Mental health policy and practice across Europe: an overview

68 Mental health policy and practice
a higher rate, helps to redistribute resources from the better off in a society to
the less well off.
The main alternative to taxation in Europe is social health insurance (SHI),
which dominates health care financing in, for example, Austria, Belgium, the
Czech Republic, France, Germany, the Netherlands and Romania. Although SHI
systems differ there are a number of common features. Contributions are usually
linked to salaries, with employers typically also making a contribution. In some
countries there may be just one or two sickness funds collecting contributions,
while in others the choices may be many and perhaps linked to profession.
Transfers from general taxation to sickness funds are made to provide cover for
unemployed, retired and other disadvantaged or vulnerable people (Normand
and Buse 2002). Premiums are not usually based on risk; but risk-adjustment
mechanisms are often used to ensure that no one sickness fund is unduly
disadvantaged (or indeed advantaged) from the ‘risk mix’ of its population.
Enrolment is compulsory in most countries with SHI, although there may be
some opportunities to opt out, dependent on income, as in Germany. Thus, the
use of additional voluntary health insurance (VHI), offered by for-profit or
non-profit companies, and taken up and paid for at the discretion of individuals
or their employers, is relatively limited in Europe. VHI usually fulfils one of
three principal roles: a substitute for SHI (as in Germany for higher paid workers),
a complement to public entitlement (as in France to cover co-payments
within the public health system) or a supplement (as in Ireland to reduce the
time before receiving treatment and to increase service choice) (Mossialos and
Thomson 2002). Unlike social insurance, VHI may be risk-rated, offering lower
premiums to low-risk individuals, which could mean that higher risk groups
in society (such as those with mental health problems) find it unaffordable,
especially as mental health problems are more prevalent among lower income
groups (see, for example, Weich and Lewis 1998).
Charges are often levied on a selection of health care services, such as pharmaceuticals,
dentistry or primary care consultations. They may be in place to
raise revenue, and/or also to discourage excessive or inappropriate utilization.
However, user charges can be costly to administer and may deter patients from
accessing the care they need. One recent study reported that the introduction of
user charges for previously exempt vulnerable groups can lead to a reduction in
the use of services (Tamblyn et al. 2001). Of course, such a reduction in utilization
may be a false economy; in the medium term costs may increase if individuals
more frequently present themselves at secondary and emergency care
facilities, as Soumerai et al. documented in their New Hampshire study (1994).
Other financing arrangements are possible. There may be ‘informal’ or
‘under-the-counter’ payments for services that are supposedly fully funded,
most commonly seen in central and eastern Europe (Lewis 2002). Funds to
invest in health – in central and eastern Europe in particular – might be boosted
by bilateral aid programmes, contributions from non-governmental organizations
(NGOs) and other international bodies. There are some modest specialist
health insurance schemes, for instance hospital cash plans, which pay out predetermined
cash benefits when individuals use health care services. Others –
quite uncommon – are employer accident insurance schemes, motor vehicle
insurance and schemes to protect against loss of earnings.