Austria Belgium 1877/1888: the industrial accident and health insurance scheme for workers (fund: 2/3 paid by workers, 1/3 paid by employers, no payment by government). Services included: free medical treatment, free medicines and adequate sickness benefits. Beginning of the 20th century: formation of mutuality to cover their members with health care. 1926: White Collar Workers Insurance Act (white collar workers in the private sector): included health insurance and work accident insurance. 1928: Agricultural Labourers Insurance Act. Situation in 1946: 2/3 of the population covered with health insurance. 1980: 99% covered; expansion of health benefits to include unlimited inpatient care, screening programmes and preventive services, routine examinations of schoolchildren and rehabilitation. 1978: the KRAZAF (hospitals cooperation fund) to limit funding pressures. 1944: a compulsory health insurance system for workers. 1963: Leburtons's Law: Creation of the National Institute for Sickness and Invalidity: access to insurance coverage for all inhabitants of Belgium. 1980's: Rapid grow of health care expenditures led to funding pressure. 1997: the LKF (performance-oriented hospital financing) to replace the KRAZAF. 2005: Health Reform (cost containment measures). 1990: Sickness Funds Act (democratization of management, transparency of costs). 1990-2006: Cost containment measures (budgeting). 2002: Palliative care law (right for everybody). Bulgaria 1918: First Health Insurance Act. 1924: Compulsory insurance for all workers and public servants. 1945: Enlargement of health insurance coverage. 1948-49: Expropriation of private hospitals, clinics, dental unions and pharmacies. 1950: Centrally run state health system, financed by general taxes. 1992: Decentralization of health system. 1998: Health Insurance Act (introduction of compulsory and voluntary health insurance); National Framework Contract (regulates payments to health care providers). 1999: Health Care Establishments Act (rules outpatient care); restructuring public health system. Croatia 1922: the Brotherhood Treasury (covered mine workers), the Central Office for Workers Insurance (covered other employees and workers), and Merkur (covered government officials), all private run. 1945: compulsory state health insurance. 1993: Consolidation of health finance under a single public entity; opt-out option for patients from the compulsory system; private providers recognized; privatizations. 2002: Consolidation of social insurance collection under the State Treasury; higher co-payments; limited coverage of compulsory insurance. Czech Republic 1918: The from the Empire (Austria-Hungary) inherited Bismarckian health system was expanded and refined. 1948: Unification of health and social insurance into a compulsory system for all citizens; Foundation of the Central National Insurance Fund (paid entirely by the employer). 1990/1991: Liberalization of health care system, Introduction of the principle of free choice of health care facilities. 1991: General Health Insurance Law and General Health Insurance Fund; Movement toward a compulsory social insurance model. Page 1 of 11
Czech Republic (cont.) 1924: Creation of the Central Social Insurance Fund (consolidated fragmented social insurance system into a single institution). 1952: unified state health care. 1968: Proclamation of the federation of the Czech and the Slovak Republics, creation of two separate ministries of health. 2003: Change of ownership of half of the state-owned hospitals to self-governing regions. 2008: Cost containment measures (fees, set of maximum prices for pharmaceuticals, etc.). Denmark Before the 18th century: "insurance" through landowners and artisan masters. 1772: First Danish doctor society established. 18th-19th century: Transition of responsibility of poor relief and health care passed to the town and counties; early measurements to improve public health: education of midwives, smallpox inoculation and improved education of physicians and surgeons. 1806: First Danish public hospital law enacted. 1857: Foundation of the National Danish Medical Association. 1960: Change from direct state grants to hospitals to block grants to counties (hospital expansion in the hand of the counties). 1973: Changement to a single payer system with the counties assuming responsibility for the National Health Security System covering general practioneers, practising specialists and medical expenses. 1990's: Focus on cost containment. 2009-2011: Establishment of DDKM (Danish Healthcare Quality Programme). Estonia Beginning of 20th century: existence of basic health care system, highly decentralized, with services developed and managed locally. Services included: clinics for mothers and children, tuberculosis, dispensaries, sanatoria, and institution for the mentally ill. 1940-1990: Implementation of the Soviet Semashko System, no private sector involvement, free access to health care services. August 1991 (Independence): Establishment of a Social Health Care System, financing through social insurance. 2012: Centralization of primary care organization. Finland Gradually development of health care, no exact point of time can be identified for the introduction of the tax financed system. Responsibility for health care before WW2: Municipalities; Services included: Public Health, treatment of tuberculosis, other communicable diseases and mental diseases. 1940: Establishment of maternal and child care measures to treat and prevent tuberculosis. 1950's: Development of a hospital system. 1960's: the National Health Insurance to cover cost of drugs, private medical care and some other services. 1972: the Primary Health Care Act and national planning system. "Population responsibility" including "Personal Doctor" system. 1993: Financial Reform of the Health Care System: subsidies from the state started to be allocated to municipalities according to demographic and other need criteria. Page 2 of 11
