O setor de saúde suplementar brasileiro operou desde os anos de 1940 sem regulação. Em 1998, o governo estabeleceu a regulação deste setor. Na regulamentação das atividades foram estabelecidas a ilimitação do número de consultas médicas, proibição de seleção de risco, entre outras medidas. O objetivo deste trabalho é investigar se a regulação resultou em aumento do número de consultas médicas por parte dos subscritores de planos de saúde, ou seja se ocorreu aumento do risco moral ex-post. Além disto, analisar alterações nos determinantes da demanda por posse de plano de saúde antes e após a regulação visando encontrar indícios de seleção adversa. Para isto, foram utilizados quatro métodos econométricos: regressão de Poisson, regressão binomial negativa e regressão quantílica de dados de contagem e um modelo Probit. O estimador de diferenças-em-diferenças foi utilizado para estimar o impacto da regulação sobre o número de consultas médicas. O modelo de regressão Probit foi utilizado para analisar os determinantes da demanda por posse de plano de saúde. Os dados utilizados provêm da Pesquisa Nacional de Amostra de Domicílios de 1998 (antes da regulação) e 2003 (depois da regulamentação). Os dados foram divididos por sexo e também pelo perfil epidemiológico, sendo selecionados os dados daqueles indivíduos que declararam ser portadores de doença renal crônica. Os resultados dos modelos mostraram que após a regulamentação ocorreu um aumento geral do número de consultas. Contudo, o sinal da principal variável de interesse, a dummy associada ao efeito da regulamentação sobre o número de consultas médicas dos subscritores de planos de saúde foi negativo e estatisticamente significativo - tanto no caso dos homens como no das mulheres - , nos três modelos e nas duas amostras. Isto indica que após a regulamentação ocorreu uma redução do número de consultas médicas dos possuidores de planos de saúde em relação àqueles que não possuíam plano de saúde. O uso da regressão quantílica possibilitou mostrar que o número de doenças crônicas e a posse de um plano de saúde são os fatores que mais afetam o número de consultas. Permitiu também mostrar que os efeitos dos regressores são diferentes entre os sexos e que não são uniformes ao longo dos quantis. Os resultados dos modelos para dados de contagem mostraram que, mesmo quando se controlam as características epidemiológicas, existe risco moral, antes e após a regulamentação. Os resultados do modelo Probit sugerem a existência de seleção adversa após a regulamentação, pois mostram que os indivíduos com maior número de morbidades têm maior probabilidade de adquirir um plano de saúde. Em suma, os resultados mostraram que após a regulamentação ocorreram dois importantes problemas no mercado de saúde suplementar: seleção adversa e risco moral. A conjunção destes dois problemas pode comprometer a sustentabilidade do setor de saúde suplementar brasileiro. / The Brazilian private health insurance sector operated since 1940’s without regulation. In 1998, the government established the regulation of this sector. The reform improved the health insurance coverage level, stating no limit to physician visits and forbiddance of the cream skimming, among others measures. The objective of this thesis is to investigate if the regulation resulted in an increase of physician visits from consumers of health insurance, that is to say, if there has been an increase of moral risk ex-post. Besides, to investigate alterations in the determinants of demand for the health insurance - before and after the regulation - seeking to find evidence or clues of adverse selection. Four econometric methods have been used for this: Poisson Regression, Negative Binominal Regression and Quantile Regression for counts and Probit Regression. The estimator of difference-in-difference was used to estimate the impact of regulation on the amount of physician visits. The Probit model regression was used to analyze the determinants of the demand for health insurance. The data used come from the 1998 Brazilian Household Survey (Pesquisa Nacional de Amostra de Domicílios-PNAD) (before the regulation) and 2003 (after the regulation). The data was divided by gender and also by the epidemiologic characteristics, selecting the data of those individuals who declared being bearers of chronic renal disease. The results of the models showed that, after the regulation, there was a general increase in the amount of consultations. However, the sign of the main variable of interest (year*regulation), the dummy associated to the effect of the regulation on physician visits of the consumers of health insurance, was negative and statistically significant – both in men and in women – in the three models and in both samples. These results suggest that after the regulation there was a reduction in the amount of physician visits of the consumers of health insurance in relation to those who did not hold a health insurance plan. The results of Probit Regression showed that after regulation there is adverse selection, since the number of chronic diseases variable after regulation was positive and statistically significant. The use of quantile regression for counts made possible showing that the number of chronic diseases and the possession of a health insurance plan are the factors which mostly affect the amount of consultations. It also allowed showing that the effects of regressors are different between the genders and also that are different in different parts of the outcome distribution. The results for the models for count data showed that, even when controlling the epidemiologic characteristics, there is a moral hazard, before and after the regulation, since individuals covered by insurance had more physician visits. The results of the Probit Model suggest the existence of adverse selection after a regulation, since it shows that individuals with a higher number of morbidities, are more likely to buy a health insurance plan. In sum, the main findings suggest that after the regulation there are two important problems: adverse selection and moral hazard. The conjunction of these two problems may generate inefficient outcomes and might compromise the sustainability of the Brazilian private health insurance market.

