CHAPTER 1: INTRODUCTION
Purpose of Study
Governmental health care centers concentrate on the provision of primary care to individuals and on controlling and managing the spread of infectious diseases and managing responses to natural disasters (Christian et al., 2008). However, in the public domain, health care differs – sometimes dramatically — from one country to another. This can be specifically analyzed in developed nations where social, economic and political factors are most likely to influence public health policies and centers and their accessibility, availability and quality (Christian et al., 2008). Therefore, this study concentrated on presenting an overview and detailed background of health centers in English-speaking countries. The countries selected were Australia, Canada, United Kingdom and United States. These four countries have their own public health policies and have installed several governmental health centers in order to provide primary care to individuals and to effectively manage disasters and epidemic outbreaks. In terms of availability, accessibility and quality of care provided in these centers vary from one nation to another and this study therefore analyzed these differences. Furthermore, emergency preparedness plans, natural disaster management plans, performance, funding and demographic data were also analyzed in order to understand the respective efficiency and effectiveness of these health care centers.
Health Care Systems in Australia
Of the 18 developed nations in the world, Australia is ranked fourth with respect to health status, after Japan, Switzerland, and France (O`Donnnell, 2005). This health status is supported by commonly used outcome measures for quality of care such as life expectancy (Comparing the U.S. and Canadian health care systems, 2013). By contrast, the United States is ranked dead last (O`Donnell, 2005). According to the Australia Commonwealth Fund (2013), “Most health services are financed and regulated by the federal government, although the states and territories have responsibility for public hospital care” (The health care system and health policy in Australia, para. 2).
In addition, approximately 50 percent of Australians are provided with additional government-subsidized health care coverage through their employers that covers private hospital stays (The health care system and health policy in Australia, 2013). In addition, the Australian Commonwealth Fund also reports that, “Current policy goals include developing a new management structure for public hospitals around local area networks, increasing the federal government`s contribution to public hospitals, introducing performance reporting, and strengthening primary care” (The health care system and health policy in Australia, 2013, para. 3).
The national health care system in Australia has been criticized for using an ethno-specific delivery model that fails to provide the cross-cultural competence needed for the country`s marginalized populations, most especially Indigenous and migrant people. For instance, according to Renzaho (2008), “The demographic profile of the Australian population indicates that Australia is a rich and complex multicultural society with more than six million migrants resettling in Australia since 1945” (p. 223). The research to date indicates that about one-third of all Australians have a culturally and linguistically diverse ancestry nearly one-quarter (23%) were born outside of Australia and another 15% of the population speaks a language besides English at home (Renzaho, 2008).
Clearly, in a country of 22 million people, these percentages represent a substantial number of Australian citizens who may require specialized interventions by virtue of their linguistic and cultural differences. Moreover, the highly mobile nature of some other segments of Australian society makes responding to the health care needs of these citizens especially challenging (Renzaho, 2008). According to Renzaho, “The challenge for health and welfare agencies is to provide a system of services to respond to the needs of diverse communities and individuals regardless of their backgrounds. However, resources are scarce and not all needs can be met” (p. 224).
Complicating matters even further is the fact that in an effort to optimize the available health care resources, government programs are designed to be “one size fits all” and there has been little progress in implementing culturally sensitive and appropriate interventions for some segments of the Australian population (Renzaho, 2080). In this regard, Renzaho emphasizes that, “For small marginal ethnic groups, an ethno-specific response becomes arguably unjustifiable” (p. 224). Nevertheless, because health care resources are by definition scarce, there will likely remain a paucity of informed interventions available for these marginalized populations in the foreseeable future. As Renzaho points out, “Although the ethno-specific model of service delivery is long recognized as more viable for larger ethnic communities, small communities are left with fewer options where there are no alternative models of service delivery” (p. 224). Taken together, Australia`s national health care system is modern and comprehensive, but there are some areas that require improvement in order to improve accessibility and availability of these services for mobile and Indigenous segments of society.
Health Care Systems in Canada
The current Canadian Medicare model is the result of a half a century of health care administration experience – and a good deal of negotiation. According to Romanow and Marchildon (2003), the first effort of the Canadian public health care system was implemented in 1947 in Saskatchewan this initiative was mirrored and amplified in British Columbia and Alberta. In 1957, following the passage of the Hospital Insurance and Diagnostic Services Act by the national government together with the provision of federal cost-sharing transfers, the Saskatchewan model of universal public hospital insurance was formally adopted by all Canadian provinces and territories by 1961 (Romanow & Marchildon, 2003).
The next stage in the development of universal health care in Canada was another initiative by Saskatchewan in 1962 to provide public health insurance for primary medical care services provided outside of hospitals (Romanow & Marchildon, 2003). Following a review of other health care models, including Alberta`s targeted subsidy approach, the Saskatchewan model was recommended by the Royal Commission on Health Services (“the Hall Commission”) for nationwide implementation to the federal government in 1962 (Romanow & Marchildon, 2003). Although the Saskatchewan-based initiative ultimately required another 50:50 cost-sharing offer by the national government as well as several years of wrangling over details, universal Medicare was implemented by all Canadian provinces and territories by 1972 (Romanow & Marchildon, 2003).
In Canada`s case, though, “universal” does not necessarily means what the term is generally understood to mean. For instance, according to Romanow and Marchildon (2003), the national parliament passed the Canada Health Act (CHA) in 1984 which restricted billing practices for medical services provided outside hospitals which had grown to ponderous levels. A concomitant consequence of this law was to “entrenched the hospital and physician-centered model of Medicare by limiting insured health services covered by the five governing principles of the Act — public administration, universality, accessibility, portability, and comprehensiveness -to medically necessary hospital and physician services” (Romanow & Marchildon, 2003, p. 284). With respect to accessibility in particular, Romanow and Marchildon emphasize that the vagaries of the CHA with respect to the delivery of health care services has created a privileged system in some territories and provinces. In this regard, these researchers report that, “Although the CHA has never blocked the provinces from providing a broader range of services under their respective health plans, it has meant that both hospital services and primary care physician services are historically privileged” (Romanow & Marchildon, 2003, p. 284).
