Commentaries The Three World Systems of Medical Care: Trends and Prospects MILTON TERRIS, MD
It takes little prescience to recognize that there exist in the world today three basic systems of medical care: public assistance, health insurance, and national health service. These in turn are associated with and correspond to the three basic economic systems extant in the world today: precapitalist, capitalist, and socialist.1 2 There are many individual variations among different countries that have the same medical care system. Furthermore, more than one system can be found coexistent within a single country; the type indicated for each country refers to the system by which the majority of the population obtains care. Finally, the systems are not fixed and immovable; there is a continuing process of revision or replacement. Nor does the change from one system to another occur according to an inevitable progression. The purpose of this paper is not so much to describe the characteristics of the three systems-a necessary precondition for discussion-as to consider current trends and the prospects of transition from one system to another.
Public Assistance The public assistance system is dominant in 108 countries* with 1,862 million people, that is, 49 per cent of the world's population. These countries are located in Asia, Africa, and Latin America, and vary from colonies to semicolonies to more independent developing nations. The economy is primarily agricultural, and the landholding system is usually feudal or semi-feudal, although a tribal economy is
Address reprint requests to Dr. Milton Terris, Professor and Chairman, Department of Community and Preventive Medicine, New York Medical College, Fifth Avenue and 106th Street, New York, NY 10029. This paper, submitted to the Journal February 21, 1978, was revised and accepted for publication April 25, 1978. A lengthier version of the paper was presented at the Annual Meeting of the American Public Health Association, Washington, DC, November 2, 1977. *Countries with less than 100,000 population are excluded from this and subsequent tallies.
AJPH November 1978, Vol. 68, No. 11
significant in some areas. There is an increasing growth of capitalist and socialist economic relationships in many of these countries. For the great majority of the population, whatever medical care is available is provided through a public assistance system for the poor which includes government hospitals and health centers financed by general taxation. The system and its facilities are generally underfinanced, overcrowded, and have insufficient personnel. Since physicians' salaries are generally low, they seek to supplement them through other positions or through private practice. The services of full-time physicians in the public system, therefore, are often part-time in fact. In addition to the public assistance system, administered by health departments, there may be programs operated by social security agencies for industrial or white collar workers. Where they exist, these programs usually cover only a small part of the population. Some of these agencies purchase care from private physicians and hospitals, as in Chile's program for white collar employees and Algeria's for non-agricultural workers. Most, however provide care in their own hospitals and polyclinics because of the shortage of adequate private and public facilities; Costa Rica, Mexico and Turkey are examples of this approach.3 In all these countries there is a small stratum of landowners, businessmen, officials, and professionals who use private physicians and hospitals for their care.
Health Insurance The health insurance system is dominant in 23 countries with 711 million people, that is, 18 per cent of the world's population. These countries are located in Westem Europe and North America and also include Australia, New Zealand, Japan, and Israel. All are industrialized nations with a capitalist economy. There are wide variations in the insurance systems. In Israel, for example, all medical care insurance is non-governmental. In most countries, however, there is a mix of governmental and non-govemmental insurance. The latter is still dominant in the United States, but governmental insur1125
COMMENTARIES
ance has emerged elsewhere as the most important component. Indeed, there are a number of countries-Canada, Denmark, Finland, Iceland, New Zealand, and Norway-in which the entire population is covered by government medical care insurance.3 In the other countries coverage is usually limited to employed persons, and there may be exclusions of certain occupational groups or those with salaries above a certain level. Dependents of insured persons are included, although Austria and Japan impose some cost-sharing on them. Switzerland, which subsidizes voluntary plans and, in some cantons, makes membership compulsory, does not include dependents of insured persons unless they are members of a plan in their own right. In the United States, national health insurance for those age 65 and over does not include dependents. Although most countries use social security taxes on employees and employers, a considerable portion of the cost is borne by general government funds. In Denmark, Iceland, Ireland, and New Zealand there are no payroll taxes on employees for medical care, while in Italy the tax on employees is extremely small (0.3 per cent of earnings). Canada finances its system primarily from general federal and provincial revenues: Quebec imposes a tax of 0.8 per cent on employees' earnings, and Ontario, Alberta, and British Columbia tax individuals a flat amount, but the other six provinces do not tax individuals directly for medical care. In the United States national health insurance for the aged uses payroll taxes and individual contributions as major sources of fi-
nancing. Although the scope of service varies, practically all national health insurance programs in the industrial nations are based on fee-for-service private practice. Physicians and other practitioners are independent entrepreneurs who contract with the government or with authorized sick funds to provide care. In some countries, such as Austria, Canada, the Federal Republic of Germany, Italy, and the Netherlands, physicians' care is provided without any additional payments by the patient. In others, such as Belgium, Finland, France, New Zealand, and Norway, patients receive a cash refund for part of their medical expenses. Denmark requires earners with incomes above the level of skilled workers to pay part of the cost of physicians' fees, while co-payments by all patients are required in Iceland, Japan, and the United States.3 The failure of most national health insurance to cover the full cost of care is a major deficiency of fee-for-service programs. An interesting exception to the reliance on private practice is Spain where, because of the shortage of other facilities, the social security system provides comprehensive medical services through its own institutions. The social security medical program covers 65 per cent of the population; they are served by 88 hospitals with more than 39,000 beds, and 187 permanent and 365 temporary outpatient clinics. The social security system employed more than 30,000 physicians in 1971.4 In the countries with national health insurance, the administrative agencies are those concerned with social secu1126
rity as a whole, namely, Ministries of Social Welfare and their Social Insurance Institutes. The only exceptions are New Zealand, where the Department of Health administers the medical benefits, and Canada, where the Department of National Health and Welfare administers the program at the federal level, and health departments predominate at the provincial level.5 The anomalous and thoroughly illogical situation whereby a health services program is administered by a finance-oriented agency is generally characteristic of national health insurance.