Introdução: Um dos impactos sociais do envelhecimento diz respeito à oferta e demanda de serviços de saúde. O sistema brasileiro garante a prestação de serviços públicos em caráter universal e admite a participação do mercado na provisão de tais serviços. Assim, todo cidadão é usuário potencial de provedores de serviços financiados pelo Estado e pode, simultaneamente, usar provedores de natureza privada. Objetivo: Identificar a ocorrência de mudança de provedor prioritário de serviços de saúde, bem como características socioeconômicas e epidemiológicas e respectiva associação com a condição de ter ou não ter plano de saúde, na população idosa do município de São Paulo, no período 2000 / 2006. Material e método: estudo de coorte desenvolvido no âmbito do Estudo SABE (Saúde, Bem-Estar e Envelhecimento). A coorte iniciou-se em 2000 com 2.143 participantes de 60 anos e mais e, em 2006, contava com 1.115 pessoas. A variável dependente é ter plano de saúde e as independentes abrangem características sociais e demográficas; morbidade referida; autoavaliação de saúde; atividades básicas de vida diária; ações de prevenção e uso de serviços de saúde. Os dados, obtidos por meio de entrevista domiciliar, foram analisados de forma descritiva e pelo desenvolvimento de um modelo de regressão logística por passos (stepwise). Resultados: Há diferenças, favoráveis aos titulares de planos, nas variáveis renda, escolaridade e condições de vida pregressa. O grupo sem planos privados realizou menos prevenção contra neoplasias e mais contra doenças respiratórias; esperou mais para ter acesso a consulta de saúde; realizou menos exames pós consulta; referiu menor número de doenças; teve maior proporção de avaliação negativa da própria saúde e relatou mais episódios de queda. Os titulares de planos privados relataram menos dificuldades no desempenho em ABVD e menor adesão à vacinação. Dentre os titulares de planos que se internaram, em 2000, 11,1por cento tiveram sua internação custeada pelo SUS. Em 2006 essa proporção se eleva para 17,9por cento . A única enfermidade associada à condição de titular de plano privado foi a osteoporose. Não houve mudança significativa entre provedores prioritários de serviços de saúde. Conclusão: as associações encontradas relacionaram-se mais às questões sociais e demográficas e ao uso de serviços do que às condições de saúde dos indivíduos / Background: Population aging influences the offer and search for health services. The Brazilian health system (Sistema Único de Saúde SUS) warrants universal access to public health services and allows the participation of the private sector. Thus, each and every citizen is a potential user of services both provided by the State and by the private sector. We assume that private health insurance holders will have their health services preferentially provided by the private sector. Objective: To identify the occurrence of changes in priority health care provider, as well as socioeconomic and epidemiologic characteristics associated with having or not private health insurance in the elderly population in the city of São Paulo from 2000 to 2006. Methods: retrospective cohort study carried out as part of the Survey on Health and Wellbeing of Elders (SABE Saúde, Bem-estar e Envelhecimento). This cohort started in 2000 with 2,143 participants aged 60 years and, in 2006, had 1,116 participants. Having a private health insurance is the dependent variable and independent variables include sociodemographic characteristics; referred morbidity, self-assessment of health, basic activities of daily living (BADL), preventive actions and the use of health services. Descriptive analysis and stepwise logistic regression were used to assess data collected in home visits. Results: There were significant changes in income, scholarship and earlier life conditions in favor of insurance holders. The group that had no private health insurance was less subjected to cancer and more subjected to respiratory disease prevention, waited longer for health appointments, did less postappointment examinations, had a more negative self-assessment of health and reported higher frequency of falls. Private health insurance holders reported less difficulty to perform BADL and lower adhesion to vaccination campaigns. Among holders that were hospitalized, 11.1per cent had their medical expenses paid by SUS in 2000 and 17.9per cent in 2006. The only morbidity associated with being a private health care insurance holder was osteoporosis. There were no significant changes in priority health provider throughout time.Conclusion: The study population/group tended to keep the same type of health care provider and associations found were more related to socio-demographic characteristics and the use of services than with health conditions of the elderly