The fact that Canada has universal health care but also has issues with respect to the availability of health care services suggests that Canadian health care consumers are not receiving the same level of diagnostic and evaluation as their counterparts in the United States, despite outperforming them on the life expectancy rating for quality of care. In this regard, the National Bureau of Economic Research reports that:
Canada provides universal access to health care for its citizens, while nearly one in five non-elderly Americans is uninsured. Canada spends far less of its GDP on health care (10.4 percent, versus 16 percent in the U.S.) yet performs better than the U.S. on two commonly cited health outcome measures, the infant mortality rate and life expectancy. (Comparing the U.S. and Canadian health care systems, 2013, para. 2)
Health Care Systems in the United Kingdom
In the United Kingdom, the National Health Service (NHS) operates and manages a nationwide system of hospital services through NHS trusts that ensure hospitals deliver high-quality health care services and that the resources allocated to these facilities is used effectively. The NHS trusts are also tasked with developing appropriate hospital development strategies (About NHS hospital services, 2013). All medical services are provided for free at NHS hospitals except for emergency care (About NHS hospital services, 2013). In addition, according to Lynch (2012), in the United Kingdom, “Community health centers have long provided an excellent model of multidisciplinary care that the private practice of medicine would do well to emulate” (p. 5).
Accessibility to health care services is regarded as generally good, but there are some regional differences (Lynch, 2012). Moreover, there are lengthy waiting times for some services and specialists (in some cases, up to 18 weeks or even longer) (About NHS hospital services, 2013). According to the National Health Service, “The NHS Constitution says you have the right to access certain services commissioned by NHS bodies within maximum waiting times. Where this is not possible and you ask for this, the NHS will take all reasonable steps to offer you a range of suitable alternative providers” (NHS waiting times, 2013, para. 2). These commitments are legally codified by NHS England and Clinical Commissioning Groups (CCGs) in the responsibilities and standing rules regulations published in 2012 (NHS waiting times, 2013).
Health Care Systems in the United States
Health centers that are funded by the federal government in the United States include those defined in Section 330 of the Public Health Service Act as follows:
1. Community Health Centers, Section 330 (e)
2. Migrant Health Center, Section 330 (g) and,
3. Health Care for the Homeless, Section 330 (h).
In addition, the federal government maintains the country`s largest system of health care facilities in the Department of Veterans Affairs Health Services Administration, with tertiary health care facilities located in each state as well as hundreds of outpatient clinics and Vet Centers across the country. Eligibility for these health care services, though, is restricted to veterans of the armed services and in a few restricted cases, their family members.
In the United States, the majority of state and local authorities initiate managed care contracts with privately managed health organizations and health maintenance organizations (McDaniel & Spiegelman, 2006). Accessibility to these health care facilities, though, is carefully controlled and is not automatic (McDaniel & Speigelman, 2006). According to McDaniel and Spiegelman (2006), “Several organizational procedures are employed to manage access to care, or gate-keeping, and counties, states, and private payers adopt them either singly or in combination” (p. 276).
Although eligibility for access to public health care facilities in the United States is rigorously controlled, the administration of policies and programs, and therefore accessibility, may differ from state to state (McDaniel & Spiegelman, 2006). Generally speaking, McDaniel and Spiegelman report that, “Gatekeeping typically establishes a single point of entry or other control over access to the treatment system and may include elements such as telephone or in-person administration of a precertification screening tool, the application of medical necessity criteria, and triage to treatment or other programs” (p. 276).
Some general indication of the respective availability, accessibility and quality of health care services provided or supported by the governments of Australia, Canada, the United Kingdom and the United States can be discerned from the numbers of hospitals beds that are available (availability), the physician/patient ratio (accessibility) and the life expectancy at birth rates (quality of health care services) which are set forth in Table 1 below and depicted graphically in the figures that follow.
Comparison of Australia, Canada, UK and US for Availability, Accessibility and Quality of Health Care Services
Availability (beds per 1,000 pop.)
Accessibility (physicians per 1,000 pop.)
Quality of Care (life expectancy at birth)*
Source: CIA world factbook (2013) at https://www.cia.gov/library/publications/the-world-factbook/geos/
* Life expectancy at birth is a commonly used indicator of quality of care (Comparing the U.S. and Canadian health care systems, 2013)
The respective ratings for health care availability for Australia, Canada, the UK and the US are depicted graphically in Figure 1 below.
Figure 1. Respective Ratings for Health Care Availability: Australia, Canada, UK and US
The respective ratings for health care accessibility for Australia, Canada, the UK and the US are depicted graphically in Figure 2 below.
Figure 2. Respective Ratings for Health Care Accessibility: Australia, Canada, UK and US
Finally, the respective ratings for quality of health care for Australia, Canada, the UK and the US are depicted graphically in Figure 3 below
Figure 3. Respective Ratings for Quality of Health Care: Australia, Canada, UK and US
Importance of the Study
As health care resources become increasingly costly and coveted both in the industrialized and developing world, nations are seeking alternative and at times unconventional methods to meet demand. Additionally, health care costs are also becoming burdensome on nation`s GDP. Regardless of the type of national healthcare system a nation may adopt, there is without a doubt a direct correlation to the nation`s economic fiscal status and its healthcare system.
Organization of the Study
This study used a five-chapter format to achieve the above-stated research objectives. Chapter one of the study introduced the issues of interest, including a statement of the problem, the objectives of the study, as well as the background of the study including a brief review of the respective health care systems used in Australia, Canada, the United Kingdom and the United States. Chapter two of the study provides a review of the relevant and peer-reviewed literature concerning the health care systems in these four countries and how accessibility, availability and quality of care affect emergency responses. Chapter three describes more fully the study`s methodology, including a description of the study approach as well as the data-gathering method and the database of study consulted. The penultimate chapter provides an analysis of the data collected during the research process and final chapter presents a summary of the research and important findings concerning the status of the nationally sponsored health care services in Australia, Canada, the United Kingdom and the United States.
Chapter 2: Literature Review
This Chapter will provide a comprehensive review of Government Sponsored Health Care systems in four different countries including Canada, Australia, the United Kingdom and the United States. Through the literature review, various aspects of the emergence of modern healthcare in these four countries will be compared. Contrasts in the approach of public health in the four regions will arise, and similarities will be revealed. As the evolution of healthcare in these representatives of the various continents is analyzed, the study will gain a good background which will help answer the research questions, as well as lays a proper foundation for chapter III.