National Health Service The national health service is dominant in 14 countries with 1,254 million people, that is, 33 per cent of the world's population. They include nine socialist nations in Europe, four in Asia, and Cuba in the Americas. All these countries are either industrialized or undergoing rapid industrialization. Unlike the public assistance systems and most of the insurance systems, national health services cover the entire population. Financing is by taxation; payroll taxes on employees are used significantly only in the German Democratic Republic where they account for less than one-fourth of the total funds.6 Like most of the public assistance systems, and unlike most of the insurance systems, services are provided by salaried physicians and other health personnel who work in government hospitals and health centers. Practically all services are included and provided free of charge. A common exception is drugs prescribed in ambulatory care, where the practice in different countries varies from no charge at all to different proportions of actual cost. The architect of the first national health service was Nikolai A. Semashko, the People's Commissar of Health of the Soviet Union from 1918 until 1930. In his book on Health Protection in the U.S.S.R.,7 published in England in 1934, Semashko stated three basic principles of the Soviet national health service: 1) Unity in the organization of the health service; 2) The participation of the population itself in the entire work of health protection; 3) Prophylactic measures the basis of the entire health service in the country. In accordance with these principles, administration of national health services in the 14 socialist countries has been entirely by health departments at national, regional, and local levels. Each health department is responsible for all health services, prophylactic and therapeutic. These unified health administrations are able to plan services in a rational manner. Regionalization of services, which is almost impossible to realize under the health insurance system, is one of the important achievements of the national health services. Major emphasis is placed on citizen participation in health programs through the activities of the standing commissions on health of local Soviets or councils; the public councils of hospitals and health centers which help the local government councils to evaluate and improve the quality of health services; the work of factory trade union committees in monitoring health and safety conditions; the activity of community organizations in health campaigns for immunizaAJPH November 1978, Vol. 68, No. 11
COMMENTARIES
tion, sanitation, health education, mass screening programs, etc.; and the participation of literally millions of voluntary health inspectors and other health activists.8'9 Preventive measures have been greatly emphasized in all of the national health services. These include not only the control of environmental and occupational hazards, and the campaigns directed to infectious diseases and maternal and child health, but a great emphasis on early detection, with many millions of people being screened every year, and on dispensarization (from the Russian word dispanser or follow-up center) for preventive supervision of vulnerable groups in the population and of persons with chronic dis-
eases.10' 11 Two other characteristics of the national health services should be mentioned. One is the great emphasis on ambulatory care through the construction of community and factory health centers close to the people being served. These health centers or polyclinics are staffed by internists, pediatricians, and a variety of specialists as well as other health personnel. 12 Another is what the Cubans call "sectorization," which they are beginning to apply in their own country now that their personnel shortages are somewhat abated. The Cuban "sector" is the Russian "uchastok," the Czech "obvod," the Polish "rayon," etc. It is a unit of 3,000 to 6,000 people living in a discrete geographical area, and is the basic unit of most of the national health services. Depending on the country's supply of health personnel, each such sector of the population is cared for by one or two internists, one-half to one pediatrician, part of an obstetrician-gynecologist, a stomatologist and a dental assistant, and adult, pediatric and maternity nurses. It should be noted, also, that the stafffor each sector is responsible not only for diagnosis and treatment but for promotion of health and prevention of disease. For example, home visits by physicians and nurses are considered essential not only to maintain needed contact with the patient but to evaluate the home conditions and obtain changes in those that affect the patient's health adversely.12
Intermediate Forms Two countries-the United Kingdom and Swedenwere included in the count of 23 nations in which health insurance is dominant though actually they occupy intermediate positions which lie somewhere between health insurance and a national health service. United Kingdom In the United Kingdom, national health insurance was begun in 1911. It was restricted to lower paid industrial workers, excluded their families, and was limited to general practitioner care and drugs. The British Medical Association proposed in 1942 to extend national health insurance to the whole working class, wage-earners and dependents alike, and to provide additional benefits. Instead, the British National Health Service was established in 1948. There were two major reasons for this action. One, perhaps the most important, was the fact that the nation's volAJPH November 1978, Vol. 68, No. 11
untary hospitals could no longer continue to support themselves; nationalization was a necessity to keep the hospital industry as well as other ailing industries operative. The other was ideological and political: British labor had demanded that significant social reforms be enacted in the post-war period. The Socialist Medical Association, with close ties to the leadership of the Labor Party, was the intellectual vehicle of the reform, while a good part of the content came from Henry Sigerist's widely discussed book on Socialized Medicine in the Soviet Union. 13' 14 The British National Health Service is incomplete. It is true that the entire population is covered for practically all health services. The general practitioners, however, are not salaried physicians working in community centers, but have the same kind of contractual relationship with the government that they had under the old insurance system. Furthermore, they work either as solo physicians or in small partnerships with other general practitioners, usually in their own offices. The National Health Service also permits consultants to work part-time and to care for their private patients in special pay-beds in the government's hospitals. The outcry against the latter practice has become so great that the government is now ending it, returning these beds to use by the general population. It is also true, unfortunately, that "preventive medicine, early diagnosis by screening tests, occupational health and accident services have a very subordinate role in Britain, while hospital medicine, especially within teaching establishments, which are highly representative of the Royal Colleges, high-status doctors and private practice are favoured disproportionately as compared with community medicine. 15 The intermediate character of the British National Health Service reflects a compromise with established interests which, as Gordon Hyde points out, was "analogous with nationalization measures in other industries. For the organizers-the minister, politicians and civil servants-were committed to a mixed economy in which profit and market considerations had a fundamental role to play."''5 The leadership of the medical profession, drawn from its more affluent sections who had most to gain from private practice,
campaigned successfully against a salaried service. This was done even though a British Medical Association questionnaire had revealed that a majority of physicians replying favored salaried practice in health centers.15 Sweden In 1970, Sweden had many of the elements of a national health service already in place. Population coverage was universal. Financing no longer included payroll taxes on employees. The long-established public hospital system served everyone without charge. Only a small minority of Sweden's physicians were in private practice; the rest worked either in the public hospital system or as government-employed district medical officers. The salaried hospital and district physicians provided 75 per cent of all ambulatory care; they charged fees, however, and patients obtained a 75 per cent
refund from the insurance fund.16 In 1970 all private practice by hospital or district sala1127
COMMENTARIES
ried physicians was abolished, with the moderate fees paid by patients going to the counties instead of the physicians.16' 17 This marked the beginning of the end of fee-forservice in Sweden. Private physicians still charge fees for which patients receive partial refunds from the insurance fund. But private practice is declining: "Of the approximately 10,000 physicians in Sweden, an estimated 1,350 or 14 per cent are in private practice. Of these, about 400 are over age 65 and work only part-time. The total number of physicians in private practice decreases yearly as the older physicians retire and only a few young ones take their place." 18 The prospects are that private practice will continue to dwindle in Sweden as it has in the socialist countries. What will take its place? S. A. Lindgren, Head of the Planning Department of the National Board of Health and Welfare (the agency responsible for health in the Ministry for Social Affairs), indicates that the preponderance of hospitals in the health system will be corrected in the coming period by the development of county-operated community health centers devoted not only to treatment but hopefully also to preventive medicine, health education, and social work.19
Prospects for Transition The examples of the United Kingdom and Sweden suggest that while a national health service is the characteristic form of health care in socialist countries, it is not necessarily limited to them. The dynamics of social reform in two major capitalist nations have already produced government health services which are still incomplete but have the potential of moving toward a fully developed national health service for everyone, provided without charge by salaried physicians and other health personnel working in health centers, hospitals, and other facilities. The reasons for a national health service are based only in part on political ideologies. Both in the U.K. and in Sweden its development has been supported by large sections of the population which do not have socialist commitments. The growing movement for a national health service in the United States consists primarily of individuals who are liberal-democratic rather than socialist in orientation. It is disillusionment with fee-for-service national health insurance for the aged-Medicare-that is largely responsible for their
position. The grounds for a national health service are logical ones. Public assistance and national health insurance are simply not the way to provide health care. The only way that does make sense is a national health service. Transition from Health Insurance There are a number of countries, such as Denmark, Finland, France, Italy, and Norway, which already have some of the characteristics of a national health service. All have a public hospital system which serves most if not all of the population and is staffed by salaried physicians.20 In Denmark, Finland, and Norway the entire population is covered by national health insurance, and in Denmark there are no
employee contributions. 1128