Finland (cont.) France Germany Late 19th century: Local sickness funds for certain workers. 1883: mandatory health insurance. 1884: Extension to work related accidents. 1889: Old age and disability. Services included: sick pay, maternity pay and death compensation. 1930: Compulsory health insurance for low-wage workers in industry and business. 1979: Occupational Health Act: obligation for employers to provide occupational health services to their employees. 1967: National insurance fund for salaried workers, agricultural and selfemployed covered by other funds. 1978: National coverage achieved. 1979: Fee schedules tightened. 1949: Reestablishment of the health care system which was in power at the end of the Weimar period. 1977: Health Insurance Cost-Containment Act: Requirement to pursue a goal of stability in contributions for the sickness funds and the provider of health care; expenditure cap on ambulatory care; global budgets for physician associations. 1984/85: Global budgets introduced for public hospitals to tighten expenditures. 1993: Global budgets introduced for private hospitals. 1994: National targets for pharmaceutical expenditures. 1996: Global budget for the health agencies to manage funding; increase of patient co-payments. 2004: A gatekeeping primary care system plus a referral system for access to secondary care (the preferred doctor scheme); and an electronic personal medical record (DMP) for the management of care were introduced. 1981: 90% coverage achieved. 1982: Out-of-pocket payments for drugs increased. 1984-86: Global budgets introduced for hospitals. 1992: Health Care Structure Act. 1996: Health Insurance Contribution Rate Exoneration Act. 1997: First and Second Statutory Health Insurance Restructuring Acts. 1998: Act to Strengthen Solidarity in Statutory Health Insurance. 2004: Reform Act of Statutory Health Insurance: higher co-payments; possibility for public health insurers to give rebates to low-cost insured; orderly of pharmaceuticals by e-mail permitted; reform of pharmacists' mark-up. 2009: Establishing of national health fund (centralising of collecting of health insurance contributions). Page 3 of 11
Greece 1917: Establishment of the Ministry of Hygiene and Social Welfare. 1934: Foundation of Social Security Organization (IKA): Provision of health and pension coverage for blue and white collar workers. 1941: Establishment of temporary public hospitals to serve the war needs. 1953: Legislation for a National Health Service. 1961: Agricultural Insurance Organization (OGO) which covered 50% of the population. 1983: a National Health Service: Reform of the health care system to ensure equity in the delivery and financing of health care services. 2001: Decentralization of the health care system and the introduction of autonomous hospital management. 2003: Reorganization of welfare services with decentralization and better management. 2005: Reorganization of public health services. Hungary 1898: National Fund of Patient Care: reimbursement of health costs for the poor. 1927: National Social Insurance Institute. 1987: a "reform secretariat" to make proposals for a needed health reform (due to a widening gap between Hungarian standards and Western European standards. 1980's/90's: a Social Insurance Fund and recognition for private providers. Ireland 1912: free medical treatment for those suffering from tuberculosis. 1947: Establishment of the Department of Health. 1953: Health Act (1953) extended free hospital and specialist care in public wards to approximately 85% of the population. 1957: the VHI Board was established as a non-profit-making, semi-state private insurance body by the Government. 1970: Health Act: shifted the responsibility for the development and execution of health policy from local authorities to the Department of Health; all residents qualify to receive services either under eligibility Category I or Category II (Cat. I: the needy, how are entitled to services without charge). 1972: Establishment of the General Medical Services (GMS) Scheme, providing a choice of private GPs and pharmacists to all Category I patients. 2005: Health Service Reform Programme: a single national entity, to be responsible for managing services came into operation. Page 4 of 11