2.0 History of Government Healthcare in Canada
Canada has a single payer system of healthcare with the government being the dominant player for most healthcare services. Unlike other jurisdictions, however, the majority of Canadian healthcare services are provided by the private sector. About 94% of the funds paid by government healthcare plan are directed at private practitioners. The Canadian government regulates the fees for most fundamental services, whereby the charges remain constant regardless of the facility or doctor a patient chooses. The Canadian health system is regarded as one of the best, most carefully designed and managed healthcare systems in the world, and certainly one of the best among the G8 countries, ahead of such countries as the US and UK in terms of the common markers of a successful healthcare system including life expectancy at birth, infant mortality rate, healthcare spending as a percentage of GDP and government budget, rating by the patients among others. This section will explore the history, nature, evolution, prospect and challenges facing the Canadian Government Health Care Centers (Katz, Cardiff, Pascali, Barer & Evans, 2002).
Canada has had a rich background of government involvement in healthcare provision. Initially, hospitals were largely built by religious and mission organizations, and usually attended mainly the poor while the able received home care. The government dealt with care centers at arm`s length, but mainly subsidized almost all services for those who could not afford private care or other bills in the public facilities. At the turn of the 20[th] century, calls for more intense and organized government involvement in healthcare increased, especially with the rise of such campaigns as community places cleanliness, hygiene and sanitation among others. Government funding was meager, and therefore the conception of a publicly funded and maintained healthcare system was not actualized until in 1935 when the United Farmers of Alberta founded a social welfare programme which attempted to fund medical expenses. This program did not succeed, and was shelved later in 1936. Doctors were mainly opposed to public insurance for fear that their jobs were at stake, but seemed to change their outlook during the Great Depression- a period when receding financial capabilities of people across Canada and the US greatly affected most sectors of the economy- in favor of government subsidy. The Canadian Department of Health owes its formation to Lyon Mackenzie, who visualized the first public health system. However, a fully operational public health care plan was not formed till 1946 (Fierlbeck, 2011).
In 1946, the Cooperative Commonwealth Federation of Saskatchewan formed a bill, called the Saskatchewan Hospitalization Act. The Act essentially provided cover for most people in the province, although the cover was not universal. Two years later, in 1948, Alberta also introduced a healthcare plan called the Medical Services Alberta Incorporated (MSAI), and was able to offer at least basic medical cover to 90% of the population (Deber, 2002). These medical cover plans were still individually conceived and maintained in the provinces and there was not medical care to incorporate the entire Canadian population. In 1957, the Health Insurance and Diagnostics Services Act was passed under the majority Liberal government. The pre-existing conditions were that any provinces that opted into the program would receive cover for up to 50 percent of all cases qualifying for subsidy under the Act (Twaddle, 2002). The HIDS Act is perhaps the pillar of modern universal Canadian government healthcare plan. It embodied the five basic tenets of the healthcare in Canada today, including universality, comprehensive, affordable, portable and publicly administered.
The Canadian Medicare Act was introduced in 1966 and this changed a lot of things as far as medical insurance is concerned. It expanded the existing HIDS Act and made it possible for the various provinces to offer universal medical aid to their citizens. Medicare is therefore an umbrella system comprised of not one but as many as ten individual medical care plans based in the provinces (Deber, 2002).
2.0.2 Nature of Canadian government sponsored healthcare centers
Type of Work Setting
Percentage of Physicians
Private Office or Clinic
Academic Health Sciences Centre
Emergency Department (in Community Hospital)
University Faculty of Medicine
Nursing Home/Home for the Aged
Community Clinic or Health Centre
Free-standing Walk-in Clinic
Free-standing Lab/Diagnostic Clinic
Other Work Setting
*Note: The combined percentage may exceed 100 percent, as some physicians reported working in more than one type of setting.
(Source: The College of Family Physicians of Canada, National Physicians Survey, 2007)
According to the table above, more than half of healthcare workers in Canada have at least some form of working contact with government institutions. Work in government related health centers may take the form of work in community hospitals, public academic institutions, university faculties, community clinics among other units. These types of medical centers, when combined, are more than all private establishments (World Health Organisation, World Health Staff, 2000).
As stated, the Canadian government provides medical services to its population through a set of individual programs located in the various provinces. The Canada Health Act lays out the basic guidelines for providing medical health care insurance, and the various provinces` plan take up the proposed guidelines and enact them. In addition to Medicare, the government also operates several other initiatives which provide health directly to certain smaller groups including the military, police, prisoners and the aged through the public health system (Makarenko, 2010). The First Nation, a term used to refer to the natives in Canada, depicts another special interest group for which the government provides basic cover through provincial health facilities. These people, concentrated in Native Reserves, are treated in the provincial hospitals which then claim compensation from the federal government regarding all expenses incurred (World Health Organisation, World Health Staff, 2000).
The Canadian government covers about 70% of all medical costs for the population, while the remaining, about 27.3%, is paid through the private sector. Most of these costs are for items not generally covered by the main government such as dentistry, optometry and prescription drugs. About 75% of Canadians are reported to have basic supplementary cover, most of it arranged with their employers. In addition, up to 70% of medical services in Canada are provided by private doctors, but the bills are met by the federal government. In the recent past, there have been fears that the Canadian medical system is gradually becoming privatized while still utilizing public funds. Without proper guidance, such a plan can have negative impacts regarding financial accountability and in the extreme cases, may lead to misappropriation of public funds.
The Canadian Medical Association is a body formed to unite the healthcare providers and general practitioners in the various Canadian provinces. This body tries to establish a regulatory framework in the healthcare sector through representation of the doctors and other private healthcare personnel in the medical fraternity. In 2007, the OECD published figures for Canada healthcare expenditure by source of funds. The following table shows the findings.
Canadian Health Expenditures, by Financial Source
Type of Financial Source
Percent of Total Expenditures
General Government Funds
Private Household Out-of-Pocket
Private Health Insurance
Public Health Insurance Premiums
*Expenditures in CAN$
(Source: OECD, 2010)
According to the table, the government is the source of the majority funding for Canadian healthcare, providing close to 70% of funds paid into medical insurance. In addition, the patient out-of – pocket payments constituted close to 15% of total medical related expenses, while private health insurance produced close to 13% of funds. All other sources of funding contributed 2.4% (NHS 2012).