In fact, Denmark appears to be moving toward a national health service. Reforms enacted in 1973 abolished all sickness funds, transferring their functions to the county councils; made coverage universal and abolished contributions by individuals; made financing entirely dependent on the general revenues of local and central government; and replaced individual governing bodies of the public hospitals by a single committee of the county council repsonsible for all hospitals in the county. However, the distinction between service and indemnity segments of the population has been maintained for ambulatory care; those with incomes above a certain level must pay the physician directly for whatever amount he charges, receiving a refund in the amount which the county pays the physician for service patients.20 The payment to general practitioners for service patients is, in Copenhagen, by capitation payments, and in the rest of the country, one-half by capitation and one-half by fee-for-service. The Danes need only to create a salaried, health center-based service outside the hospitals, and end the indemnity category of patients, to have all the basic ingredients of a national health service. How soon they will move in this direction will depend on a number of factors: the pressure to relieve the high costs of fee-for-service; recognition of the need to improve the quality of out-of-hospital care; the example of neighboring Sweden; the relative power of the private practitioners; and the political temper of the country. The general political factors are probably decisive; Italy, which has a national health insurance system that is less advanced than that of Denmark, may nevertheless achieve a national health service earlier. Italy's ruling Christian Democratic Party, in 1973, proposed to abolish national health insurance and substitute a national health service financed by general revenues.21 Since this approach has the support of all the major political parties, and there appears to be a continuing leftward trend of the electorate, it would seem reasonable to expect a national health service in Italy fairly soon. The outlook for other nations is difficult to assess without an intimate knowledge of the political trands in each country, the character of the health services, and the degree of popular dissatisfaction with them. The latter factor is of major importance in the growth of the movement for a national health service. In the United States, which because of its political conservatism and ideological commitment to private practice would seem to be completely refractory to such ideas, there is a growing interest in a national health service. The widely respected Cambridge Survey offered four alternatives to those interviewed in a national poll and found that 8 per cent were undecided; 13 per cent were for keeping things as they are; 23 per cent favored giving medical insurance to poor people and major medical insurance to all; 35 per cent were for comprehensive national health insurance for everyone; and 22 per cent favored a totally nationalized system in which comprehensive care is provided for all and doctors and hospitals are taken over by the government.22 The fact that at least one-fifth of the American people AJPH November 1978, Vol. 68, No. 11
COMMENTARIES
chose a national health service is reflected in the changing attitudes of public health workers. The American Public Health Association, which in 1964 had testified before Congress in favor of government health insurance for the aged, and in 1970 supported comprehensive national health insurance for all, by 1976 was urging Congress to establish a national health service because, among other things, national health insurance "will simply support the present inadequate system of private health care delivery and would neither make high quality health care available to all Americans nor effectively control the rising costs of health care."23 Some proponents of national health insurance in the United States have taken the position that a national health service is premature and that a prior stage of comprehensive national health insurance is inevitable. This ignores the fact that the United States has already lived through national health insurance, for those 65 years and older, with unsatisfactory results. It also disregards the experience of Great
Britain. Furthermore, if those who believe in inevitable stages were consistent, they would support government subsidy of voluntary plans. This was, after all, the usual progression in Europe: first, the growth of voluntary plans; second, government subsidy and regulation of the plans; and third, government health insurance.24 Australia is now in the process of moving from stage two to stage three. The United States is still in stage 1, and subsidy of private insurance plans would be the next "inevitable" step. Indeed, there is a very real danger that neither the proponents of national health insurance nor of a national health service will have their way in the United States. The likelihood of this outcome has nothing to do with stages or inevitability, but with political power; the insurance companies exercise tremendous economic and political leverage. In the absence of a political party of labor such as exists in every other industrial nation, it will take heroic efforts to avoid the establishment of subsidized private insurance, or of government health insurance administered by private insurance companies. Transition from Public Assistance Probably the most interesting example of transition to a national health service is the first one, that of the Soviet Union. Sigerist points out that Zemstvo medicine was significant "not only from the point of view of Russia but from that of world medicine at large. It was the first attempt to organize medicine as a public service on a large scale."'3 Introduced in 1865, the Zemstvos or district assemblies rapidly increased their medical resources; they more than doubled the number of hospital beds, feldshers, midwives, and pharmacists, and tripled the number of physicians. But the resources were still inadequate: toward 1900 there was still only one physician for every 25,000 people. Sigerist states that despite these shortcomings "Zemstvo medicine paved the way for Soviet medicine in several respects. It created a medical organization, created a network of medical stations all over the country that could be improved and increased in number. And, above all, it accustomed the people AJPH November 1978, Vol. 68, No. 11
to the idea that medicine was not a trade but a public service. "13 It is interesting that social insurance was used to help finance the national health service in the early years in the Soviet Union. The contributions were paid by enterprises and institutions as a fixed percentage of the wage bill; under no conditions could they be deducted from wages. In 1936, social insurance contributions amounted to 2.3 billion rubles, or 37 per cent of the total health budget. In 1937, medical services were transferred almost entirely to the state budget; they have been financed from general revenues ever since. 3. 25 One of the best known examples of transition to a national health service is Cuba, which before 1959 exhibited the classic features of a public assistance system. "Most of the physicians were in private practice in the major cities, although about 10 per cent of the population were insured for medical care through mutual aid societies (mutualistas). The great majority of the population, who were poor, received care through 46 meagerly staffed government hospitals, some first-aid stations in Cuba's main cities, and eight maternal and child health stations for the national population of about 8.5 million people. The rural population had to be mainly dependent on traditional healers for ambulatory care or, if they were close enough to a town, on a crowded hospital outpatient department."26 Cuba moved directly from public assistance to the creation of a national health service based on these principles: "The health of the people should be a responsibility of the State; health services should be available to all; the community should play an active part in health programs; health services should have integrated preventive and curative functions."27 In the past 16 years, Cuba has succeeded in establishing a complete national health service and is moving now to raise its quality and effectiveness through scientific and technical advances, mass screening programs, sectorization and dispensarization. Perhaps the most startling example of transition from a charity system to a national health service is Mongolia, which prior to 1921 was "a country of monasteries, the country of lamaism." In this incredibly backward feudal country, whatever medical care existed was provided by lamas who practiced traditional Tibetan medicine. In 1925 a Health Department was created for the first time, and the first hospital, providing 15 beds and ambulatory care, was opened in the capital, Ulan-Bator. In 1930, state funds were no longer budgeted for traditional practitioners, and the government adopted an official policy limiting its support to scientific medicine. Remarkable progress has been made since: construction of a network of hospitals and ambulatory care centers which cover the entire country; development of an effective public health organization for the prevention of infectious deseases and protection of maternal and child health; establishment of schools for training health personnel, including a medical school in 1942; and an increase in the number of physicians from 1 per 100,000 in 1930 to I per 700 in 1965. Infant mortality was 500 per 1,000 live births in 1923-24 and less than 70 per 1,000 in 1959.28 Cuba and Mongolia are very different yet very much 1129
COMMENTARIES
alike. Cuba, like a number of other countries in Latin America, was a relatively developed underdeveloped country; this made it possible to establish its national health service quite rapidly. Mongolia, on the other hand, started with literally nothing: no hospitals, no clinics, no physicians, and no public health organization. The national health service of Mongolia took much longer to build; it was over 20 years, for example, before the country had a medical school. Despite the enormous differences between the two countries, they were able to bypass the health insurance stage because of two factors in which they were alike: their socialist orientation, and the advice and assistance which they received from countries with a developed national health service. In the case of Mongolia this was the Soviet Union; Cuba received help from a number of countries, including the Soviet Union, Czechoslovakia, and Hungary. Among the newly liberated countries in Asia and Africa, there is a fairly large number which have a socialist orientation and may also move directly from the public assistance system to a national health service. These include such countries as Laos and Iraq in Asia, and Algeria and Guinea in Africa. Many countries with a public assistance system still have a very dependent neocolonial status, however, and it is difficult to see how they can develop either toward national health insurance or a national health service under these conditions. Until they achieve a measure of economic as well as political independence, it will be difficult to assess their prospects for transition in either direction. There are a number of nations, particularly in Latin America, having a capitalist orientation, which have achieved a certain amount of economic and political independence, and may be able to make the transition from public assistance to national health insurance. But this will, in all likelihood, be a different kind of health insurance from that which is traditional in Europe and North America. Chile, in 1952-long before the advent of the socialistoriented Popular Unity government-took the bold and imaginative step of combining into a single system the public assistance hospitals and clinics, the polyclinics and hospitals of the social security system for blue collar workers, and the public health services of the Ministry of Health. This unified health service was financed primarily through general revenues; in 1962, for example, social insurance contributions accounted for only 16 per cent of the total. The coverage of the program has been estimated to be 70 to 75 per cent of the
population.29 The election of the Popular Unity government in 1970 created the possibility of further evolution to a complete national health service for the entire population. A key step would have been to merge the fee-for-service insurance program for white collar employees into the public program. But the coup by the fascist junta intervened, and the development of the Chilean National Health Service is currently in abeyance. In Costa Rica, Mexico, and many other developing countries, the shortage of facilities has made it necessary for the social security system to build its own hospitals and polyclinics employing salaried physicians. In these nations it 1130
will be logical to follow the Chilean example and combine the public assistance and social security hospitals and polyclinics with the public health services to create a unified health service. Costa Rica is apparently moving in this direction as a result of recent legislation for integration of services.3 Sooner or later, in Chile and in other countries, such unified health services for the majority of the people will be expanded to become national health services for the entire population.29 In the industrial capitalist countries with well intrenched health insurance systems-in which practitioners are essentially small businessmen selling their services-the resistance to change to a salaried service is very great. Nevertheless the trend is unmistakably toward the national health service. The latter has demonstrated not only its superiority in terms of quality and cost effectiveness, but has shown that it is unnecessary to submit to the blind forces of the medical marketplace; nations can plan rationally for their health services, and can plan them well. A national health service, finally, makes it possible to plan democratically and humanely, not for a minority but for all citizens and with all citizens. This is the lesson of our time. Increasingly the nations will understand and act upon it.
