Equity in health care financing is recognised as a main goal in health policy. It implies that payments should be linked to capacity to pay and that households should be protected against catastrophic health expenditure (CHE). The risk of CHE is inversely related to the share of out-of-pocket payments (OOP) in total health expenditure. In Portugal, OOP represented 26% of total health expenditure in 2010 [one of the highest among Organisation for Economic Co-operation and Development (OECD) countries]. This study aims to identify the proportion of households with CHE in Portugal and the household factors associated with this outcome. Additionally, progressivity indices are calculated for OOP and private health insurance. Data were taken from the Portuguese Household Budget Survey 2010/2011. The prevalence of CHE is 2.1%, which is high for a developed country with a universal National Health Service. The main factor associated with CHE is the presence of at least one elderly person in households (when the risk quadruples). Payments are particularly regressive for medicines. Regarding the results by regions, the Kakwani index for total OOP is larger (negative) for the Centre and lower, not significant, for the Azores. Payments for voluntary health insurance are progressive.

In the past two decades, setting up independent health technology assessment (HTA) agencies has become a popular tool to inform reimbursement decision-making in health care, spreading from Northern European countries across Western Europe but much less so to post-communist countries. Structural political science explanations leave gaps in clarifying this diffusion pattern. This paper proposes a theoretical model focusing on the influence of domestic epistemic communities mitigating policy diffusion. Based on a review of HTA institutions in the EU, it proposes a chronological taxonomy of HTA agencies in Europe (the forerunners, the mainstreamers and the non-adopters) and asks why there is such an important East-West divide. The paper discusses theoretical explanations from different literatures, finding unsatisfactory many traditional political science answers such as the degree of centralization of a country’s health system, its financial organization (Bismarckian or Beveridgian), the attitude toward independent regulatory bodies in general, the influence of international actors, or lack of resources. Finally, it suggests cases for empirical testing of the domestic epistemic communities model.

While studies have shown that reductions in out-of-pocket payments for vaccination generally encourages vaccination uptake, research on the impact on health outcomes has rarely been examined. Thus, the present study, using municipal-level survey data on a subsidy programme for influenza vaccination in Japan that covers the entire country, examines how reductions in out-of-pocket payments for vaccination among non-elderly individuals through a subsidy programme affected regional-level influenza activity. We find that payment reductions are negatively correlated with the number of weeks with a high influenza alert in that region, although the correlation varied across years. At the same time, we find no significant correlation between payment reductions and the total duration of influenza outbreaks (i.e. periods with a moderate or high alert). Given that a greater number of weeks with a high alert indicates a severer epidemic, our findings suggest that reductions in out-of-pocket payments for influenza vaccination among the non-elderly had a positive impact on community-wide health outcomes, indicating that reduced out-of-pocket payments contributes to the effective control of severe influenza epidemics. This suggests that payment reductions could benefit not only individuals by providing them with better access to preventive care, as has been shown previously, but also communities as a whole by shortening the duration of epidemics.

The Finnish health care system is widely respected for its pilot role in creating primary-care-led health systems. In the early 1990s, however, a severe economic downturn in Finland reduced public funding and weakened the Finnish system’s deeply decentralized model of health care administration. Recent Bank of Finland projections forecasting several decades of slow economic growth, combined with the impact of an aging population, appear to make major reform of the existing public system inevitable. Over the last several years, political attention has focused mostly on administrative consolidation inside the public sector, particularly integration of health and social services. Current proposals call for a reformed health sector governance structure based on a new meso-level configuration of public administration. In addition, Finland’s national government has proposed replacing the current multi-channel public funding structure (which includes health insurance subsidies for occupational health services) with a single-channel public funding structure. This commentary examines several key issues involved in reforming the delivery structure of the Finnish health care system. It also explores possible alternative strategies to reform current funding arrangements. The article concludes with a brief discussion of implications from this Finnish experience for the wider health reform debate.

Medical savings accounts (MSAs) allow enrolees to withdraw money from earmarked funds to pay for health care. The accounts are usually accompanied by out-of-pocket payments and a high-deductible insurance plan. This article reviews the association of MSAs with efficiency, equity, and financial protection. We draw on evidence from four countries where MSAs play a significant role in the financing of health care: China, Singapore, South Africa, and the United States of America. The available evidence suggests that MSA schemes have generally been inefficient and inequitable and have not provided adequate financial protection. The impact of these schemes on long-term health-care costs is unclear. Policymakers and others proposing the expansion of MSAs should make explicit what they seek to achieve given the shortcomings of the accounts.