2.4 million cases and more than 229,000 deaths. Socialist Medicine: Alterations in Russia and China Te socialist model of health care delivery features central government ownership of all facilities, state employment of health workers, and free universal care paid out of the national budget. It largely disappeared during 1989–1991, when communism collapsed in Eastern Europe and the former Soviet Union. Of the four remaining com- munist countries, socialist health care persists only in Cuba and North Korea, while China and Vietnam have replaced the former socialist system with health insurance programs. In Cuba, for example, health care remains in a traditional socialist mode, is considered a right of citizenship, and is virtually free of charge. Medical and nursing  CHAPTER 17  Global Health Care 429 schools, along with other health-related training programs, are also free for the stu- dents selected to attend directly out of high school. All medical school graduates are required to serve two years in rural areas before they are allowed to train in a specialty, which helps alleviate shortages of doctors in rural communities. Many remain general practitioners. Doctors are paid low salaries (about $40 a month on average) in Cuba by the state as determined by years of service and specialty, but they are given housing and subsidies for food. Te Cuban health care system is highly organized and focused on preventive care, but there are serious defciencies in modern medical technology and medicines blamed on a trade embargo with the United States. In this section, we will review the alteration of the socialist form of health care in Russia and China. Both countries have experienced several years of economic reform, with the Chinese seemingly adjusting to the transition to a market-based system better than the Russians. Ning Hsieh (2015) found in her comparative study that older adults in China who lived through this period had greater economic security and social cohe- sion than older Russians, who showed more depression about their circumstances. In China, the ruling communist government remained intact, but in Russia communism failed to survive and the delivery of health care was redesigned. Russia Following the collapse of the old Soviet Union in 1991, the new Russian Federation passed legislation establishing a system of health insurance consisting of compulsory and voluntary plans (Twigg 2000, 2002). Te compulsory social health insurance plan is fnanced by central government subsidies for pensioners and the unemployed, along with contributions (3.1 percent of payrolls) from employers to cover workers. Health insurance is mandatory for all employees, provides the same basic benefts without choice, and is administrated by 89 regional government health insurance funds that make payments to participating private insurance companies. Individuals or employ- ers have a choice of insurance companies, and competition between these companies is expected to control costs and ensure quality services. Tere is also a voluntary plan of private insurance that anyone can purchase out of his or her own pocket that provides supplemental benefts. Te intent is to move away from the former Soviet method of paying for health care directly out of the central government’s budget and to replace it with a universal system of health insurance, providing basic benefts for all citizens in the form of payments to providers. One of the most important changes was to shif funding from the federal to the local level, so the fnancing of health care (about 60 percent) comes mainly from local budgets (which are based on both federal and local allocations) and the remainder from health insurance. Tis development marks a major change in fnancing health care delivery for the Russian people. Prior to the collapse of communism, the health care delivery systems in the former Soviet Union and Eastern Europe were philosophically guided by Marxist-Leninist ideas for transforming capitalism into socialism. Te ultimate goal was the estab- lishment of a classless society, featuring an end to class exploitation, private prop- erty, worker alienation, and economic scarcity. However, Marxist-Leninist ideology 430 PART IV  Health Care Delivery Systems pertaining to health was never developed in depth. Te Soviet state established in the afermath of the 1917 revolution nevertheless faced serious health problems, includ- ing large-scale epidemics and famine. More out of practical than theoretical necessity, the Soviet government mandated that health care would be (1) the responsibility of the state, (2) controlled by a central authority, and (3) provided without direct cost to patients, and that (4) priority for care was allocated to workers, with an emphasis on preventive care. Because of the critical need for doctors and a shortage of manpower resulting from industrial and military demands, large numbers of women, especially nurses with working-class backgrounds, were sent to medical schools, where they were given cram courses and certifed as physicians. William Knaus (1981:83) explained the situation at that time this way: Many had no ambitions beyond a weekly paycheck. Te Soviet government responded in kind with a low wage scale and a social status for medicine that treated the new physician with no more respect given a factory worker. Profes- sionalism was