REFERENCES 1. Roemer MI: Health departments and medical care-A world scanning. Am J Public Health 50:154-160, 1960. 2. Kozusznik B: Health care systems in the modem world. La
Sante Publique 3:243-253, 1967. 3. U.S. Department of Health, Education, and Welfare, Social Security Administration. Social Security Programs throughout the World, 1975. Wash., DC: U.S. Govt. Printing Office, 1975. 4. Segovia de Arana JM: Spain. In Bowers JZ and Purcell E, eds: National Health Services: Their Impact on Medical Education and Their Role in Prevention. New York: Josiah Macy, Jr. Foundation, 1973. 5. Terris M: The epidemiologic revolution, national health insurance and the role of health departments. Am J Public Health 66:1155-1164, 1976. 6. Kaser M: Health Care in the Soviet Union and Eastern Europe. Boulder, Colo.: Westview Press, 1976. 7. Semashko NA: Health Protection in the U.S.S.R. London: Gollancz, 1934. 8. World Health Organization. Health Education in the U.S.S.R. Geneva: WHO, 1963. 9. Petrovsky B: Public Health in the U.S.S.R. Moscow: Novosti Press Agency Publishing House, undated. 10. Popov GA: Principles of Health Planning in the U.S.S.R. Geneva: WHO, 1971. 11. Lisitsin Y: Health Protection in the U.S.S.R. Moscow: Progress Publishers, 1972. 12. Terris M: Ambulatory Care in the U.S.S.R. Paper presented at the Annual Meeting of the American Public Health Association, Wash., DC, October 31, 1977. 13. Sigerist HE: Socialized Medicine in the Soviet Union. New York: W.W. Norton & Co., 1937. 14. Terris M: The contributions of Henry E. Sigerist to health service organization. Milbank Mem. Fund Quart., Health and Society 53:489-530, 1975. 15. Hyde G: The Soviet Health Service, a Historical and Comparative Study. London: Lawrence & Wishart, 1974. 16. Shenkin BN: Politics and medical care in Sweden: The seven crowns reform. New Eng. J. Med. 288:555-559, 1973. 17. Hjern, B: What About Socialized Medicine in Sweden? Arch. Surg. 111:941-944, 1976.
AJPH November 1978, Vol. 68, No. 11
COMMENTARIES 18. Andrews JL, Jr: Medical care in Sweden, lessons for America. JAMA 223: 1369-1375, 1973. 19. Lindgren SA: Sweden. In Douglas-Wilson I and McLachlan G, eds: Health Service Prospects, An International Survey. Boston: Little, Brown, 1973. 20. Maynard A: Health Care in the European Community. Pittsburgh: Univ. of Pittsburgh Press, 1975. 21. The New York Times, February 8, 1973, p9. 22. The Chicago Sun-Times, October 12, 1975, p7. 23. Resolution adopted by the Governing Council of the American Public Health Association, October 20, 1976: Establishment of a National Health Service. Am J Public Health 67:86-87, 1977. 24. Perrott G St J and Mountin JW: Voluntary health insurance in
25. 26. 27.
28. 29.
western Europe: Its origins and place in national programs. Pub H Rep 62:733-767, 1947. Sigerist HE: Medicine and Health in the Soviet Union. New York: The Citadel Press, 1947. Roemer MI: Political ideology and health care: Hospital patterns in the Philippines and Cuba. Int J Health Services 3:487492, 1973. Riveron Corteguera R, Ferrer Garcia H and Valdes Lazo F: Advances in pediatrics and child care in Cuba, 1959-1974. Bull Pan Amer Health Org'n. 10:9-24, 1976. Ibrahimov MA: Public health protection in the Mongolian People's Republic. La Sante Publique 5:271-278, 1962. Roemer MI: Medical Care in Latin America. Wash., DC: Organization of American States, 1963.
Fellowships in Family Practice Announced Twelve, two-year fellowships for physicians seeking full-time careers as teachers of family medicine are available at the Universities of Iowa, Utah, and Washington in Seattle, beginning July 1, 1979. Selection of fellows is made by the three universities' family practice departments. To be eligible, applicants must have completed (and excelled in) residency training in family practice or one of the other primary care specialties such as internal medicine or pediatrics and be board certified or eligible; an applicant must be committed to an academic career in family medicine, which includes teaching, research, and patient care in a medical school or affiliated residency training program. This national program is sponsored by the Robert Wood Foundation. The fellowships program has been designed by the participating departments of family practice so the fellows may acquire the capabilities needed for their academic careers. In addition to maintaining clinical competence, fellows will develop research and teaching skills. Areas of study include administration, biostatistics, research methodology, quality of care assessment, and development and evaluation of educational programs. Grants totaling nearly $2,000,000 to the three universities are being used to develop the programs and to provide stipends for fellows and faculty support. The application deadline for fellowships beginning July 1, 1979 is November 15, 1978. For applications and information contact one of the following individuals: Robert E. Rakel, MD, Chairman Department of Family Practice University of Iowa College of Medicine S-150 Children's Hospital Iowa City, IA 52242
Hilmon Castle, MD, Chairman Department of Family and Community Medicine University of Utah College of Medicine 50 North Medical Drive Salt Lake City, UT 84132 T. J. Phillips, MD, Professor Department of Family Medicine RF-30
University of Washington School of Medicine Seattle, WA 98195
AJPH November 1978, Vol. 68, No. 11
1131
It takes little prescience to recognize that there exist in the world today three basic systems of medical care: public assistance, health insurance, and national health service. These in turn are associated with and correspond to the three basic economic systems extant in the world today: precapitalist, capitalist, and socialist.1 2 There are many individual variations among different countries that have the same medical care system. Furthermore, more than one system can be found coexistent within a single country; the type indicated for each country refers to the system by which the majority of the population obtains care. Finally, the systems are not fixed and immovable; there is a continuing process of revision or replacement. Nor does the change from one system to another occur according to an inevitable progression. The purpose of this paper is not so much to describe the characteristics of the three systems-a necessary precondition for discussion-as to consider current trends and the prospects of transition from one system to another.