La présente recherche analyse la mise en œuvre de la politique d’encouragement à l’achat de la carte d’assurance-maladie publique au Vietnam. Pour ce faire, le premier axe de recherche consiste à faire un état des lieux du système vietnamien d’assurance-maladie et de l’utilisation de la carte d’assurance-maladie par les différentes catégories socio-professionnelles. Le deuxième axe de recherche consiste à élucider la question de savoir si ce programme gouvernemental est porteur d’ambiguïtés. Il s’agit là d’une analyse documentaire de la présente politique elle-même. Le troisième consiste à éclaircir les logiques différentes, à décrire les conflits et les tensions entre les groupes d’intérêts divers, à savoir : l’État, les médecins, les professionnels de l’assurance-maladie et les groupes sociaux, surtout les acteurs visés par la politique, qui n’ont pas encore la carte d’assurance-maladie. Le dernier axe de recherche essaie de comprendre comment et dans quelles mesures ces divers acteurs pourraient entrer en négociation pour en arriver à des compromis et à la réalisation de ladite politique. À partir de cette analyse, nous comprendrions mieux quel en serait le mode de régulation et/ou de gouvernance à l’heure actuelle le mieux adapté à la situation vietnamienne. En termes d’approche méthodologique, la présente recherche propose tout d’abord une analyse « bottom-up » des conflits et des tensions à partir de la définition de l’action des acteurs les plus bas du système d’acteurs que sont les groupes sociaux non-bénéficiaires de la carte d’assurance-maladie publique. Ainsi, leurs besoins, leurs attentes, leurs objectifs, leurs moyens et leur rationalité, ou plutôt leur logique, nous guident dans la détermination des logiques d’achat de ce produit public. À partir de là, nous analysons les interactions entre ceux-ci et d’autres acteurs comme l’État, les médecins, les professionnels de l’assurance-maladie, qui consistent à construire le système d’assurance-maladie du Vietnam. Cette approche méthodologique nous permet de faire des études qualitatives et quantitatives au travers des échantillonnages représentant les groupes d’intérêts divers relatifs à cette politique d’universalisation et d’encouragement à l’achat volontaire de la carte d’assurance-maladie publique.La recherche utilise des outils méthodologiques tels que des entretiens approfondis auprès des autorités centrales et locales en matière d’assurance-maladie publique, des médecins, des professionnels de l’assurance-maladie et des groupes sociaux qui se divisent en deux sous-groupes : les détenteurs de la carte d’assurance-maladie publique et ceux qui n’ont pas adhéré à cette offre. Un autre outil méthodologique est l’observation participante sur des espaces sociaux où se trouve une condensation des interactions, par exemple : au cabinet de consultation d’un médecin, au guichet de remboursement des frais d’hospitalisation…C’est dans ces espaces sociaux que les conflits et/ou tensions se défrichent aussi d’une manière « spontanée » et nous aident dans leur découverte. / The study aims at examining the implementation process of public health insurance card in Vietnam. In order to accomplish the research aim, the study has five research objectives. First, this study analyzes the situation of the health insurance system in Vietnam, as well as the use of health insurance card among different population groups with different socioeconomic backgrounds. Second, the study examines the transparency of the health insurance card promotion run by the government. Literature review was conducted to address this objective. Third, stemming from the existing conflicts among different stakeholders, the study investigates motivations and actions of the stakeholders, including: governors, physicians, health insurance staff, and target beneficiaries. Target beneficiaries include people without health insurance. Fourth, the study explores the social negotiation strategies used by different stakeholders in order to implement health insurance. Last but not least, the study recommends strategies for health insurance regulation and management tailored to the Vietnamese context. Regarding methodology, this study adopts the bottom-up approach to investigate social conflicts by identifying action logic of the lowest group in the social hierarchy. The lowest group refers to the most disadvantaged group without public health insurance. The study examines needs, motivations, expectations, objectives, means, and strategies of people in this group which lead to their decision-making (purchasing voluntary health insurance or not). Furthermore, the study analyzes social interactions of stakeholders in this disadvantaged group, as well as their interactions with other stakeholders, such as governors, physicians, and health insurance staff. These interactions construct the health insurance system in Vietnam. Adopting this approach, the researcher applies both qualitative and quantitative research methods. The study sample is representative of different social groups regarding policies of voluntary health insurance. The study applies different data collection methods. First, the researcher conducted in-depth interviews with: (1) representatives of health insurance managers at different levels, from central to local level; (2) physicians; (3) health insurance staff; (4) people using public health insurance; and (5) people not using public health insurance. Second, the researcher conducted participant observation in appropriate settings, such as health clinics, health insurance offices, etc. These settings exposed social conflicts among different stakeholders inherently. Combining different data collection methods yields fruitful results for the study.