Italy Latvia Luxembourg Malta 1861-1920: Autonomous mutual aid associations for artisans and workers, the Catholic Church and charitable institutions established several health care providers. Moreover, provincial and municipal networks provided social assistance to disabled and needy people. 20th century: Provision of health services by private practitioners, costs borne by patients. 1732: First official document about health care forbidding medical practice without licence. 1818: Medical Commission to regulate everything "relative to the exercise of the different branches of the art of healing" (replaced by the Medical College in 1818). 1901: compulsory health care insurance. 1875: Foundation of a Sanitary Office (closed down after a few years due to insufficient funds). 1898: First insurance for occupational accidents. 1923: Right for hospital care for the needy. Before WW1: Employee Insurance Law which restricted the right and autonomy of sickness funds. 1930: Law which required compulsory health insurance for employees. 1930: Entire employed urban and rural population had insurance cover. 1902: Grand-Ducal decree introduced an impressive system for monitoring communicable diseases; minor role for the state in managing hospitals. 1937: Medical and Health Department Ordinance: control of public health and management of hospitals. Mutual aid societies converted to local branches of national insurance program. 1958: Creation of an independent Ministry of Health. 1978: Creation of the National Health Service (SSN). 1973: Working population, their families and all pensioners were covered by compulsory health insurance. 1974: Significant injection of state resources (40%) in the funds. 1976: Legislation to increase the influence of the state in the hospital sector. 1990: Move from per diem to DRG payments for hospitals. 1992: Creation of regional enterprises to limit spending; regional enterprises can contract out services, hospitals can become independent. 1994: First National Health Plan: definition of national health targets and establishment of uniform levels of assistance should be guaranteed to all citizens. 1998/2003/2006: National Health Plans. 1993: Reform to abolish central planning system. 1994: establishment of sickness funds with the function of redistributing state budget money to health care providers. 1997 merger of the sickness funds. Since 1998: A central institution (SCHIA) redistributes financial resources from the state budget on the basis of contractual arrangements with providers. 1992: New financing system for hospitals. 1993: Health Reform. Page 5 of 11
Netherlands 1941: Sickness Fund Decree. 1964: Sickness Fund Act. 1980: Health Tariff Act. 1989: First Reform Act, flat rate premium in sickness fund insurance. 1991: Second Reform Act: deregulation planning and tariff expansion. 1991: Maximum Tariff Act: end of mandatory contracting of self-employed health professionals by sickness funds. 1998: Health Insurance Restructuring Act: improving the insurance position of people over 65. 1999/2001: new supervising structures. 2003: systemic reform: includes managed competition elements and a single compulsory health insurance scheme for all. Poland Foundation and expansion of health services during the Polish independence from 1918-1939. 1945: Centralization of Health Care under Soviet rule. First set of reforms aimed to develop free and universal public health care; limited free health care was available in rural areas. 1972: Establishment of integrated health care management units (ZOZ) to manage hospitals, outpatient clinics, specialist and primary health care. 1980: Decentralisation of health care administration. After 1990: Further decentralisations, strengthening of primary care, and introduction of compulsory health insurance. 2003: Introduction centralised National Health Fund (but by decision of Constitutional Court it was unconstitutional). 2004: Law on Health Care Services Financed from Public Sources 2011: Several Key Reforms (for example, Law on Therapeutic Activity, Law on the Information System in Health Care). Portugal 1901: First act of public health legislation, prior to that date: Provision of health care by the hospitals of religious charities. 1944: Social Services Statutory Statute 1945: Public maternity and child welfare. 1946: Creation of mandatory social health insurance system. 1979: Creation of National Health Service (free at the point of use). 1990: Law on the Fundamental Principles of Health: user charges, decentralization of health system and contracting out of NHS services. 1995: The first experience to put a NHS hospital under the management control of a private consortium was initiated with the launching of a public bid for proposals according to a set of pre-defined terms. 1998: experimental payment system for general practitioner: performance based and no fixed salary. 2002: Cost containment measures (new management of hospitals, prescriptions substituted by generics). 2007: Expansion of co-payments. Page 6 of 11
