2005年-世界发展银行全球_Health_Systems_in_East_Asia___What_Can_Developing_Countries_Learn_from_Japan_and_the_Asian_Tigers__21页_348kb

Summary of Health Systems in East Asia: Lessons for Developing Countries

Core Content

This paper analyzes the health systems of Japan and the Asian Tigers (Hong Kong (China), Republic of Korea, Singapore, and Taiwan (China)) to identify lessons that can be applied to developing countries in East Asia. Despite significant differences in income and health financing models, these systems have managed to control health spending effectively, offering valuable insights into progressivity, cost control, and service delivery.

Main Points and Key Information

1. Health Spending and Income Levels

• Per Capita Health Spending: Japan spends more on health than the other systems, even though it is richer than the Tigers. The Tigers, especially Singapore, spend less than expected based on GDP per capita.
• Trends in Spending: Between 1998 and 2001, all systems increased their health spending as a share of GDP, with Taiwan (China) increasing the fastest and Singapore the slowest.
• Out-of-Pocket Payments: All systems have out-of-pocket payments exceeding 30% of total health expenditure, except Japan. These payments are more regressive in Japan and Korea, while more proportional in Hong Kong (China) and Taiwan (China).

2. Health Financing Models

• Revenue Sources:
  • Hong Kong (China): Relies heavily on general and non-tax revenues (over 50%).
  • Japan, Korea, and Taiwan (China): Social insurance covers about half of health spending.
  • Singapore: Relies on out-of-pocket payments for two-thirds of its health spending.
• Progressivity of Financing:
  • Only Hong Kong (China) has a fully progressive system.
  • Japan has a proportional system, but with a wide variety of insurance plans.
  • Korea and Taiwan (China) have progressive systems due to exemptions and reduced copayments for the poor.
• Catastrophic Payments:
  • Korea has the highest incidence of catastrophic out-of-pocket payments.
  • Taiwan (China) shows increasing concentration of catastrophic payments among the poor as the threshold increases.
  • Singapore has relatively low levels of catastrophic payments, though they have not decreased significantly since the introduction of medical savings accounts (MSAs).
  • Japan has a cap on out-of-pocket payments for insured services, reducing vulnerability.

3. Healthcare Delivery and Utilization

• Public vs. Private Sector:
  • Hong Kong (China) and Singapore: Publicly owned hospitals, but privately funded ambulatory care.
  • Japan, Korea, and Taiwan (China): Private hospitals, but public financing through social insurance.
• Provider Payment Models:
  • All systems use fee-for-service (FFS) for first-level providers.
  • Japan has successfully managed cost control and profit margins through a detailed fee schedule and bundling of services.
  • Korea and Taiwan (China) have experimented with diagnosis-related groups (DRGs), which have led to cost savings and a shift to outpatient care.
• Service Utilization:
  • Korea has a high rate of Caesarian sections (43%) and specialty care use.
  • Japan has a more balanced use of services, with lower rates of high-tech care and higher emphasis on primary care.
  • Taiwan (China) has a differentiated fee schedule, encouraging hospitals to improve their facilities to get higher reimbursement rates.
• Reforms and Outcomes:
  • Japan introduced per diem reimbursement and DRG pilots, leading to cost reductions and improved efficiency.
  • Korea and Taiwan (China) saw cost savings and reduced length of stay with DRG implementation.
  • Singapore’s MSAs have not reduced out-of-pocket payments significantly, and its system has not been as effective in protecting the poor from catastrophic health expenses.

4. Key Lessons for Developing Countries

• Progressivity of Financing: Exemptions, reduced copayments, and caps on out-of-pocket payments are essential to protect the poor from catastrophic health spending.
• Cost Control: Careful design of fee schedules, such as Japan’s, can help control costs without compromising service quality.
• Provider Payment Reforms: DRGs and other prospective payment methods can lead to cost savings and more efficient service delivery.
• Separation of Prescribing and Dispensing: This is important for promoting rational use of medicines and controlling costs.
• Universal Health Insurance (UHI): Early introduction of UHI, as in Korea and Taiwan (China), can reduce out-of-pocket spending and improve access to care.

Conclusion

The health systems of Japan and the Asian Tigers provide a rich set of experiences for developing countries in East Asia. While the systems differ in their approaches to financing and delivery, they share common challenges and solutions. The paper highlights the importance of progressivity in health financing, effective cost control mechanisms, and the role of provider payment reforms in shaping service utilization. These insights are crucial for developing countries aiming to achieve universal health coverage and reduce health system vulnerabilities.