*Bartosz Kobuszewski
Financing of tasks in the area of public health in selected European Union countries and Norway
Finansowanie zadań z zakresu zdrowia publicznego w wybranych krajach członkowskich Unii Europejskiej i Norwegii
Department of Economics, Law and Management, School of Public Health, Centre of Postgraduate Medical Education, Warsaw
Head of Department: Iwona Wrześniewska-Wal, MD, PhD
Streszczenie
Wstęp. Po latach starań środowiska naukowego władza publiczna w Polsce dostrzegła znaczenie zdrowia publicznego i w 2015 roku zdecydowano się na uchwalenie ustawy o zdrowiu publicznym. Nowy akt prawny wprowadza rozwiązania, mające zapewniać maksymalizację korzyści płynących z realizacji zadań z zakresu zdrowia publicznego, m.in. dzięki nowym mechanizmom i źródłom ich finansowania.
Cel pracy. W kontekście nowych rozwiązań legislacyjnych w Polsce, w niniejszej pracy dokonano międzynarodowej analizy porównawczej wydatków na zadania z zakresu zdrowia publicznego w wybranych krajach Unii Europejskiej i Norwegii.
Materiał i metody. W analizie porównawczej wykorzystano dane publikowane przez OECD za lata 2000-2014. Analizę wielkości wydatków na ochronę zdrowia oraz zadania z zakresu zdrowia publicznego przeprowadzono łącznie dla 22 krajów (21 państw członkowskich UE i Norwegii).
Wyniki. W 2013 roku w analizowanych krajach na zadania z zakresu zdrowia publicznego przeznaczano nie więcej niż 0,5% PKB, co stanowiło od 0,7% (na Łotwie) do 5,9% (w Finlandii) ogółu wydatków na ochronę zdrowia. W Polsce na zdrowie publiczne przeznaczono w 2013 roku blisko 1,5 mld USD, czyli 0,2% PKB, co stanowiło 2,6% ogólnych wydatków na ochronę zdrowia.
Wnioski. Wielkość wydatków na zadania z zakresu zdrowia publicznego jest bardzo zróżnicowana w krajach Unii Europejskiej, jednak we wszystkich krajach włączonych do analizy obserwuje się ich stały nominalny wzrost. Dzięki temu można założyć także wzrost znaczenia zdrowia publicznego w Unii Europejskiej.
Summary
Introduction. After years of efforts of the scientific community, the public authority in Poland saw importance of public health and in 2015 it decided to enact the law on public health (LPH). The new act introduced a solution designed to provide maximization of the benefits of realization of tasks in the field of public health, among other things thanks to the new mechanisms and sources of financing.
Aim. In the context of the new legislative solutions in this paper the international comparative analysis of expenditures on public health tasks in selected EU countries and Norway was made.
Material and methods. In the comparative analysis, the OECD data for the years 2000-2014 was used. The analysis of the expenditures on health and tasks in the area of public health was carried out in total for 22 countries (21 EU Member States and Norway).
Results. In 2013, these expenses amounted to maximum 0.5% of GDP and ranged from 0.7% (Latvia) to 5.9% (Finland) of the total expenditures on health care. In Poland, it was nearly $ 1.5 billion, i.e. 0.2% of GDP, which accounted for 2.6% of the total expenditures on health care.
Conclusions. The amount of the expenditure on the tasks related to public health is very diverse in the EU countries, however in all countries included in this analysis their steady nominal growth is observed. It allows us to assume the increasing importance of public health in the European Union.
INTRODUCTION
The State is responsible for carrying out of activities that are aimed at protection and improvement of the health of its citizens. In response to the task himfaced by it, the Ministry of Health has undertaken work on the development of the law on public health (LPH). The effect of these works was presented on 17 March 2015 – The Ministry of Health published the draft of LPH then. It was argued that “the need for the preparation of the Act is primarily due to the need to establish mechanisms to achieve improvement in the health of the society. (...) There is no doubt that population health is a value in itself while a coherent and effective state policy in the field of public health in a fundamental way affects the functioning of the society. Good health of citizens is a prerequisite for the development of the country, on the one hand by stimulating economic growth, on the other hand not burdening the social security system and health. (...)” (1). The bill was discussed by the Parliament on 16 July 2015 and voting on its adoption took place on 11 September 2015 – 278 MPs voted in favor, 0 against and 147 abstained. The Senate did not suggest any amendments to the bill and finally it was signed by the President on 26 October 2015.