2.0.3 Challenges of the Canadian system
The Canadian medical system, though among the best rated regionally, is not without its challenges. Firstly, the system of government funding for services offered in public and private institutions, which is the fundamental insurance arrangement, is under constant threat of infiltration by the private healthcare practice. Fears have been raised that what started as a public health insurance system is being turned into a publicly funded private health scheme with government control receding. If unchecked, the system may develop into a complex public fund scum with private investors raking in billions of public dollars in exaggerated fees and un-offered services (Mullner, 2009).
The other challenge is with regard to the First Nation initiative. Numerous negotiations have been tabled and decisions regarding comprehensive medical cover for the Canadian natives agreed upon. However, recent debates regarding the quality of cover for this group are raising questions on the government`s commitment to provision of medical cover to the First Nation members. Initially, this group was entitled to full medial cover for most basic medical services whereby the government would meet bills for services and medication advanced to them in the various government and private facilities (Mullner, 2009). In the recent times, however, it has been postulated that a variety of medical services rendered to them such as dentistry have not been compensated by the federal government. The other significant emerging challenge is the financial budget. It is estimated that the current healthcare bill will double by 2020 and will increase by 400% by the year 2030 (Blanchette & Tolley, 2010).
According to the figure below, the estimated government expenditure (GHEX) on healthcare will rise from the current estimate of slightly above $5000 million to $10000million by 2020 and double that by 2030 to stand at $20000 million.
This may hold serious implications for the Canadian government unless either new ways of generating revenue are conceived or there is a reduction in costs for operating the healthcare insurance. Both of these options will obviously have implications for the quality of service offered in the mentioned government centers. Firstly, a reduction in cost of operations may, in some circumstances, imply that the quality of care as measured by waiting time, appropriateness of medication, number of staff in attendance and referrals are going to change. Secondly, generation of new funds to meet the increasing bill may mean co-sharing the medical expenses between the government and the insured. Either way, these changes pose a great likelihood of financial expenses for the insured persons (Commission on the Future of Health Care in Canada, 2002).
2.1 Australian Government Healthcare Centers
In Australia, there are significantly more public hospitals than private hospitals, reflecting the nature of health insurance which features a public-private combination of insurers. For instance, in 2007, there were 758 public hospitals as compared to 557 private hospitals. In addition, the number of facilities (as measured by the number of beds and chairs for inpatient customers) was double that of private hospitals at 55 905 as compared to only 26678. As marked by length of stay, the various public hospitals have a longer average stay at 3.7 days, as compared to 2.5 days for private hospitals. The number of visits for public hospitals is higher for public hospitals (17439) as compared to 7669 for private hospitals. This shows a larger tendency for people to visit the public hospitals than private ones, as well as a longer stay in public than private hospitals. The figures indicated in the table do not show smaller care units, as well as home based care for the Australian population.
Beds/chairs (annual average)
Total patient days
Average length of stay
Average length of stay excluding all same-day separations
Non-admitted patient occasions of service
(a) Acute and psychiatric hospitals.
(b) Acute and psychiatric hospitals and free-standing day hospital facilities.
(c) Full-time equivalent.
(d) Current price. Refers to amounts as reported, unadjusted for inflation.
(e) Current price terms not adjusted for inflation.
Source: ABS Private Hospitals, Australia, 2006-07 (4390.0) Australian Institute of Health and Welfare, `Australian Hospital Statistics
Private hospitals, however, show a bigger operating expenditure and higher revenues than the public hospitals. According to the figures, public hospitals had an operating recurrent expenditure of $26290 million, while the public hospitals, even though lesser in number had an operating recurrent expenditure of $6582 million. The revenue generated by public hospitals was $2325 million against $7539 million discovered by the private hospitals (Duncan, R., et al, 2010).
2.1.1 Nature of operation
Australian government operates a public healthcare insurance program called Medibank, the largest insurer with a 30% market share. The nature of insurance is that the government levies a 1.5% income tax on all persons with an income beyond a certain threshold. At the same time, the government tries to advocate for people to take out private medical insurance. The way to do this is to levy an additional tax of 1% from the income of all people within a certain income range ($80000 and above for individuals and $168000 for couples or more) (Reece, 2013). The government waives the tax if the individual or couple can channel it to a private healthcare insurance. This leaves the person or couple with the choice of either losing their money to taxation or investing it in a healthcare plan. The advantage with the healthcare plan is that the couple can benefit from the care in the event of a medical occurrence, while a tax is generally not recoverable and therefore the easier, more favorable option is to take a health insurance with a private insurer (Twaddle, 2002).
Australia is one of the four countries with a highest percentage of reliance on private medical schemes. Therefore, the government has instituted a policy, called the Private Health Insurance Act, 2007, which governs most of the operations and regulates the activities of the private insurance sector. An important consideration with regard to the nature of Australian healthcare insurance is that private insurers are given a certain level of control regarding the nature and terms of insurance they can give people with pre-existing conditions and those who are aged. This consideration is not provided in the US, whose current Medicare plan is closest in mode of operation to the Australian one. In the US, a patient is entitled to equal rights and terms of insurance regardless of pre-existing conditions and age (Wall, 2002).
The Australian government allocates an annual operating budget to its Medicare plan, the parent scheme through which money to run public healthcare facilities is channeled (Reece, 2013). In addition to general healthcare, the Australian government has also incorporated the Department of Health and Aging to cater for the aging and the aged, seeing that a significant percentage of people who visit the government health facilities are the aging or aged.
(a) Increases in services over time reflect structural changes to the Medicare Benefits Schedule, changes in service provision (services previously provided by state and territory governments under grant arrangements now covered by Medicare), population growth, ageing, etc.
(c) In current prices.
Source: Medicare Australia Data Commonwealth Department of Health and Ageing.
From the table above, it can be seen that the annual healthcare budget for the government continues to increase in the last decade. As of the year 2009, the annual budget for healthcare as met by the national government was $294million. In 2013, the figure was $140.2 billion, a significant rise from the previous year`s estimates. Most of this fund goes towards staff costs as well as meeting healthcare expenses for the insured. According to Australian Government Institute of Health and Welfare, in 2012 the government met 43.6 % of all healthcare charges in the country. Other companies and insurance funds met a combined percentage of only 24%, while 17.5% of total health costs were met by individuals.