Public Assistance The public assistance system is dominant in 108 countries* with 1,862 million people, that is, 49 per cent of the world's population. These countries are located in Asia, Africa, and Latin America, and vary from colonies to semicolonies to more independent developing nations. The economy is primarily agricultural, and the landholding system is usually feudal or semi-feudal, although a tribal economy is
Address reprint requests to Dr. Milton Terris, Professor and Chairman, Department of Community and Preventive Medicine, New York Medical College, Fifth Avenue and 106th Street, New York, NY 10029. This paper, submitted to the Journal February 21, 1978, was revised and accepted for publication April 25, 1978. A lengthier version of the paper was presented at the Annual Meeting of the American Public Health Association, Washington, DC, November 2, 1977. *Countries with less than 100,000 population are excluded from this and subsequent tallies.
AJPH November 1978, Vol. 68, No. 11
significant in some areas. There is an increasing growth of capitalist and socialist economic relationships in many of these countries. For the great majority of the population, whatever medical care is available is provided through a public assistance system for the poor which includes government hospitals and health centers financed by general taxation. The system and its facilities are generally underfinanced, overcrowded, and have insufficient personnel. Since physicians' salaries are generally low, they seek to supplement them through other positions or through private practice. The services of full-time physicians in the public system, therefore, are often part-time in fact. In addition to the public assistance system, administered by health departments, there may be programs operated by social security agencies for industrial or white collar workers. Where they exist, these programs usually cover only a small part of the population. Some of these agencies purchase care from private physicians and hospitals, as in Chile's program for white collar employees and Algeria's for non-agricultural workers. Most, however provide care in their own hospitals and polyclinics because of the shortage of adequate private and public facilities; Costa Rica, Mexico and Turkey are examples of this approach.3 In all these countries there is a small stratum of landowners, businessmen, officials, and professionals who use private physicians and hospitals for their care.
Health Insurance The health insurance system is dominant in 23 countries with 711 million people, that is, 18 per cent of the world's population. These countries are located in Westem Europe and North America and also include Australia, New Zealand, Japan, and Israel. All are industrialized nations with a capitalist economy. There are wide variations in the insurance systems. In Israel, for example, all medical care insurance is non-governmental. In most countries, however, there is a mix of governmental and non-govemmental insurance. The latter is still dominant in the United States, but governmental insur1125
COMMENTARIES
ance has emerged elsewhere as the most important component. Indeed, there are a number of countries-Canada, Denmark, Finland, Iceland, New Zealand, and Norway-in which the entire population is covered by government medical care insurance.3 In the other countries coverage is usually limited to employed persons, and there may be exclusions of certain occupational groups or those with salaries above a certain level. Dependents of insured persons are included, although Austria and Japan impose some cost-sharing on them. Switzerland, which subsidizes voluntary plans and, in some cantons, makes membership compulsory, does not include dependents of insured persons unless they are members of a plan in their own right. In the United States, national health insurance for those age 65 and over does not include dependents. Although most countries use social security taxes on employees and employers, a considerable portion of the cost is borne by general government funds. In Denmark, Iceland, Ireland, and New Zealand there are no payroll taxes on employees for medical care, while in Italy the tax on employees is extremely small (0.3 per cent of earnings). Canada finances its system primarily from general federal and provincial revenues: Quebec imposes a tax of 0.8 per cent on employees' earnings, and Ontario, Alberta, and British Columbia tax individuals a flat amount, but the other six provinces do not tax individuals directly for medical care. In the United States national health insurance for the aged uses payroll taxes and individual contributions as major sources of fi-
nancing. Although the scope of service varies, practically all national health insurance programs in the industrial nations are based on fee-for-service private practice. Physicians and other practitioners are independent entrepreneurs who contract with the government or with authorized sick funds to provide care. In some countries, such as Austria, Canada, the Federal Republic of Germany, Italy, and the Netherlands, physicians' care is provided without any additional payments by the patient. In others, such as Belgium, Finland, France, New Zealand, and Norway, patients receive a cash refund for part of their medical expenses. Denmark requires earners with incomes above the level of skilled workers to pay part of the cost of physicians' fees, while co-payments by all patients are required in Iceland, Japan, and the United States.3 The failure of most national health insurance to cover the full cost of care is a major deficiency of fee-for-service programs. An interesting exception to the reliance on private practice is Spain where, because of the shortage of other facilities, the social security system provides comprehensive medical services through its own institutions. The social security medical program covers 65 per cent of the population; they are served by 88 hospitals with more than 39,000 beds, and 187 permanent and 365 temporary outpatient clinics. The social security system employed more than 30,000 physicians in 1971.4 In the countries with national health insurance, the administrative agencies are those concerned with social secu1126
rity as a whole, namely, Ministries of Social Welfare and their Social Insurance Institutes. The only exceptions are New Zealand, where the Department of Health administers the medical benefits, and Canada, where the Department of National Health and Welfare administers the program at the federal level, and health departments predominate at the provincial level.5 The anomalous and thoroughly illogical situation whereby a health services program is administered by a finance-oriented agency is generally characteristic of national health insurance.
