International Health Systems
Cuba has a population of 11,236,000 which is about the same as Ohio. The life expectancy is 74.7 for males and 79.2 for females in 2001 compared to 74.3 for males and 79.5 for females in the U.S. The infant mortality rate is 7 per 1,000 live births. Cuba’s universal health system began in 1959 with the change of government. Cuba spends 6.3 percent of it GDP on healthcare, and its 1997 per capita expense was $131-USD. Despite Cuba’s low spending, it was ranked 39th for “overall health system performance” by the World Health Organization, compared to the U.S. ranking of 37 (out of 191 countries).
Cuba has a national health service. Services are available without charge to everyone. They are provided by salaried personnel in facilities run by the government. Patients have access to 24-hour, neighborhood doctor and nurse teams (1 doctor-nurse team per 120-170 patients). If necessary, patients are referred to multi-specialty clinics (“polyclinics”) and/or hospitals. A patient may change their GP to a doctor in another neighborhood. Physicians spend their mornings in their practice and their afternoons making house calls to the elderly and the infirm. Every patient is seen at least twice a year, either by coming into the clinic or by a house call from the physician.
The government pays for 89.2 percent of health expenditures. Benefits include full medical and dental services, as well as prescription drugs. Private out-of-pocket expenditures account for the remaining 10.8 percent of health expenditures. Because of the strict embargo, Cuba relies on donations of some medical supplies from Canada, Europe, Latin America, and U.S. NGOs. However, Cuba exports physicians to practice all over Central and South America, Africa, and Asia. Cuba also has established medical schools, staffed by Cuban professors, in Guyana, Benin, Uganda, Ghana, Yemen and Equatorial Guinea.
*Compiled by Jeanine Valrie, February 2004
Sturm, Tanja. “Cuba: Cuban Healthcare in the Twenty- First Century: Does It Work?” World Markets Research Centre. 2002.
americas_Cuba_health.html (3 Feb 2004).
Bourne, Peter G. “Asking the Right Questions: Lessons from the Cuban Healthcare System.” Center for the Advancement of Health.(Date unkown)
http://www.cfah.org/pdfs/Peter_Cuban_Healthcare_Presentation_Revised.pdf (2 Feb 2004).
Veeken, Hans. “Cuba: Plenty of care, few condoms, no corruption.” British Medical Journal (International) v311n7010 (Oct 7, 1995): 935-937.
The World Health Report 2000. “Health Systems: Improving Performance.” World Health Organization. 2000.
Finland has a population size of 5 million people, which is about the same number of people who live in the state of Maryland. Finland has an infant mortality rate of 4.2 per 1,000 live births and its life expectancy at birth is 73.5 years for men and 80.6 years for women. The country spends 6.9% of GDP on health care, and its 1998 per capita expense was $1,502-US. In 1964, national health insurance was enacted in Finland.
The Finnish health system is primarily funded (80%) by general tax revenues collected by the local and national governments. The basic administrative levels in Finland are divided into communes and municipalities. The local authorities in Finland number 445, averaging about 10,000 people each.
GP’s practice mostly in health centers. They are salaried, but many are paid fee-for-service for overtime. Hospital physicians, who must be specialists, are salaried.
Denmark, a small country, is home to 5.3 million people - the same number as in the state of Wisconsin. Its infant mortality rate is 4.7 per 1,000 live births, and its life expectancy at birth is 73.7 years for men and 78.6 years for women. Denmark has had a single-payer national health system since 1961. Approximately 8.3% of GDP is spent on health care, and the 1998 per capita expense was $2,133-US.
The Danish health care system is funded by progressive income taxes, and is publicly administered. Hospitals are run by the 14 counties and the City of Copenhagen. Physicians who work with the hospitals receive salaries, which are determined by negotiation between government and doctor’s unions. GP’s are 40% per capita fee, and 60% fee-for-service. Specialists are mostly fee-for-service. All medical and nursing education is free.
There is strong incentive for patients to choose a GP in their immediate area of residence. GP’s will then make referrals to specialists. There are no co-pays for physician or hospital care, but patients do pay a share of drug costs - usually between 25 and 50%. Private insurance, held by approximately 27% of the population, is used mainly for medications and dental expenses.
France has a population close to that of the entire Midwest - 60.9 million people. France has an infant mortality rate of 4.7 per 1,000 live births and a life expectancy at birth of 74.6 years for men and 82.2 years for women. The country has had a national health insurance system since 1928, but universal coverage did not occur until 1978. Approximately 9.6% of France’s GDP is spent on health care, and its 1998 per capita expense was $2,077-US.
The French health care system is primarily funded by Sickness Insurance Funds (SIF’s), which are autonomous, not-for-profit, government-regulated bodies with national headquarters and regional networks. They are financed by compulsory payroll contributions (13% of wage), of employers (70% of contributions) and employees (30% of contributions). SIF’s cover 99% of the population and account for 75% of health expenditures. The 3 main SIF’s
(CNAMTS, MSA, and CANAM) cover about 95% of the population, and the remaining 5% of the insured population are covered under 11 smaller schemes. The remainder of health expenditures is covered by the central government, by patients’ out-of-pocket payments, and by Mutual Insurance Funds (MIF’s), which provide supplemental and voluntary private insurance to cover cost-sharing arrangements and extra billings. MIF’s cover 80% of the population and account for 6% of health expenditures. The major public authority in the French health system is the Ministry of Health. Below this are 21 regional health offices that regulate each of the 95 provinces.
Patients are free to choose their providers and have no limits on the number of services covered. GP’s have no formal gatekeeper function. Private physicians are paid on a fee-for-service basis and patients subsequently receive partial or full reimbursement from their health insurance funds. The average charge for an office visit to a GP and a specialist are $18 and $25, respectively. Private hospitals are profit-making and non-profit making, usually with fee-for-service physicians. Public hospitals employ salaried physicians, who make up 1/3 of all GP’s in France. All medical and nursing education is free.
Germany is home to approximately 82 million people, nearly 1/3 of the U.S. population. Germany’s infant mortality rate is 4.7 per 1,000 live births, and its life expectancy at birth is 74.5 years for men and 80.5 years for women. In 1883, Germany was the first country to establish the foundations of a national health insurance system and has since gradually expanded coverage to over 92% of the population. Today, Germany spends 10.6% of its GDP on health care, and the 1998 per capita expense was $2,424-US.
Everyone in Germany is eligible for health insurance, and individuals above a determined income level have the right to obtain private coverage. The German health care system is predominantly characterized by Sickness Insurance Funds (SIF’s), which are funded by compulsory payroll contributions (14% of wage), equally shared by employers and employees. SIF’s cover 92% of the population and account for 81% of health expenditures. The rest of the population (the affluent, self-employed, and civil servants) is covered by private insurance, which is based on voluntary, individual contributions. Private insurance accounts for 8% of health expenditures.
GP’s have no formal gatekeeper function. Private physicians, over half of which are specialists, are paid on a fee-for-service basis. Representatives of the sickness funds negotiate with the regional associations of physicians to determine aggregate payments. Physicians who work in hospitals are full-time salaried specialists, whose work is entirely devoted to in-patients. All medical and nursing education is free.