2.1.2 Challenges facing healthcare centers in Australia
One of the challenges facing modern government healthcare centers in Australia is the rising cases of heart diseases and cigar related cancer. Heart diseases have become a major cause of death in Australia, where the rate of hospitalized cases of heart related problems is quite high (Department of Health Australia, 2014). The government healthcare centers are therefore likely to meet more of these cases, implying a significant rise in number of hospitalizations and higher expenses. Skin cancer is also an emerging concern for the modern Australian population especially in the Queensland area (Dunlevy, 2013).
2.2 Government Healthcare Centers in the US
According to the Agency for Healthcare Research and Quality, there were more than 1200 hospitals under government sponsorship by 2010, and the number has increased to about 1500. This number represented 22% of all hospitals in the US, and took an average of 14% of all inpatient cases. A significant number of those visiting the public or government funded healthcare centers are either unemployed, low income or reliant on Medicaid. In the year 2010 alone, an estimated 5.6 hospitalizations were done in public medical facilities, with the government being the major cost bearer, especially for all cases provided for in the Patient Protection Act.
Currently, there are over 1200 public hospitals in the US, or 22% of all hospitals in the US. 16.5 % of these are metropolitan – including those in the urban and the sub-urban areas. Smaller and medium-size towns have 20% share of all US hospitals, while the largest percentage, 64% of government healthcare institutions are in rural areas American Hospital Association (AHA, 2011). Metropolitan hospitals receive the highest number of patients, and have on average 45% of all cases of admission of public hospitals. Generally, metropolitan public hospitals have more room for admissions than rural hospitals, averaging 285 beds, compared to 215 beds for micropolitan units. Rural hospitals had only 47 beds on average. On average, public hospitals in the US have 3.5 registered nurses per 1000 people in the population, lower than the ratio for private NFP hospitals (at 3.8). Rural hospitals had the lowest ratio at only 3.2 nurses per 1000 population (Department of Health Australia, 2014).
In addition, rural hospitals showed the most unfavorable ratio of nurses to patients (1.7) compared to metropolitan public healthcare units with a ration of 0.8 patients per nurse (Johnstone, 2013). These statistics show that the time of attendance, as well as the quality of care in the majority of US hospitals is considerably adequate and up to standard. The table below illustrates some of the findings:
Other vital characteristics of public hospitals in the US as measured in the report include the ratio of registered nurses per other nurses, as well as the percentage residency programs as approved by the ACGME. These indicators are likely to point out the value of patient care, burden on staff, and income implications of people visiting the public hospitals in the US (Karen & Schoen et al., 2007). Other measurements conducted in evaluating the nature of patients and service types offered in public hospitals include the severity of conditions in the patients received, age of patients, the average stay days for those admitted among others. Since most public hospitals receive low income earners, the majority of their operating expenses are met by the federal government. The figure below shows payment ability of patients visiting government healthcare centers in US
From the graph, it can be shown that most visitors to public hospitals are insured using Medicare (32.5%), but this figure is significantly less than that of patients using Medicare who visit private NFP healthcare units. In both categories of healthcare units, the uninsured present the least number of patients. However, it can be seen that almost double the number of uninsured persons visit public healthcare facilities than visit private NFP hospitals. This significant difference indicates that there is still a large percentage of Americans who are unable to meet the cost of even the most basic care. In order to understand what the various medical insurance schemes mean, the following section will explore the history and current status of American healthcare insurance(Karen & Schoen et al., 2007).
Health policy in the U.S has been a major concern over the last decade, with as much as 16 % of the population un-insured in 2010, and U.S. lagging other members of the G5 in life expectancy and having the most costly healthcare system in the world in 2008. Government health initiatives through Medicare, Medicaid, military and other specialized healthcare programs cover about 27.8% of the population with the rest of the population either self insured, employer covered or uninsured (United Healthcare Insurance Company, 2008). Other than through licensing and safety related regulations, the government has little control over the health sector, which is essentially dominated by private practice. A debate has in the recent past been ongoing as to whether health care should be put under government control or market systems. The Patient Protection and Affordable Care Act of 2010 is the current basis for healthcare insurance in the US.
The Patient Protection and Affordable Care Act 2010 were signed by the US president Barrack Obama in March, 2010. The Act is the most significant one to be passed in the public healthcare category since the Medicare and Medicaid legislation of 1965. The care arrangement has brought major changes to the healthcare sector especially with regard to the three main issues including quality, affordability and percentage population coverage: the main areas of contention in healthcare provisions for a long time (Kings Fund, 2012). Thus, the Obama administration intended the new ACA program to benefit the largest number of US citizens, giving the best care possible, and on a platform that allows the beneficiaries choices of preferred care insurers. Even though this care plan has not been without major challenges especially regarding political opposition, systems inconveniencies and efficiency complaints, majority of people agree that the cover is inherently a good plan capable of realizing major benefits for most people especially the unemployed and low income earners. One significant complication with the Act is that it fails to consider family care plan costs while setting the 9.5% of income threshold when deciding who is eligible for the subsidies. What this means is that employees whose individual cover cost is such that it does not go beyond the 9.5% of income threshold but who have families and therefore need additional premium contributions to insure their families get left out of the cover benefit (NHS Careers, 2013). This research will explore the nature of this problem and propose possible amendments so that the ACA can benefit everyone.
Essentially, the ACA act is based on some fundamental provisions. The key provisions are as below.
2.2.1 Individual mandate provision: in this provision, people who do not have any alternative cover are required to subscribe to a health care cover else they will face an annual penalty of $95, or 1% income. By 2016, the penalty will be $695 for families and 2.5% of income for individuals. The penalty clause is pro-rated, exempting charges for parties who were covered for at least a 9 month period during the year. Other exemptions are with regard to cases in which the minimum contributions for any specified plan would exceed 8% of a person`s income, as well as US resident citizens who have a citizenship with another country as defined by Internal Revenue Service (IRS) regulations. Any penalties arising from the ACA will be determined by the IRS during an individual`s annual tax returns, and failure to meet these penalties will force the IRS to withhold any future tax returns as an individual may claim (Kongstvedt, 2012).
2.2.2 Eligibility scale: initially, the plan covers people with up to 138% of marked poverty level. Individual states have a right to raise the eligibility amount, whereupon the federal government will decreasingly continue its expansion subsidies from 100% to 90% by 2020. The figures adopted for the federal poverty levels are in the table below.