National Health Service The national health service is dominant in 14 countries with 1,254 million people, that is, 33 per cent of the world's population. They include nine socialist nations in Europe, four in Asia, and Cuba in the Americas. All these countries are either industrialized or undergoing rapid industrialization. Unlike the public assistance systems and most of the insurance systems, national health services cover the entire population. Financing is by taxation; payroll taxes on employees are used significantly only in the German Democratic Republic where they account for less than one-fourth of the total funds.6 Like most of the public assistance systems, and unlike most of the insurance systems, services are provided by salaried physicians and other health personnel who work in government hospitals and health centers. Practically all services are included and provided free of charge. A common exception is drugs prescribed in ambulatory care, where the practice in different countries varies from no charge at all to different proportions of actual cost. The architect of the first national health service was Nikolai A. Semashko, the People's Commissar of Health of the Soviet Union from 1918 until 1930. In his book on Health Protection in the U.S.S.R.,7 published in England in 1934, Semashko stated three basic principles of the Soviet national health service: 1) Unity in the organization of the health service; 2) The participation of the population itself in the entire work of health protection; 3) Prophylactic measures the basis of the entire health service in the country. In accordance with these principles, administration of national health services in the 14 socialist countries has been entirely by health departments at national, regional, and local levels. Each health department is responsible for all health services, prophylactic and therapeutic. These unified health administrations are able to plan services in a rational manner. Regionalization of services, which is almost impossible to realize under the health insurance system, is one of the important achievements of the national health services. Major emphasis is placed on citizen participation in health programs through the activities of the standing commissions on health of local Soviets or councils; the public councils of hospitals and health centers which help the local government councils to evaluate and improve the quality of health services; the work of factory trade union committees in monitoring health and safety conditions; the activity of community organizations in health campaigns for immunizaAJPH November 1978, Vol. 68, No. 11
COMMENTARIES
tion, sanitation, health education, mass screening programs, etc.; and the participation of literally millions of voluntary health inspectors and other health activists.8'9 Preventive measures have been greatly emphasized in all of the national health services. These include not only the control of environmental and occupational hazards, and the campaigns directed to infectious diseases and maternal and child health, but a great emphasis on early detection, with many millions of people being screened every year, and on dispensarization (from the Russian word dispanser or follow-up center) for preventive supervision of vulnerable groups in the population and of persons with chronic dis-
eases.10' 11 Two other characteristics of the national health services should be mentioned. One is the great emphasis on ambulatory care through the construction of community and factory health centers close to the people being served. These health centers or polyclinics are staffed by internists, pediatricians, and a variety of specialists as well as other health personnel. 12 Another is what the Cubans call "sectorization," which they are beginning to apply in their own country now that their personnel shortages are somewhat abated. The Cuban "sector" is the Russian "uchastok," the Czech "obvod," the Polish "rayon," etc. It is a unit of 3,000 to 6,000 people living in a discrete geographical area, and is the basic unit of most of the national health services. Depending on the country's supply of health personnel, each such sector of the population is cared for by one or two internists, one-half to one pediatrician, part of an obstetrician-gynecologist, a stomatologist and a dental assistant, and adult, pediatric and maternity nurses. It should be noted, also, that the stafffor each sector is responsible not only for diagnosis and treatment but for promotion of health and prevention of disease. For example, home visits by physicians and nurses are considered essential not only to maintain needed contact with the patient but to evaluate the home conditions and obtain changes in those that affect the patient's health adversely.12
Intermediate Forms Two countries-the United Kingdom and Swedenwere included in the count of 23 nations in which health insurance is dominant though actually they occupy intermediate positions which lie somewhere between health insurance and a national health service. United Kingdom In the United Kingdom, national health insurance was begun in 1911. It was restricted to lower paid industrial workers, excluded their families, and was limited to general practitioner care and drugs. The British Medical Association proposed in 1942 to extend national health insurance to the whole working class, wage-earners and dependents alike, and to provide additional benefits. Instead, the British National Health Service was established in 1948. There were two major reasons for this action. One, perhaps the most important, was the fact that the nation's volAJPH November 1978, Vol. 68, No. 11
untary hospitals could no longer continue to support themselves; nationalization was a necessity to keep the hospital industry as well as other ailing industries operative. The other was ideological and political: British labor had demanded that significant social reforms be enacted in the post-war period. The Socialist Medical Association, with close ties to the leadership of the Labor Party, was the intellectual vehicle of the reform, while a good part of the content came from Henry Sigerist's widely discussed book on Socialized Medicine in the Soviet Union. 13' 14 The British National Health Service is incomplete. It is true that the entire population is covered for practically all health services. The general practitioners, however, are not salaried physicians working in community centers, but have the same kind of contractual relationship with the government that they had under the old insurance system. Furthermore, they work either as solo physicians or in small partnerships with other general practitioners, usually in their own offices. The National Health Service also permits consultants to work part-time and to care for their private patients in special pay-beds in the government's hospitals. The outcry against the latter practice has become so great that the government is now ending it, returning these beds to use by the general population. It is also true, unfortunately, that "preventive medicine, early diagnosis by screening tests, occupational health and accident services have a very subordinate role in Britain, while hospital medicine, especially within teaching establishments, which are highly representative of the Royal Colleges, high-status doctors and private practice are favoured disproportionately as compared with community medicine. 15 The intermediate character of the British National Health Service reflects a compromise with established interests which, as Gordon Hyde points out, was "analogous with nationalization measures in other industries. For the organizers-the minister, politicians and civil servants-were committed to a mixed economy in which profit and market considerations had a fundamental role to play."''5 The leadership of the medical profession, drawn from its more affluent sections who had most to gain from private practice,
campaigned successfully against a salaried service. This was done even though a British Medical Association questionnaire had revealed that a majority of physicians replying favored salaried practice in health centers.15 Sweden In 1970, Sweden had many of the elements of a national health service already in place. Population coverage was universal. Financing no longer included payroll taxes on employees. The long-established public hospital system served everyone without charge. Only a small minority of Sweden's physicians were in private practice; the rest worked either in the public hospital system or as government-employed district medical officers. The salaried hospital and district physicians provided 75 per cent of all ambulatory care; they charged fees, however, and patients obtained a 75 per cent
refund from the insurance fund.16 In 1970 all private practice by hospital or district sala1127
COMMENTARIES
ried physicians was abolished, with the moderate fees paid by patients going to the counties instead of the physicians.16' 17 This marked the beginning of the end of fee-forservice in Sweden. Private physicians still charge fees for which patients receive partial refunds from the insurance fund. But private practice is declining: "Of the approximately 10,000 physicians in Sweden, an estimated 1,350 or 14 per cent are in private practice. Of these, about 400 are over age 65 and work only part-time. The total number of physicians in private practice decreases yearly as the older physicians retire and only a few young ones take their place." 18 The prospects are that private practice will continue to dwindle in Sweden as it has in the socialist countries. What will take its place? S. A. Lindgren, Head of the Planning Department of the National Board of Health and Welfare (the agency responsible for health in the Ministry for Social Affairs), indicates that the preponderance of hospitals in the health system will be corrected in the coming period by the development of county-operated community health centers devoted not only to treatment but hopefully also to preventive medicine, health education, and social work.19
Prospects for Transition The examples of the United Kingdom and Sweden suggest that while a national health service is the characteristic form of health care in socialist countries, it is not necessarily limited to them. The dynamics of social reform in two major capitalist nations have already produced government health services which are still incomplete but have the potential of moving toward a fully developed national health service for everyone, provided without charge by salaried physicians and other health personnel working in health centers, hospitals, and other facilities. The reasons for a national health service are based only in part on political ideologies. Both in the U.K. and in Sweden its development has been supported by large sections of the population which do not have socialist commitments. The growing movement for a national health service in the United States consists primarily of individuals who are liberal-democratic rather than socialist in orientation. It is disillusionment with fee-for-service national health insurance for the aged-Medicare-that is largely responsible for their
position. The grounds for a national health service are logical ones. Public assistance and national health insurance are simply not the way to provide health care. The only way that does make sense is a national health service. Transition from Health Insurance There are a number of countries, such as Denmark, Finland, France, Italy, and Norway, which already have some of the characteristics of a national health service. All have a public hospital system which serves most if not all of the population and is staffed by salaried physicians.20 In Denmark, Finland, and Norway the entire population is covered by national health insurance, and in Denmark there are no
employee contributions. 1128