The objectives of the enactment of LPH were: “(...) the establishment of structures responsible for coordinating and monitoring of the activities of the public authorities that could affect the health status of the population. Another goal is to ensure stable financing mechanisms. (...) The law also aims to systematize the tasks in the field of public health carried out currently, to ensure their continuity, adequacy and comprehensiveness. Public health functions carried out thanks to the adoption of the law will correspond to the objectives in the field of the PH, resulting from the documents of the European Region of WHO (...)” (1).
In accordance with the provisions of the newly enacted LPH (2), funding for the tasks in the field of public health (PH) will originate from the funds being at the disposal of ministers, including the minister responsible for health, the state organizational units and the executive agencies, including the National Health Fund (NFZ), as well as local government units (LGUs). The limit of the budgetary expenditures, resulting from implementation of the provisions laid down by the law, is expected to be PLN 80.7 million per year (including PLN 0.7 million in the budgets of provincial governors) in the years 2017-2025. The executors of the PH tasks determined in the Act may apply also for their financing from the Gambling Problem Elimination Fund, Physical Culture Development Fund and the Sports Activities Fund for the students, while the limit of expenditures from these sources has been set at PLN 60 million per year between 2017-2025 (art. 29 of LPH).
LGUs, as implementers of statutory tasks in the field of the PH, may apply for additional funding from the National Health Fund. They must at the same time demonstrate compliance of the undertaken activities with the operational objectives of the National Health Program and the priorities of the regional health policy. It is also required to obtain a positive opinion of the Agency for Health Technology Assessment and Tariff System. When the formal requirements are met, decisions on financing of the activities of the local government units are taken by the appropriate provincial branch of the National Health Fund. Grants may amount to 80% or 40% of the total planned expenditures. The amount of the funding has been made dependent on the size of the population of a municipality, county or province – higher subsidies will go to the local government, which is inhabited by no more than 5,000 people. The Act has also reserved that additional funding from the National Health Fund can only be received by the units that provide other health care services than those ones specified in the lists of guaranteed services within the realized program. The legislator has also defined the maximum limit of expenditures of NFZ on this purpose – they cannot be higher than 0.5% of the planned value of health care services (art. 22 of LPH).
In the context of the solutions introduced in the Polish system, aimed at providing funds for realization of the PH tasks, it is worth looking more closely at the level of funding for these activities in the European Union (EU).
aim
The aim of this article was a comparative analysis of expenditures of selected EU Member States and Norway on health care and on the duties of public health.
MATERIAL AND METHODS
The comparative analysis included the expenditures of 22 countries – most of the EU countries and Norway.The data published in the database OECD statistics, based on the System of Health Accounts for the years 2000-2014, was used for this purpose (3). Due to the lack of data or its incompleteness, 7 EU Member States were excluded from the analysis: Bulgaria, Croatia, Cyprus, Ireland, Malta, Romania and the United Kingdom.
The system of Health Accounts (SHA) has been proposed by the OECD (Organization for Economic Co-operation and Development). It consists of a set of basic tables, taking into account: the source of funds in the system, the entities to which the funds are transferred and the services and goods that the money is spent on.
The system classifying the expenditures on health has been described in the new International Classification for Health Accounts (ICHA) by:
1. Classification of Sources of Funding – ICHA-HF.
2. Classification of Health Care Providers – ICHA-HP.
3. Classification of Health Care Functions – ICHA-HC (4).
The functional classification (ICHA-HC) includes: goods and services consumed by the individual people who receive benefits according to individual needs and desires, and the goods and services consumed collectively, provided to the entire population. The specific categories included in the functional classification are shown in table 1 (5).