Source: US Census Bureau, 2013
According to the table, the family`s of individual`s poverty level threshold in dollars per annum is determined by the income, number of family members and the number of family members who are children below 18 years. This table is used a guide to reveal those people eligible for government subsidy.
2.2.3 Minimum package provision
Any provider allowed to offer care insurance must offer the following emergency services, ambulance services, hospitalization, maternity, mental health, laboratory services, preventive cure, pediatric services and substance abuse services. In addition to offering quality healthcare to more people at more affordable terms, the ACA is aimed to make insurance companies provide cover with minimum standards while effectively maintaining the same rates as initially used regardless of initial applicable conditions such as gender, age among other factors. In order to maintain a quality, competitive setting in the healthcare market, the Act so formulated the policies such as insurance exchanges, insurer mandates and federal subsidies (Twaddle, 2002).
Together, these facilities provided the policy takers with a wide range of options from which to choose, and the insurers with statutory obligations towards the buyers in order to avoid misrepresentation of the employees when claiming the insurance benefits. In addition, the federal government offers to subsidize the cover costs for certain income brackets, specifically those people in employment whose minimum cover premiums are such that they are higher than 9.5% of their individual income. The government has however required that all persons eligible by virtue of their age and lack of other existing insurance cover enroll to a cover of their choice, whereupon they will be required to remit their premiums. Failure of such persons to honor their individual cover obligations will attract a penalty. The foregoing elements of the ACA Act will be discussed exhaustively below.
2.2.4 Insurance exchanges
Insurance exchanges are essentially insurance markets in which people have variety. These are institutions that help people choose their preferred insurance providers and have representation in every state. The key element in these market exchanges is that beneficiaries may gain information regarding which insurance providers are providing cover eligible for government subsidies. Exchanges are government regulated and the facilitators must be registered with the government. These exchanges have been in operation since October 2013 and individuals have a six month period through which to select their preferred cover plan. President Obama explained the concept of exchanges as a one-place stop where insures will be able to compare prices, benefit packages and additional offers for each care plan. Every plan must, however, guarantee an affordable minimum package that prevents from and in the case of occurrence protect the insured from a catastrophe.
The healthcare plans are arranged in tiers according to a member`s ability to contribute. The tiers are designated bronze, silver, gold and platinum. Other than in an individual member`s tier, the providers are limited in the charging limits for similar conditions based on such factors as age and smoking habits. The maximum allowable ratio based on age is a variance of 3:1, while for smoking is 1.5:1.
2.2.5 Challenges for the Government Healthcare Centers in US
One of the most significant challenges for the US care centers is the unbalanced staff- patient ratio in public and private hospitals. It has emerged that private hospitals have a better ratio of staff to patient that public care centers, and within the public section, metropolitan hospitals have a better ratio than rural area centers. This may compromise the quality of care of patients especially in the case of an emergency (Kongstvedt, 2012).
The other challenge is the rising number of people without insurance and those on low income subsidy. The PPACA Act has led to the rise of segment of the population such as illegal immigrants, low income earners, and the unemployed who are unable to afford healthcare insurance and who therefore must rely on the cheapest points of aid in emergency cases. These people always end up at the government healthcare centers and this may imply an occasional influx of needy patients. This may present challenges of unsustainable workload for an understaffed unit and therefore lesser quality care for the patients (Fleming & Parker, 2011).
2.3 Government Healthcare Centers in the UK
The government funded hospitals in the UK are institutions which rely wholly or to the main part on government funding in order to provide services for patients. The hospitals and other public healthcare centers include those in Wales, Scotland, England and Ireland. In England, the government funded healthcare centers employ a total of 1.3 million people through the National Health Services (NHS), and spend about 70% of the allocated funding on staff costs. With a fairly healthy population, the UK has a mean life expectancy at 2010 of 78.2 years at birth. The total UK population as at 2010 was 62.3 million, and is estimated to rise to 73 million by 2030. This region has some of the least population growth rates, a factor which might help the government meet healthcare demands in the next decades easily.
However, this maybe countered by the fact that the median age in these countries is likely to remain high due to the low birth rate (NHS England, 2013). By 2011, one in six people in the UK was aged. Thus, there is likely to be more persons per 1000 people in the population in need of medical attention in the UK than in other countries. NHS continually recruits new staff every year to supplement additional staff. In 2011/2012, the NHS recruited 5020 in 2012. The general patient rating of NHS hospitals in the UK is positive. Recently, the UK department of health has instituted measures to streamline issues in the NHS hospitals (Connolly, Bevan & Mays, 2010).
2.3.1 Patient Care and Protection in UK Government Hospitals
In order to deliver its mandate, the NHS has come up with standards which must be met in line with the international regularization of modern healthcare (Welsh Government 2013). The objectives of the standards include formulation of a care system based on common values with a global dimension, and which is patient centered, to implement continous development and improvement in the quality of care, to promote a platform on which care providers can evaluate themselves and be easy to evaluate by external organs such as government bodies, and to enhance the image of NHS as a quality health services provider and regulatory authority(NHS,2012). The Standards are set along three dimensions of Clinical Outcomes, Patient experience, healthcre governance,and public health (Welsh Assembly Govt, 2012).
(Welsh Assembly Government 2005)
2.3.2 Patient Experience
Patient experience is about enhancing pateint experience through seeking opinion and contributions from relatives, patients, and other interested parties regarding how care standards maybe lifted. According to the above report, patient experience is one of the four most important dmains of the Welsh healthcare policy. In this respect, the Welsh approach to health resembles the English approach, as both bodies are under the NHS (NHS England, 2013).
2.3.3 Clinical Outcomes
Clinical outcomes domain is mainly concerned with service delivery durations, quality of service and sustainability of best practise. All treatment and care is evidence based and delivered by qualified professionals, in conditions of appropriate supervision, and that regular audit is done to ensure care proffesionals are performing in accordance with set procedures. In addition, clinical practice including research and experimentation is conducted within the procedures and principles outlined in the National Institute for Clinical Guidelines (NICE) framework . NICE is mandated with oversight of the health policies in the Wales and the larger UK (NICE, 2013). One major drawback in this organization`s mandate is that it does not enforce the guidelines, it simply formulates them (NICE, 2013). This means that the healthcare institutions do not have to implement these decisions unless they want to, which is a major drawback to the Welsh policy (NHS England, 2013).