In fact, Denmark appears to be moving toward a national health service. Reforms enacted in 1973 abolished all sickness funds, transferring their functions to the county councils; made coverage universal and abolished contributions by individuals; made financing entirely dependent on the general revenues of local and central government; and replaced individual governing bodies of the public hospitals by a single committee of the county council repsonsible for all hospitals in the county. However, the distinction between service and indemnity segments of the population has been maintained for ambulatory care; those with incomes above a certain level must pay the physician directly for whatever amount he charges, receiving a refund in the amount which the county pays the physician for service patients.20 The payment to general practitioners for service patients is, in Copenhagen, by capitation payments, and in the rest of the country, one-half by capitation and one-half by fee-for-service. The Danes need only to create a salaried, health center-based service outside the hospitals, and end the indemnity category of patients, to have all the basic ingredients of a national health service. How soon they will move in this direction will depend on a number of factors: the pressure to relieve the high costs of fee-for-service; recognition of the need to improve the quality of out-of-hospital care; the example of neighboring Sweden; the relative power of the private practitioners; and the political temper of the country. The general political factors are probably decisive; Italy, which has a national health insurance system that is less advanced than that of Denmark, may nevertheless achieve a national health service earlier. Italy's ruling Christian Democratic Party, in 1973, proposed to abolish national health insurance and substitute a national health service financed by general revenues.21 Since this approach has the support of all the major political parties, and there appears to be a continuing leftward trend of the electorate, it would seem reasonable to expect a national health service in Italy fairly soon. The outlook for other nations is difficult to assess without an intimate knowledge of the political trands in each country, the character of the health services, and the degree of popular dissatisfaction with them. The latter factor is of major importance in the growth of the movement for a national health service. In the United States, which because of its political conservatism and ideological commitment to private practice would seem to be completely refractory to such ideas, there is a growing interest in a national health service. The widely respected Cambridge Survey offered four alternatives to those interviewed in a national poll and found that 8 per cent were undecided; 13 per cent were for keeping things as they are; 23 per cent favored giving medical insurance to poor people and major medical insurance to all; 35 per cent were for comprehensive national health insurance for everyone; and 22 per cent favored a totally nationalized system in which comprehensive care is provided for all and doctors and hospitals are taken over by the government.22 The fact that at least one-fifth of the American people AJPH November 1978, Vol. 68, No. 11
COMMENTARIES
chose a national health service is reflected in the changing attitudes of public health workers. The American Public Health Association, which in 1964 had testified before Congress in favor of government health insurance for the aged, and in 1970 supported comprehensive national health insurance for all, by 1976 was urging Congress to establish a national health service because, among other things, national health insurance "will simply support the present inadequate system of private health care delivery and would neither make high quality health care available to all Americans nor effectively control the rising costs of health care."23 Some proponents of national health insurance in the United States have taken the position that a national health service is premature and that a prior stage of comprehensive national health insurance is inevitable. This ignores the fact that the United States has already lived through national health insurance, for those 65 years and older, with unsatisfactory results. It also disregards the experience of Great
Britain. Furthermore, if those who believe in inevitable stages were consistent, they would support government subsidy of voluntary plans. This was, after all, the usual progression in Europe: first, the growth of voluntary plans; second, government subsidy and regulation of the plans; and third, government health insurance.24 Australia is now in the process of moving from stage two to stage three. The United States is still in stage 1, and subsidy of private insurance plans would be the next "inevitable" step. Indeed, there is a very real danger that neither the proponents of national health insurance nor of a national health service will have their way in the United States. The likelihood of this outcome has nothing to do with stages or inevitability, but with political power; the insurance companies exercise tremendous economic and political leverage. In the absence of a political party of labor such as exists in every other industrial nation, it will take heroic efforts to avoid the establishment of subsidized private insurance, or of government health insurance administered by private insurance companies. Transition from Public Assistance Probably the most interesting example of transition to a national health service is the first one, that of the Soviet Union. Sigerist points out that Zemstvo medicine was significant "not only from the point of view of Russia but from that of world medicine at large. It was the first attempt to organize medicine as a public service on a large scale."'3 Introduced in 1865, the Zemstvos or district assemblies rapidly increased their medical resources; they more than doubled the number of hospital beds, feldshers, midwives, and pharmacists, and tripled the number of physicians. But the resources were still inadequate: toward 1900 there was still only one physician for every 25,000 people. Sigerist states that despite these shortcomings "Zemstvo medicine paved the way for Soviet medicine in several respects. It created a medical organization, created a network of medical stations all over the country that could be improved and increased in number. And, above all, it accustomed the people AJPH November 1978, Vol. 68, No. 11
to the idea that medicine was not a trade but a public service. "13 It is interesting that social insurance was used to help finance the national health service in the early years in the Soviet Union. The contributions were paid by enterprises and institutions as a fixed percentage of the wage bill; under no conditions could they be deducted from wages. In 1936, social insurance contributions amounted to 2.3 billion rubles, or 37 per cent of the total health budget. In 1937, medical services were transferred almost entirely to the state budget; they have been financed from general revenues ever since. 3. 25 One of the best known examples of transition to a national health service is Cuba, which before 1959 exhibited the classic features of a public assistance system. "Most of the physicians were in private practice in the major cities, although about 10 per cent of the population were insured for medical care through mutual aid societies (mutualistas). The great majority of the population, who were poor, received care through 46 meagerly staffed government hospitals, some first-aid stations in Cuba's main cities, and eight maternal and child health stations for the national population of about 8.5 million people. The rural population had to be mainly dependent on traditional healers for ambulatory care or, if they were close enough to a town, on a crowded hospital outpatient department."26 Cuba moved directly from public assistance to the creation of a national health service based on these principles: "The health of the people should be a responsibility of the State; health services should be available to all; the community should play an active part in health programs; health services should have integrated preventive and curative functions."27 In the past 16 years, Cuba has succeeded in establishing a complete national health service and is moving now to raise its quality and effectiveness through scientific and technical advances, mass screening programs, sectorization and dispensarization. Perhaps the most startling example of transition from a charity system to a national health service is Mongolia, which prior to 1921 was "a country of monasteries, the country of lamaism." In this incredibly backward feudal country, whatever medical care existed was provided by lamas who practiced traditional Tibetan medicine. In 1925 a Health Department was created for the first time, and the first hospital, providing 15 beds and ambulatory care, was opened in the capital, Ulan-Bator. In 1930, state funds were no longer budgeted for traditional practitioners, and the government adopted an official policy limiting its support to scientific medicine. Remarkable progress has been made since: construction of a network of hospitals and ambulatory care centers which cover the entire country; development of an effective public health organization for the prevention of infectious deseases and protection of maternal and child health; establishment of schools for training health personnel, including a medical school in 1942; and an increase in the number of physicians from 1 per 100,000 in 1930 to I per 700 in 1965. Infant mortality was 500 per 1,000 live births in 1923-24 and less than 70 per 1,000 in 1959.28 Cuba and Mongolia are very different yet very much 1129
COMMENTARIES
alike. Cuba, like a number of other countries in Latin America, was a relatively developed underdeveloped country; this made it possible to establish its national health service quite rapidly. Mongolia, on the other hand, started with literally nothing: no hospitals, no clinics, no physicians, and no public health organization. The national health service of Mongolia took much longer to build; it was over 20 years, for example, before the country had a medical school. Despite the enormous differences between the two countries, they were able to bypass the health insurance stage because of two factors in which they were alike: their socialist orientation, and the advice and assistance which they received from countries with a developed national health service. In the case of Mongolia this was the Soviet Union; Cuba received help from a number of countries, including the Soviet Union, Czechoslovakia, and Hungary. Among the newly liberated countries in Asia and Africa, there is a fairly large number which have a socialist orientation and may also move directly from the public assistance system to a national health service. These include such countries as Laos and Iraq in Asia, and Algeria and Guinea in Africa. Many countries with a public assistance system still have a very dependent neocolonial status, however, and it is difficult to see how they can develop either toward national health insurance or a national health service under these conditions. Until they achieve a measure of economic as well as political independence, it will be difficult to assess their prospects for transition in either direction. There are a number of nations, particularly in Latin America, having a capitalist orientation, which have achieved a certain amount of economic and political independence, and may be able to make the transition from public assistance to national health insurance. But this will, in all likelihood, be a different kind of health insurance from that which is traditional in Europe and North America. Chile, in 1952-long before the advent of the socialistoriented Popular Unity government-took the bold and imaginative step of combining into a single system the public assistance hospitals and clinics, the polyclinics and hospitals of the social security system for blue collar workers, and the public health services of the Ministry of Health. This unified health service was financed primarily through general revenues; in 1962, for example, social insurance contributions accounted for only 16 per cent of the total. The coverage of the program has been estimated to be 70 to 75 per cent of the
population.29 The election of the Popular Unity government in 1970 created the possibility of further evolution to a complete national health service for the entire population. A key step would have been to merge the fee-for-service insurance program for white collar employees into the public program. But the coup by the fascist junta intervened, and the development of the Chilean National Health Service is currently in abeyance. In Costa Rica, Mexico, and many other developing countries, the shortage of facilities has made it necessary for the social security system to build its own hospitals and polyclinics employing salaried physicians. In these nations it 1130
will be logical to follow the Chilean example and combine the public assistance and social security hospitals and polyclinics with the public health services to create a unified health service. Costa Rica is apparently moving in this direction as a result of recent legislation for integration of services.3 Sooner or later, in Chile and in other countries, such unified health services for the majority of the people will be expanded to become national health services for the entire population.29 In the industrial capitalist countries with well intrenched health insurance systems-in which practitioners are essentially small businessmen selling their services-the resistance to change to a salaried service is very great. Nevertheless the trend is unmistakably toward the national health service. The latter has demonstrated not only its superiority in terms of quality and cost effectiveness, but has shown that it is unnecessary to submit to the blind forces of the medical marketplace; nations can plan rationally for their health services, and can plan them well. A national health service, finally, makes it possible to plan democratically and humanely, not for a minority but for all citizens and with all citizens. This is the lesson of our time. Increasingly the nations will understand and act upon it.