not rewarded nor even encouraged. Medicine became a job and women were the ones chosen to do it. Russia has more doctors per capita than most countries (about 4.3 physicians for every 1,000 people in 2013, the most recent fgure available), and some three-quarters are women. However, men hold the majority of academic positions in medicine and medical posts in the Ministry of Health. In 1987, four years before the collapse of the Soviet regime, the average salary for health care providers was about 30 percent less than the national average for all salaries. Doctors were paid about the same as high school teachers. Prominent physicians, however, had special privileges with respect to housing, vacations, and schools for their children, access to restricted stores, and other benefts. Te public did not have a choice of physicians, as assignment to a medical practitioner was made on the basis of residence. In order to receive more personal attention from their doctors and better care, patients typically provided gifs or bribes, which evolved into a second economy within the overall health care system. It was paradoxical that payments by patients were brought back in a system designed to remove fnancial incentives from the patient–physician relationship. Te former Soviet health care system is now part of history, as the Russian Federation’s new insurance-based structure has come into existence. Russian doctors now have an improved payment structure based on income from insurance and patients for services rendered, but bribes still allegedly exist in some places because of low salaries. In 2021, the average salary for a physician was $3,312 (or 244,000 rubles) a month, with doctors in Moscow making much more and those in rural areas making much less. Nevertheless, serious problems remain, including low fnancing of health care services and declining life expectancy. In the Russian Federation in the mid-1990s, less than 2 percent of GDP was spent on health, and the fgure was only 5.3 percent of GDP in 2018. Tis is a lower percentage in comparison to Western countries and less than one would expect, given the magnitude of health problems in the country and the aging of its population.  CHAPTER 17  Global Health Care 431 From the end of World War II until the mid-1960s, health progress in the former Soviet Union was rapid and consistent. In Russia (the former Russian Soviet Federa- tive Socialist Republic in the old Soviet Union), life expectancy for males increased from 40.4 years in 1938 to 64.0 years in 1965; for females, life expectancy increased from 46.7 years to 72.1 over the same period. However, in the mid-1960s—ironically just as the former Soviet Union reached its highest point of economic development in relation to the West—life expectancy began a downward trend, largely brought on by rising mortality from heart disease among middle-age working-class males. With the collapse of the Soviet Union in 1991 and deterioration of Russia’s standard of liv- ing for many people in the 1990s, the decrease in life expectancy for both men and women accelerated. Te longevity of women appeared to be most afected by stress and men by unhealthy lifestyles, with heavy alcohol consumption bufering their stress (Cockerham 2012). Male life expectancy in Russia fell from 64.0 in 1965 to 61.4 in 1980, but improved to 64.9 in 1987. Russian demographers credit this brief rise in male longevity to Premier Mikhail Gorbachev’s anti-alcohol campaign in the mid-1980s, which signif- cantly curtailed both the production and consumption of vodka and made it more costly to purchase. Vladimir Shkolnikov and Alexander Nemtsov (1994) calculated the diference between observed and expected deaths by sex and age and found that longevity increased 3.2 years for males and 1.3 years for females during the campaign’s short duration, with the greatest advances occurring in 1986. Shkolnikov and Nemtsov (1994:1) concluded that “the rapid mortality decrease in the years 1984 to 1987 can be assumed to refect a pure efect of reduced alcohol abuse on mortality, because there were no other signifcant changes in conditions of public health in that short period.” But the campaign was discontinued in late 1987 because of its widespread unpopular- ity, and both alcohol consumption and male mortality correspondingly increased. Following the 1991 collapse of the former Soviet Union, life expectancy for Rus- sian males had dropped to 57.6 years by 1994, 6.4 years less than the 1965 average. For females, there was a relatively slow but consistent upward trend between 1965 and 1989, from 72.1 years to 74.5 years. In 1991, in the new Russia, females lived 74.3 years on average, but by 1994 life expectancy for women had fallen to 71.2 years. Con- sequently, both Russian men and women had a lower life expectancy in 1994 than in 1965. Between 1995 and 1998, however, there was a slight increase in life expectancy for both Russian men and women because of a reduction in alcohol-related deaths (Shkolnikov, McKee, and Leon 2001). It wasn’t that people were actually living longer but that the most vulnerable people had already died and life expectancy looked better. Tis was not a genuine improvement in longevity, as life expectancy fgures resumed their downward movement from 61.8 years for males in 1998 to 58.9 years in 2005, only to fnally recover to 66.9 years in 