The UK, unlike the other three countries of study, shows the biggest account of healthcare fragmentation. This is experienced through the devolution of healthcare services into the four regions which together form the UK including Wales, Scotland, England and Ireland. The body mandated with the provision, regularization and control of healthcare services in the four jurisdictions is the National Health Service NHS, which is decentralized to the four autonomous regions. NHS England controls the largest portion of the annual NHS budget, but the other three regions receive their budgets individually (Webster, 2002). There are more than 1600 NHS hospitals in the UK that are spread in the various countries. The majority of healthcare in the UK is government funded and therefore most hospitals are operated by the NHS. With a workforce of more than 1.3 million, the NHS is one of the largest labor forces globally. 0.6 Million of these are qualified clinical staff including scientists, nurses, doctors, therapists and other staff. Because the NHS operates, also, many university hospitals, it trains more than 8000 students each year who eventually get absorbed in its programs. The general hospital operations are strictly managed through systems of customer feedback, patient protection and information sharing policies, and other legislation. The money to run NHS comes primarily from the UK taxpayers. In 2010 for instance, the NHS had a budget of more than $100billion, which rose to $104billion in 2012. The government contributions for medical services in the NHS healthcare centers are uniform per person.
Unlike in the other countries, the NHS program in UK is free at point of use. This means that out of the four countries under comparison, the UK is the only place where government healthcare centers can be said to be totally free for the widest range of services. Other than minimal prescription charges and dentistry services, the NHS provides most other services totally free. Because of the extended nature of the jurisdictions under the UK, the NHS appears to have slightly varying policies and modes of operation in the four countries, but the underlying principles are the same. To understand the history and mode of operation of the public body through which UK government healthcare centers are managed, below is a historical perspective on the NHS Wales.
With more than 90,000 staff, the Welsh NHS is the biggest public employer in Wales (Welsh Assembly Government 2011). With an annual budget upward of Pound7 billion, the Welsh healthcare system is under the Ministry for Health and Social Services, and encompasses medication as well as nursing and care (Welsh Assembly Government 2011).
The National Health Service NHS is supported by 22 local health boards, corresponding to the 22 local authorities. These are meant to work in liason with the 14 NHS trusts in order to cordinate service delivery. Local community participation in policy formulation is incorporated through the community health councils. The regional offices take recomendations from the local health boards, local authorities and the NHS trusts, and then answers to the director of NHS in Wales. These regional offices are strategically situated in the north, mid, south west of Wales. The director of NHS in wales is on the same strategic level as the Chief Medical Officer in the national implementation of the healthcare policies. While this structure is intended to achieve inclusion of the patients in policy formulation, the nationalwide agendas are not always passed through community discussion forums for deliberations, a factor which significantly allienates the consumer from policy implementors (Simmons, 2009).
Both the Chief medical officer and the national director NHS report to the Minister for Health and Social Services, who in turn reports to the National Assembly of Wales Health and Social Services Committee. The Local Health Boards are mandated with asessing the needs of the society and recomending neccesary products in healthcare. The Boards are constituted by Local General Practitioners (GPs),dentists, optometrists, nurses,pharmacists, memebrs of other local authorities, represnetatives form voluntary and non governmental organisations, among other groups. The NHS trusts, on the other hand, are mainly the prvders of essential services such as general medication, patient care (both institutional and home) and mental health care to the general population who are eligible for public health cover. The community health councils engage the population with a view to collect their concerns and incorporate their opinions in the implementation of healthcare practices (Klein, 2006).
2.3.4 Welsh Healthcare Standards
In order to deliver its mandate, the NHS has come up with standards which must be met in line with the international regularization of modern healthcare (Welsh Government 2013). The objectives of the standards include formulation of a care system based on common values with a global dimension, and which is patient centered, to implement continous development and improvement in the quality of care, to promote a platform on which care providers can evaluate themselves and be easy to evaluate by external organs such as government bodies, and to enhance the image of NHS as a quality health services provider and regulatory authority(NHS,2012). The Standards are set along three dimensions of Clinical Outcomes, Patient experience, healthcre governance,and public health (Welsh Assembly Govt, 2012). It is important at this point to state that the operating guidelines of the three other countries in the UK have structures very similar to the Welsh NHS policy, with minimal variations regarding internal processes, goal setting and motivational incentives, among other personalized activities.
2.3.5 Challenges of the Government Healthcare Centers in the UK
As observed, unlike the other three countries under comparison, the UK has an almost total reliance on public funding to run its public hospitals. This essentially means that the burden on the taxpayer for providing medical services is higher than the average country with a public- public combination of funding systems. In addition, the NHS work is made more complex by the fragmentation of its region of jurisdiction by countries. This means the workload per medical unit is higher, and the management of patient records harder as the scheme is serving so many people spread over different countries (Klein, 2006).
Another problem with UK hospitals, like other countries` hospitals, is the waiting time. In the NHS funded healthcare centers, patients are booked for appointment with the hospitals for specialized treatment or surgery depending on their ability to immediately pay for the service, the insurer`s amount of commitment to the particular service, and the number of patients waiting in line to for the same services. Typically, a booking can take upto several weeks depenidng on the availability of specialized doctors. This waiting time is less than that of US and Canada, and comparable to that of Australian goverrnment health centers. In is common for patients to wait between 14- 28 days for specialized treatment, and more than 50% say they have to wait for at least a week before getting specialized treatment.
An emerging problem or challenge for the NHS in the recent past has been with regard to funding. It is estimated that over the mext 10 years, the NHS will be faced with a progressive budget deficit closing at an estimated $30billion. If this gets actualized, its implication on the quality of service in the NHS hospitals, as well as the staffing and other related issues, may become significantly affected, thereby reducing the overall rating of the scheme.
2.4 Comparison of the various Healthcare Centers in UK,Canada, US and Australia.
There exists similarities as well as differences between the various countries` as well as differences. On a broad perspective, government healthcare systems in all the four countries rely on government funding for the majority of their operations, but to varying degrees. The table below shows the nature of the comparison.
Primary care role
Primary care payment
Is registration required?