Slovak Republic Slovenia Spain Around 1900: first act of social insurance covering accident and sickness insurance for certain groups of the population. 1854: Miners Act: Health insurance system for miners. Services included: fraternal funds providing compulsory insurance to miners and foundry workers, extension to railway workers in 1958. 1855: Basic Health Act: creation of organizational framework for health care. 1900: Accidents at Work Act: Start of social insurance system. 1924: Compulsory sickness insurance for wider groups of the population. 1888: Extension to incorporate health insurance (Health insurance paid 1/3 by employers and 2/3 by employees). 1889: First sickness fund for compulsory health insurance. 1919: Foundation of association of health insurance funds. 1937: Foundation of pension and disability insurance programmes. 1908: Creation of the National Institute for Social Insurance: Protection of the population against a variety of risks. 1942: Statutory Sickness Insurance. 1948: Unification of health and social insurance into a compulsory system for all citizens; Foundation of the Central National Insurance Fund (paid entirely by the employer). 1952: unified state health care. 1968: Proclamation of the federation of the Czech and the Slovak Republics, creation of two separate ministries of health. 1945-1954: Model of social insurance (pension and disability insurance, health insurance and maternity insurance): coverage for all workers, pensioners together with their family members; no coverage for farmers, self-employed, craft workers and other professional groups. 1954/55: Separation of health insurance and social security. 1970: Seven Crown Reform: considerable reduction of fees incurred by the patient. 1972: Full equality between workers and farmers. 1944: Basic Health Act. 1963: Approval of Basic Social Security Act which implied the transition from a previous means-tested set of social insurance schemes to a system of social security coverage for the bulk of the working population and dependants. 1967: Implementation of Basic Social Security Act. 1990: Government adopted the document Reform of structure, management and financing of health care (aim: remove state monopoly on health). 1992: Foundation of State Health Fund and the National Health Promotion Centre, establishing of the Institute for the the Health Insurance Plan. 1993: Insurance scheme began (universal coverage of comprehensive free of charge health care services based on mandatory health insurance), decentralisation. 2003: o-payments; further decentralisations. 1992: Reform of the health care system by replacing direct funding from the ministry of health by employment based financing, Privatisation of public health networks. 2005: Law on Changes and Amendments to the Health Care and Health Insurance Act: The Law aims to put an end to cream-skimming, which started after general insurance companies entered the VHI market. 2008: Resolution of the National Health Plan 2008-2013. 2008: Amendment to the Health Care and Health Insurance Act: The Act mainly stipulates exemptions from co-payments for low-income groups and introduces liability of income from various forms of contract work for contributions to compulsory health insurance. 1981: Creation of Ministry of Health. 1986: General Health Care Act (start with transition from Bismarck model to NHS model). 1986: Completion of devolving central public health powers to the region was completed. 1989: Switch from social insurance to general taxation as the main source of funding of the health care system. Page 7 of 11
Spain (cont.) Sweden Sweden (cont.) United Kingdom 1765: Agreement of the four estates: permission to the local authorities to spend locallycollected resources on the construction of a hospital. 1928: Hospital Act: County councils became legally responsible for providing hospital care. 1911: Manual workers and low wage workers covered. 1946: National health insurance. 1978: Decentralisation of health care system, introduction of co-payments. 1979: Administration of health care system by National Institute of Health (INSALUD, semi-independent public agency). 1946: National Health Insurance Act: universal coverage for physician consultations, prescription drugs and sickness compensation (Act implemented in 1955). Post-war era: expansion of national health care, mostly consumed in hospitals (hospital based). 1968: Transformation of the Royal Medical Board into the National Board of Health and Welfare (for supervision of health care). 1948: the National Health Service: Collective responsibility by the state for a comprehensive health service which was to be available to the entire population free at the point of use. 1995: Approval of the first National Health Plan. 1997: the self-governing status of health care centres. 2002: decentralisation of responsibility of health care to 10 autonomous communities. 2006: SNS common benefits package is defined. 1982: Health and Medical Services Act: county councils receive responsibility for health services. 1985: DAGMAR reform: county councils financially responsible publicly financed private care (full implementation 1994). 1992: ÄDEL - Reforms: Municipalities receive responsibility for providing long-term health care and social welfare services to elderly and disabled. 1994: Family Doctor Act: Residents could choose a family doctor. 1998: Drug reform: county councils took over financial responsibility for prescription drugs. 2011: the New Act on Patient Safety. 1990: National Health Service and Community Care Act: GPs become "fundholders", they receive capitates payment per patient and must pay for services (drugs, inpatient care, emergency care), hospitals become "trusts" (similar to not-for-profit business). Global budgets established with NHS; salaries of physicians established with NHS. 1998 reform: Local Health Action Zones to set health goals and coordinate goals; Primary Care Groups made up of all physicians in an area will replace fundholders. 2003: The Health and Social Care Act 2003 introduces a new form of organization for hospital services. 2007: The Local Government and Public Involvement in Health Act 2007 creates a requirement for a joint needs assessment between health and local authorities. Page 8 of 11