Tab. 1. Functional classification of health care
| ICHA Code | Health care functions | ICHA Code | Health care functions |
| HC.1-HC.5 | Goods and services consumed individually | HC.6-HC.7 | Goods and services consumed collectively |
| HC.1 | Therapeutic services | HC.6 | Prevention and public health* |
| HC.1.1 | Hospital treatment | HC.6.1 | Maternal and child health, family planning and family counseling* |
| HC.1.2 | “One day” treatment | HC.6.2 | Medical school* |
| HC.1.3 | Outpatient treatment | HC.6.3 | Prevention of infectious diseases* |
| HC.1.3.1 | Treatment in primary care | HC.6.4 | Prevention of non-communicable diseases* |
| HC.1.3.2 | Dental treatment | HC.6.5 | Occupational medicine* |
| HC.1.3.3 | Specialist treatment | HC.6.9 | Other services in the field of public health* |
| HC.1.3.9 | The remaining patient care | HC.7 | Administration health and insurance |
| HC.1.4 | Treatment services in the patient’s home | HC.7.1 | Government administration |
| HC.2 | Rehabilitation services | HC.7.1.1 | Government administration with the exception of health insurance |
| HC.2.1 | Patient rehabilitation | HC.7.1.2 | Administration of (public) health insurance funds |
| HC.2.2 | Rehabilitation day | HC.7.2 | Administration and health insurance in the private sector |
| HC.2.3 | Ambulatory rehabilitation | HC.7.2.1 | Administration and private social insurance |
| HC.2.4 | Rehabilitation in the patient’s home | HC.7.2.2 | Administration and other private health insurance |
| HC.3 | Services in long-term nursing care | HC.R | Functions related to health |
| HC.3.1 | Stationary long-term care nursing | HC.R.1 | Accumulation of capital in the sector of medical providers |
| HC.3.2 | Stationary daily long-term care nursing | HC.R.2 | Education and training of medical personnel |
| HC.3.3 | Long-term nursing care provided in the patient’s home | HC.R.3 | Research and development in health care |
| HC.4 | Auxiliary health care services | HC.R.4 | Control of food, hygiene and drinking water |
| HC.4.1 | Laboratory tests | HC.R.5 | Environmental health |
| HC.4.2 | Image diagnosis | HC.R.6 | Administration and provision of social services for the chronically ill and disabled |
| HC.4.3 | Transport services and emergency assistance | HC.R.7 | Administration and provision of cash benefits |
| HC.4.9 | Other ancillary services | | |
| HC.5 | Medical products for outpatients | | |
| HC.5.1 | Temporary use medicines and materials | | |
| HC.5.1.1 | Prescription drugs | | |
| HC.5.1.2 | Drugs without prescription | | |
| HC.5.1.3 | Other temporary use medical materials | | |
| HC.5.2 | Therapeutic equipment and durables | | |
| HC.5.2.1 | Glasses and other optical products | | |
| HC.5.2.2 | Orthopedic aids | | |
| HC.5.2.3 | Hearing aids | | |
| HC.5.2.4 | Technical medical devices | | |
| HC.5.2.9 | Other medical durables | | |
Source: J. Suchecka (ed.) 2011 (5)
*Features from the area of the PH (code HC.6) have been marked in grey
ICHA classification also includes expenditures on the PH and prevention (code HC.6 – in table 1 marked in grey*), which include: maternal and child health, family planning and family counseling; medicine school; prevention of infectious diseases; prevention of non-communicable diseases; occupational medicine and other services in the field of public health.
RESULTS
Expenditures on health care in relation to GDP
Globally, expenditures on health care are growing at a very fast pace. According to available data of the OECD, in 2014 the biggest amount was spent health care in Germany and the Netherlands – 11.1% of GDP (tab. 2). It is worth noting that in 2000 the expenditures did not exceed 10% of GDP in any of the examined countries (the greatest amount was spent in Germany – 9.8% of GDP). However, in 2013, for which the data is more complete, more than 10% of GDP was spent on health care in 7 countries: Austria, Belgium, Denmark, France, Germany, the Netherlands and Sweden. In the period from 2000 to 2013, the expenditures increased on average by 1.7 p.p. of GDP, which shows the scale of increase in the resources devoted to health care in recent years. In Poland, 6.4% of GDP was spent on health care in 2013, which puts our country on the fourth place from the end – Poland is ahead of only the Baltic countries.