Mixed including FFS, cost sharing
Not for profit70%
Per diem and case based
Mixture of private, public and not for profit private
Mixed with significant public
Case by case
Source: Comonwealth Fund, 2012
The table above shows that UK and Australia have the highest concentration of public health centers of the four countries. Australia relies mainly of Medibank public health insurance to pay bills in the public hospitals. Australia has 67% of health centers as public, and 33% private. Care is provided in both inpatient and out-patient levels. In UK where most of the care is provided by NHS hospitals, the hospitals require that all staff be registered with the relevant bodies before commencing service. This is in contrast with other countries such as the US and Canada where the majority practice is carried out by private consultants who bill patients using a universal payment range approved by the various healthcare regulatory bodies (Twaddle, 2002).
Already, the table points towards a diverse healthcare center arrangement with regard to the majority care provider type (public versus private), mode of payment and the regulations governing entry to healthcare services provision. All countries, however, do show that reliance on public hospitals is high, especially in UK where almost all major care centers are government operated. This diversity also has a bearing on the nature of consumer ratings for the various healthcare centers and insurance schemes in the four study countries (Peterson & Burton, 2008).
2.4.1 Waiting times
Another important consideration in this section is the average waiting time for the various government healthcare centers in the four countries. Waiting times arise when a patient cannot immediately access medical services, especially surgery and specialized treatment, due to existence of large numbers of other patients waiting for the same services. In addition, patients can be forced to wait for medical services due to unavailability of funds to privately cater for treatment, as the majority of hospitals using government insurance typically receive lots of patients and are forced to schedule them for different dates. Long waiting times are typical of hospitals especially in the US and Canada. Healthcare of Canada reported in a 2010 survey that 42% of Canadians as well as 29% of Americans typically wait for 2 hours of more in emergency departments before being attended. In addition, 43% of Canadians as well as 10% of Americans had to wait for more than 4 weeks before being seen by a specialist. 37% of Canadians admitted that they had found it hard to access medical care in government establishments and elsewhere once the evening comes, with at least 37% saying that they had to result to emergency departments to get help. In public health establishments, about half the patients from both countries felt that they could have accessed most of the services they sort from emergency department if only they would have managed to get appointments with their ordinary care points (Simmons, 2009).
NHS based hospitals in UK also reported high waiting times for advanced medical services including surgical procedures, specialist services among others. The bigger concern for NHS though, is streamlining medical care provision routines. The UK`s proportionately higher dependence on government health centers for care as well as the geographical and political diversity of the region under care of NHS have made it necessary for the NHS to come up with a global records management platform that will provide seamless transfer of patient records between jurisdictions without compromising information security and tampering.
2.4.2 The Quality of Care
The quality of care for medical services providers, as well as government schemes, is measured alongside the three items including beds per 1000 people in the population, life expectancy at birth, and physicians per 1000 people in population. The CIA World Fact book reported the following data for the four study countries in 2010 (Armstrong, 2011).
Comparison of Australia, Canada, UK and US for Availability, Accessibility and Quality of Health Care Services
Availability (beds per 1,000 pop.)
Accessibility (physicians per 1,000 pop.)
Quality of Care (life expectancy at birth)*
Source: CIA world fact book (2013) at https://www.cia.gov/library/publications/the-world-factbook/geos/
The US has the least number of beds per 1000 people, which means that the availability of government aided healthcare in US is lower than in all other countries. This factor is not conclusive in that the data provided is for the general medical care society, and not specifically reflective of only the public healthcare facilities funded by the government. Canada, however, has a lower accessibility than that of the US. Accessibility is measured in terms of number of physicians per 1000 persons in the population. Canada has the lowest ratio at 1.91, while Australia has the highest at 2.99. These figures can perhaps be explained by the nature of health care arrangements in the various countries. Australia has shown the most diverse healthcare funding allowance, with the government advising the population to have a private medical insurance scheme on top of the government`s own scheme and charging taxes for those above a certain income limit without this insurance. This may explain the high number of private care providers and therefore physicians per unit population. The UK shows a median figure of 2.74, which is above that of Canada and lower than that of Australia.
The other indicator f healthcare quality in the four countries is the life expectancy at birth. This figure can be determined by factors outside the quality of care in the healthcare facilities in the parent country, such as war, political instability, and adverse weather among others. However, when all other factors held constant, it can have a direct correlation with the quality of care in a country`s healthcare institutions as well as policies laid out by the departments of health. According to the CIA Fact book, Australia has the highest life expectancy at 81.98, followed by Canada at 81.57, UK at 80.29 and the US at 78.62. In this view therefore, the US has the lowest life expectancy rating. The overall rating of the four countries` healthcare systems can be attained as a simple average of all key indicators. When the averages are obtained, Australia emerges the best in term of quality of care, followed by Canada, then the UK and finally the US (Armstrong, 2011).
The foregoing discussion has shown that each of the four countries have similar yet different government healthcare policies as well as healthcare centers. While the UK and Canada show a mainly government controlled and insured healthcare system, the US and Australia show a more mixed approach with both government and private sector participating widely in healthcare provision. Yet, the average rating for US is the extreme opposite of Australia in terms of quality of care. Still, it is true that the US had a wider distribution of economic, social and racial communities. This may imply, perhaps, that the US has a small percentage of the population accessing very quality healthcare while another larger segment is unable to afford even the most basic care. And, with the government unable to provide free medical care for everyone, the US government healthcare centers are more often filled with low income people or uninsured persons seeking cheap or subsidized medical care (Behan, 2007). The UK on the other hand experiences situations entirely different from those of the US.
The entire population is much smaller (only about 10 percent that of the US at 61 million) and less diverse in terms of economical, and social-cultural dimensions. In addition, the government has managed to provide free medical care for most of the basic facilities. This has the implications that the UK government must invest more on healthcare infrastructure than the other countries. However, the UK also has four independent jurisdictions in which NHS policies may slightly vary (Armstrong, 2011). The biggest challenge for UK hospitals is the quality of service, as opposed to US`s access to service for the 23 million people who lacked insurance at the onset of PPACA care.
For Australia, the healthcare centers are adequate and the service quality agreeable. The biggest current concern for the Australian government healthcare facilities is the proliferation of lifestyle related ailments such as heart diseases, tobacco related conditions, and skin cancer. While these issues are currently under control by the healthcare policies, it is unclear if Australia will continue to enjoy top of the range healthcare quality or if the current emerging threats will increase the demand for healthcare in public and government centers and possibly weaken the quality of care. The next chapter will focus on methods used to collect data which will inform the study questions and therefore meet the objectives.
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