REFERENCES 1. Roemer MI: Health departments and medical care-A world scanning. Am J Public Health 50:154-160, 1960. 2. Kozusznik B: Health care systems in the modem world. La
Sante Publique 3:243-253, 1967. 3. U.S. Department of Health, Education, and Welfare, Social Security Administration. Social Security Programs throughout the World, 1975. Wash., DC: U.S. Govt. Printing Office, 1975. 4. Segovia de Arana JM: Spain. In Bowers JZ and Purcell E, eds: National Health Services: Their Impact on Medical Education and Their Role in Prevention. New York: Josiah Macy, Jr. Foundation, 1973. 5. Terris M: The epidemiologic revolution, national health insurance and the role of health departments. Am J Public Health 66:1155-1164, 1976. 6. Kaser M: Health Care in the Soviet Union and Eastern Europe. Boulder, Colo.: Westview Press, 1976. 7. Semashko NA: Health Protection in the U.S.S.R. London: Gollancz, 1934. 8. World Health Organization. Health Education in the U.S.S.R. Geneva: WHO, 1963. 9. Petrovsky B: Public Health in the U.S.S.R. Moscow: Novosti Press Agency Publishing House, undated. 10. Popov GA: Principles of Health Planning in the U.S.S.R. Geneva: WHO, 1971. 11. Lisitsin Y: Health Protection in the U.S.S.R. Moscow: Progress Publishers, 1972. 12. Terris M: Ambulatory Care in the U.S.S.R. Paper presented at the Annual Meeting of the American Public Health Association, Wash., DC, October 31, 1977. 13. Sigerist HE: Socialized Medicine in the Soviet Union. New York: W.W. Norton & Co., 1937. 14. Terris M: The contributions of Henry E. Sigerist to health service organization. Milbank Mem. Fund Quart., Health and Society 53:489-530, 1975. 15. Hyde G: The Soviet Health Service, a Historical and Comparative Study. London: Lawrence & Wishart, 1974. 16. Shenkin BN: Politics and medical care in Sweden: The seven crowns reform. New Eng. J. Med. 288:555-559, 1973. 17. Hjern, B: What About Socialized Medicine in Sweden? Arch. Surg. 111:941-944, 1976.
AJPH November 1978, Vol. 68, No. 11
COMMENTARIES 18. Andrews JL, Jr: Medical care in Sweden, lessons for America. JAMA 223: 1369-1375, 1973. 19. Lindgren SA: Sweden. In Douglas-Wilson I and McLachlan G, eds: Health Service Prospects, An International Survey. Boston: Little, Brown, 1973. 20. Maynard A: Health Care in the European Community. Pittsburgh: Univ. of Pittsburgh Press, 1975. 21. The New York Times, February 8, 1973, p9. 22. The Chicago Sun-Times, October 12, 1975, p7. 23. Resolution adopted by the Governing Council of the American Public Health Association, October 20, 1976: Establishment of a National Health Service. Am J Public Health 67:86-87, 1977. 24. Perrott G St J and Mountin JW: Voluntary health insurance in
25. 26. 27.
28. 29.
western Europe: Its origins and place in national programs. Pub H Rep 62:733-767, 1947. Sigerist HE: Medicine and Health in the Soviet Union. New York: The Citadel Press, 1947. Roemer MI: Political ideology and health care: Hospital patterns in the Philippines and Cuba. Int J Health Services 3:487492, 1973. Riveron Corteguera R, Ferrer Garcia H and Valdes Lazo F: Advances in pediatrics and child care in Cuba, 1959-1974. Bull Pan Amer Health Org'n. 10:9-24, 1976. Ibrahimov MA: Public health protection in the Mongolian People's Republic. La Sante Publique 5:271-278, 1962. Roemer MI: Medical Care in Latin America. Wash., DC: Organization of American States, 1963.
Fellowships in Family Practice Announced Twelve, two-year fellowships for physicians seeking full-time careers as teachers of family medicine are available at the Universities of Iowa, Utah, and Washington in Seattle, beginning July 1, 1979. Selection of fellows is made by the three universities' family practice departments. To be eligible, applicants must have completed (and excelled in) residency training in family practice or one of the other primary care specialties such as internal medicine or pediatrics and be board certified or eligible; an applicant must be committed to an academic career in family medicine, which includes teaching, research, and patient care in a medical school or affiliated residency training program. This national program is sponsored by the Robert Wood Foundation. The fellowships program has been designed by the participating departments of family practice so the fellows may acquire the capabilities needed for their academic careers. In addition to maintaining clinical competence, fellows will develop research and teaching skills. Areas of study include administration, biostatistics, research methodology, quality of care assessment, and development and evaluation of educational programs. Grants totaling nearly $2,000,000 to the three universities are being used to develop the programs and to provide stipends for fellows and faculty support. The application deadline for fellowships beginning July 1, 1979 is November 15, 1978. For applications and information contact one of the following individuals: Robert E. Rakel, MD, Chairman Department of Family Practice University of Iowa College of Medicine S-150 Children's Hospital Iowa City, IA 52242
Hilmon Castle, MD, Chairman Department of Family and Community Medicine University of Utah College of Medicine 50 North Medical Drive Salt Lake City, UT 84132 T. J. Phillips, MD, Professor Department of Family Medicine RF-30
University of Washington School of Medicine Seattle, WA 98195
AJPH November 1978, Vol. 68, No. 11
1131