2018. Nevertheless, males averaged only 2.7 more years of life expectancy in 2018 compared to 1965—a period of 53 years. Longevity for females rose 5.5 years during the same period to 77.6 years. Te gender gap in life expectancy in 2018 continued to be among the largest in the world, although shrinking somewhat, as the average Russian female lived 10.7 years longer than the male. With high death rates and falling birth rates, it is not surprising that Russia’s population declined from 147 million persons in 1989 to 145.9 million in 2020. In 432 PART IV  Health Care Delivery Systems order to maintain its labor force, Russia raised the ofcial age of retirement in 2018 from 60 years to 65 years for men and from 55 years to 63 years for women. Russia’s overall life expectancy was 73.3 years in 2019, but because of COVID-19 it fell to 71.2 years in 2020—a decline of 2.2 years for the country as a whole. Te decline of life expectancy in Russia and elsewhere in the old Soviet bloc coun- tries was one of the most signifcant developments in world health in the late twentieth century. It has improved, but its efects linger today in Russia, Belarus, and Ukraine. Tis situation is without precedent in modern history. Nowhere else has health wors- ened so seriously and for so long in peacetime among industrialized nations not expe- riencing a pandemic. Ironically, the former socialist countries espoused an ideology of social equality that theoretically should have promoted health for all. However, the reverse occurred, and life expectancy turned downward in the region in the mid-1960s without fully recovering in some parts of the former Soviet Union. Tis is a surprising development, as such a prolonged decline in public health was completely unexpected. Te rise in mortality was greatest in Russia and came very late to East Germany, but virtually all former Soviet bloc countries were afected to varying degrees. Te deaths largely stemmed from higher rates of heart disease and to a lesser extent from alcohol abuse and alcohol-related accidents. Te increase in cardiovascular deaths, in turn, was brought by an extraordinarily high level of alcohol consumption featuring frequent binge drinking that was part of an unhealthy lifestyle (Cockerham 1997, 1999, 2000, 2006, 2007, 2012; Cockerham, Snead, and DeWaal 2002; Grigoriev et al. 2014; Gugushvili et al. 2018; Hinote, Cockerham, and Abbott 2009a; Leon et al. 2010; Manning and Tikhonova 2009; Medvedev 2000; Nazarova 2009; Pietilä and Rytkonen 2008; Rose 2009; Van Gundy et al. 2005). Tis lifestyle was not only characterized by extremely heavy alcohol use, but also smoking, high-fat diets, and little or no leisure- time exercise, and was noted to be particularly common among middle-aged working- class males who were the principal victims of the rise in premature deaths. Tus, gender (male), age (middle age), and class (working class) were the key sociological variables in this health crisis. Medical treatment could not compensate for the damage to the circulatory system caused by unhealthy lifestyle practices, and the pathological efects they engendered overshadowed the contributions of infectious diseases, environmental pollution, and medically avoidable deaths to the increase in mortality during this period. A health policy that failed to cope with the rise in heart disease and stress was also an impor- tant causal factor. Te Soviet system lacked the fexibility, both administratively and structurally, to adjust to chronic health problems that could not be handled by the mass measures successful in controlling infectious ailments (Field 2000). Ultimately, the unhealthy lifestyle of a particular segment of the population appears to be the major social determinant of the downturn in life expectancy. In addition to the per- vasiveness of unhealthy lifestyles, the poor performance of the health care system and government neglect of the population’s social and material needs were also important (Grigoriev et al. 2014; Scheiring, Irdam, and King 2019). For example, the amount of alcohol consumed in Russia annually is about 13.5 liters of pure alcohol per capita (Zaridze 2017). Tis is the highest per capita consumption of alcohol in the world. When it is noted that adult males consume 90 percent of the  CHAPTER 17  Global Health Care 433 alcohol yet constitute 25 percent of the population, it is apparent that the drinking practices of males far exceed per capita consumption and refect a tremendous con- centration of drinking. Not only is per capita consumption extraordinarily high, but also the type of alcohol typically consumed (vodka) and the drinking style (oriented toward drunkenness and binge drinking) are considerably more harmful than the moderate drinking of beer and wine. Cigarette consumption is also higher in Russia than in the West, and male deaths from lung cancer are extremely high by international standards (Quirmbach and Gerry 2016). Moreover, women are showing signs of increased smoking, while men continue to smoke at about the same levels (Shkolnikov et al. 2013). Over 53 percent of all Russian men and 20 percent of women smoke. However, in 2013, the Russian government banned smoking in public places as a health measure. Also in that year, beer was designated an alcoholic beverage instead of a food and was prohibited from being sold at street-corner kiosks. As for nutrition, the R