La thèse présente le système de santé en Chine à travers son évolution depuis les années 50 et en fait une analyse institutionnelle pour comprendre comment le gouvernement chinois a réagi pendant les différentes phases de développement face à la demande de la population en termes de protection sanitaire. L’idée de cette thèse est de combiner une analyse institutionnelle avec une étude de cas à Weifang en Chine pour comprendre en profondeur le système de santé Chinois, mais aussi pour essayer de fournir des supports utiles pour les autres études qui pourraient être menées sur ce sujet. / This thesis tries to explain the Chinese health system since the 50s, and make an institutional analysis to understand how Chinese government reacted during different steps of development face to population’s demand in terms of health protection. The purpose of this thesis is to associate an institutional analysis with a case study in Weifang in China to deeply understand chinese health system, at the meanwhile this thesis tries to provide useful support for other future studies on this subject.

Thesis (LLM ( Labour law)) --University of Limpopo, 2013 / Refer to document

綜觀世界社會福利進步之國家，一方面致力於促進經濟成長，提高國民所得，一方面則積極推展社會保險，以兼顧社會福利及安全，俾使經建成果為全民共享。我國憲法明文規定社會安全為基本國策之一，而社會安全重心首推全民健康保險，故推行全民健康保險是政府責無旁貸任務，而其成效之良窳，端賴其是否妥善規劃。就現今實施全民健康保險，，規劃仍有未盡周詳之處，因而不僅易招致民怨，製造徵納雙方無謂困擾，更違反政府謀求全體國民最大福祉之目標，因此為鞏固全民健康保險實施基礎，以確保其千秋大業，更須針對全民健康保險制度之疏失予以檢討改善。 　　本研究係針對全民健康保險規劃未盡周延之處，分析問題之所在，繼而集思廣益去蕪存菁以尋求問題之改善方法，茲將研究結果歸納如下︰ 　　一、為謀求全體國民最大福祉，追求社會公平正義，全民健康保險法無職業受扶養親屬規定應與所得稅制無職業受扶養親屬二者作一銜接與配合。 　　二、為避免全民健康保險予擾所得稅制之機能，維持實質所得稅制免稅額（扶養親屬寬減額）與保險費扣除額不變，應將所得稅制下免稅額、保險費扣除額予以調整反映之。 　　三、鑒於投保金額分級，以每一等級之上限為投保金額，產生非預期性逆所得重分配現象，違反社會公平正義，宜將投保金額予以修正。 　　四、全民健康保險保險費徵收基礎，因被保險人身份產生差異，考量公平原則、所得重分配效果、行政效率及費率影響，故將標準予以調整。 　　五、眷屬投保金額反映以被保險人投保金額設算眷屬經濟能力之特質，若被保險人僅具扶養之名，不具扶養之實，為求眷屬保費負擔公平及合理性，宜尋求適當投保金額。 　　為使全民健康保險成為我國社會保險之中流砥柱，對保障全體國民身心健康，維護社會安全，貢獻良多，應秉持促進全體國民最大福祉原則，將全民健康保險法規定之不合理地方，考慮與所得稅制相關規定銜接與配合，並參酌專家學者意見，國外實施社會保險國家之經驗，以解決全民健康保險制度未盡周延之處。

The purpose of this study is to find existing circumstances in our country and a elder long-term care system of preventing transitions. Through the existing social insurance, for example: health insurance, national pension, labor insurance and the elderly welfare legal in our country, to compare with the other social countries, I hope to use the research analysis to find the problems of policies or legislated process that we need to prevent before the elder long-term care insurance started. Through the generalize analysis and history development of elder long-term care in many countries, use the Constitution and the Administrative Law to examine what Council of Grand Justices about Social Insurance interpretation and compare with the official policy offered by our government. I expect to avoid making mistakes and dispute like before and establishing the elder long-term care