Macedonia Norway Switzerland 1911: Health and Accident Insurance Law: required health insurance funds that wished to take advantage of federal subsidies to register with the Federal Office for Social Insurance and to abide by its rules. Services included: ambulatory care, drugs and hospital stays of limited duration, and to allow people a certain degree of freedom to change funds. 1945: compulsory state health insurance. 1967: Creation of the National Insurance Scheme (NIS). 1964: Health Insurance Reform: Revised system of subsidies to the funds based on age and gender and the introduction of compulsory user charges in the statutory health insurance system. 1991: Law on Health Care (established insurancebased system). Since 1997: privatisations and several cost containment measures. 1984: Municipalities Health Care Act: Responsibility of local authorities for all primary health care. 2001: Liberalisation of pharmacy market. 2002: Hospital reform: central government took over control for specialist health care 2012: Coordination Reform (improve coordination between municipalities and hospitals, put more emphasis on public health care). 1994-1996: Health Care Reforms: strengthen solidarity and contain costs. Australia 1946: Hospital Benefits Act: public subsidies for hospitals. 1950: Pharmaceutical Benefits Act: subsidized pharmaceuticals. 1953: National Health Act. 1975: National health insurance Medibank: universal tax-funded system. 1981: Reform: individuals could opt out of Medibank. 1983-96: Re-established a universal, tax-funded health insurance system, Medicare, remains today. Page 9 of 11
Canada 1947: First provincial health insurance program. 1966: Establishment of Medicare. 1972: Last jurisdiction enacts Medicare. 1984: Canada Health Act; physicians must accept government payment as payment in full: Hospitals: global budgets established with universal coverage; Certification of Need required for expansion of a hospital. 1988: First province starts with regionalization of health system (last 1996). 1990: Federal payments to provinces frozen; tighter supply-side limits by provinces; merging of hospitals; cutback in public coverage (dental care, visions exams). 1995: Federal government reduces cash transfer to provinces and territories. 2004: 10 year plan to strengthen health care (increase of federal funding). Japan 1922: Health Insurance Law covered some workers (extended in 1938). 1958: National Health Insurance mandated. 1961: All local governments implemented. Early 1980ies: Tighter fee schedules for hospitals ad physicians. 1985-87: Hospital beds and expansion capped. 1997: Substantial increase in patient co-insurance, mandated prices for pharmaceuticals eliminated. 2006: Structural Health Care Reform Act (Fifth Revision of the Medical Care Act, Revision of the Health Services for the Elderly Act and other health insurance-related Acts). New Zealand 1900: Public Health Act: Creation of a Public Health Department headed by a chief health officer while those appointed as local district health officers were to be medical practioneers with "special knowledge of sanitary and bacteriological science". 1938: Social Security Act: comprehensive health system that mandated the provision of free care for all. 1947: Set up of a predominantly taxfunded health care system that made most services available free. 1980s: Decentralization of the "welfare state" health system. 1983: Area Health Boards Act: Provided the basis for establishing local boards. 1990s: Movement to Regional Health Authorities away from centrally funded systems. 1993: Health and Disability Services Act. Page 10 of 11
United States In general: No universal public health insurance. DRG: Diagnosis related groups. 1965: Creation of Medicaid (support for the poor) and Medicare (support for the elderly). 1983: Prospective payment for hospital admission. 1992: Fee schedule for physicians. 1993 proposal (failed): universal insurance coverage. 1996: Health Insurance Portability of Insurance for job to job transitions. 1997: Balanced Budget Act: choices in Medicare are expanded. 2003: Medicare and Medicaid reimbursement of drug costs expanded. 2010: Health insurance reform legislation (enables coverage of 95% of all U.S. citizens). 2010: Adoption of the Affordable Care Act (ACA): central aim: improvement of coverage, further goals: controlling expenditures and improving quality. Sources: WHO Europe, Health Care Systems in Transition, http://www.euro.who.int/en/home/projects/observatory/publications/health-system-profiles-hits/full-list-of-hits (accessed 13 April 2011), updated 25 June 2014. For the United States only: The White House, Health Care (http://www.whitehouse.gov/issues/health-care), accessed 23 April 2010; WHO, Health Systems in Transition (HiT) 2013, updated 25 June 2014. Page 11 of 11