Tab. 2. Expenditures on health as % of GDP
| Country\year | 2000 | 2005 | 2010 | 2011 | 2012 | 2013 | 2014 |
| Austria | 9.2 | 9.6 | 10.1 | 9.9 | 10.1 | 10.1 | – |
| Belgium | 8 | 9 | 9.9 | 10.1 | 10.2 | 10.2 | – |
| Czech Republic | 5.7 | 6.4 | 6.9 | 7 | 7.1 | 7.1 | – |
| Denmark | 8.1 | 9.1 | 10.4 | 10.2 | 10.4 | 10.4 | – |
| Estonia | 5.2 | 5 | 6.1 | 5.7 | 5.8 | 6 | – |
| Finland | 6.7 | 7.7 | 8.2 | 8.2 | 8.5 | 8.6 | 8.7 |
| France | 9.5 | 10.2 | 10.8 | 10.7 | 10.8 | 10.9 | – |
| Germany | 9.8 | 10.3 | 11 | 10.7 | 10.8 | 11 | 11.1 |
| Greece | 7.2 | 9 | 9.2 | 9.7 | 9.1 | 9.2 | – |
| Hungary | 6.8 | 8.1 | 7.7 | 7.6 | 7.5 | 7.4 | – |
| Italy | 7.6 | 8.4 | 8.9 | 8.8 | 8.8 | 8.8 | 8.9 |
| Luxembourg | 5.9 | 7.2 | 7.2 | 6.8 | 6.6 | – | – |
| Netherlands | 7 | 9.5 | 10.4 | 10.5 | 11 | 11.1 | 11.1 |
| Norway | 7.7 | 8.3 | 8.9 | 8.8 | 8.8 | 8.9 | 9.2 |
| Poland | 5.3 | 5.8 | 6.5 | 6.3 | 6.3 | 6.4 | – |
| Portugal | 8.3 | 9.4 | 9.8 | 9.5 | 9.3 | 9.1 | 9.1 |
| Slovakia | 5.3 | 6.6 | 7.8 | 7.5 | 7.7 | 7.6 | – |
| Slovenia | 8.1 | 8 | 8.6 | 8.5 | 8.7 | 8.7 | 8.6 |
| Spain | 6.8 | 7.7 | 9 | 9.1 | 9 | 8.8 | – |
| Sweden | 7.4 | 8.3 | 8.5 | 10.6 | 10.8 | 11 | – |
| Latvia | – | 5.9 | 6.1 | 5.6 | 5.4 | 5.3 | – |
| Lithuania | – | 5.6 | 6.8 | 6.5 | 6.3 | 6.1 | – |
Source: own study based on OECD data, www.stats.oecd.org (accessed on 15.12.2015)
Expenditures on the public health tasks in relation to GDP and the total health care expenditure
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Piśmiennictwo
Uzasadnienie projektu ustawy z dnia 15 lipca 2015 r. o zdrowiu publicznym, druk sejmowy nr 3675.
Ustawa z dnia 11 września 2015 r. o zdrowiu publicznym.
Baza danych statystycznych OECD: www.stats.oecd.org (dostęp z dnia: 15.12.2015 r.).
Schneider M, Kawiorska D, Baran M et al.: System Rachunków Zdrowia w Polsce. Praca zbiorowa, s. 9-10; http://www.bpz.gov.pl/old/file/SHA.pdf (dostęp z dnia: 15.12.2015 r.).
Strzelecka A: Wydatki publiczne na ochronę zdrowia. [W:] Suchecka J (red.): Finansowanie ochrony zdrowia. Wolters Kluwer, Warszawa 2011: 64-65, 69-71.
Sprawozdania budżetowe jednostek samorządu terytorialnego, oficjalna strona Ministerstwa Finansów; http://www.mf.gov.pl/ministerstwo-finansow/dzialalnosc/finanse-publiczne/budzety-jednostek-samorzadu-terytorialnego/sprawozdania-budzetowe (dostęp z dnia: 15.12.2015 r.).
Główny Urząd Statystyczny: Zdrowie i ochrona zdrowia w 2013 roku. Zakład Wydawnictw Statystycznych, Warszawa 2014; www.stat.gov.pl.