system which relieving burdens. After the analysis, I found that all of the advanced countries are almost confronting by problems like aging of population and the birthrate has been decreasing, and also confronting lack of care members and long-term care needed huge monetary payment issues. The key core of all the problems is whether it has enough money to the whole social welfare countries to be successful. Social welfare in democratic countries also face election activities carrying on social welfare politics. Ignoring national finance situations and majority political men were merely thinking off-the-shelf votes. It is priority for elder¡¦s policy but ignores the generation justice issues. Let me worry about whether descendant whom need care, not these elders, are there generations conflict being happened? In my opinion, to solve these problems is strengthening family function. If the whole social and nation wants to be stable, it is important to strengthen the family function. Therefore, the elder long-term care should be considered main family basis, in addition to ought to maintain the elder long-term care system and dualism and co-operate with National Health Insurance to work in coordination. The other elder social insurances have to adjust to unity, includes all kinds of old-age pensions similar nouns. Finally, it should be a definite principle and laws, and decrease indefinite concepts of law and reduce administrative discretion rights regarding pay items, thus it will protect people¡¦s rights instead of incurring damage beyond that could bring supervisory mechanism functions into full play after that.

Source: Masters Abstracts International, Volume: 46-05, page: 2674. Adviser: Carl Hacker. Includes bibliographical references.

This work presents a systematic investigation of two topics. One is in stochastic dynamic general equilibrium. It incorporates private information into dynamic general equilibrium framework. An existence of competitive equilibrium is established. Quantitative analysis is provided for health insurance problem. The other topic is in decision problems under ambiguity. Lack of precise information regarding a decision problem is represented by a set of probabilities. Descriptive richness of the set of probabilities is defi ned. It is used to generalize Skorohod's theorem to sets of probabilities. The latter is used to show the constancy of the coefficient in alpha-maximin multiple prior preferences. Examples illustrate: the implications of this representation; and the restrictions arising from the failure of descriptive richness. / text

Purpose: The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations' capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications: The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value: This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.