In many countries of the world there are systems in place to ensure the health care of the population. However, the structures and operating principles of the various national health systems differ considerably. This has to do with the different historical developments and political cultures as well as with the respective socio-economic context of the individual countries.
In the health policy reform debates in Germany, international comparisons are repeatedly made to determine the advantages or disadvantages of individual systems. This learning tour uses the examples of five European countries – Great Britain, the Netherlands, Sweden, Switzerland and France – to illustrate the differences, but also the similarities, of different national health systems.
Comparison of health systems
Health care systems are usually very complex structures. They have a large number of institutions and actors with diverse and complicated relationships. One reason for this is that the health systems we know today have undergone a long and varied historical development. The origins of national systems date back to the 19th century or even earlier. They originated from specific social, health, political and economic problems.
Health policy is often the result of conflicts between social actors with different interests, perceptions of problems and objectives. Since their beginnings, health care systems have undergone continuous development. Sometimes this happens in small steps, sometimes there are far-reaching structural reforms that put the health care of the population on a new basis. As a result, there are now 27 different national health systems in the European Union.
On the one hand, there is the question of who pays for the services of the health system. Financing can be based on a variety of different sources:
What is the significance of state tax revenues?
What do public or private insurance companies do?
To what extent are companies, employees and not least private households involved in financing the health system?
On the other hand, health systems are differentiated according to who provides the actual medical, nursing, preventive and rehabilitative services. Care can also be organised very differently.
Who are the service providers?
What role do public and private service providers play?
Are they profit-oriented or non-profit organisations?
Finally, the regulation of the health care system is an important feature:
Who sets the rules that apply to the different actors in the system?
How are the relationships between the funding agencies, the service providers and the users of the health care system structured?
In contrast, the state plays a weaker role in the second type, the social security system. Financing is regulated by social security systems, the contributions of which are provided, for example, by companies and their employees, as is the case in Germany.
The lesser importance of the state is also reflected in the provision of services, where actors from the private sector are active alongside public providers. The regulation of social security systems is characterised by the fact that the non-state actors can to a certain extent shape their relations on their own (self-administration principle).
Finally, private or private-sector systems represent the third ideal type. In private systems, the state largely withdraws from the financing, organisation and control of the health system and leaves these tasks to private actors. Financing is mainly provided by private insurance and private household expenditure. Care is provided by private providers in competition with other service providers, and the regulation of the system is largely left to the mechanisms of the market.
Since the statutory health insurance introduced in the German Reich under Chancellor Bismarck in 1883 was the world’s first social insurance scheme for workers, social insurance systems are also referred to as “Bismarck systems”. In contrast, state health services are also referred to as “Beveridge systems,” named after economist William Henry Beveridge, who is considered the “architect” of the 1946 National Health Service (NHS).
If you look at individual health systems, however, you will find that they never fully correspond to one of the three ideal types. In public health services, too, there are financing shares that do not come from tax revenues, as well as private service providers. And even systems that are predominantly privately organized – as in the USA, for example – have a not inconsiderable share of state financing, service provision and regulation. In reality, therefore, we find mixed systems in which elements of the various ideal types are combined with one another. Nevertheless, they can be assigned to one or the other type on the basis of a certain basic structure.
Health systems in Europe
In the Member States of the European Union, public health services and social security systems predominate. This learning tour describes the health systems in five European countries, which are repeatedly used as (positive or negative) comparative models in health policy reform debates. With Sweden and Great Britain two systems are presented which have a national health service. In the Netherlands, Switzerland and France, on the other hand, we find social security systems. On the one hand, the learning tour provides a basic knowledge of the characteristics of the various systems.
The presentation gives an insight into the financing systems, the organisation of service provision and the mechanisms of regulation. In addition to the basic structures of the health care systems, it also presents the health policy changes of the recent past and gives readers an insight into current health policy reform debates. On the one hand, important structural differences emerge that make it difficult to transfer reform measures to other systems. On the other hand, despite the differences in the systems, numerous similarities can also be observed in the problem perceptions and reform models discussed.
The study “Towards High-Performance Health Systems” stresses that there is no patent remedy and no ideal solutions to improve the performance of health systems. The definition of an appropriate health policy must take into account the specific characteristics of each country. The report shows that countries can learn a great deal from each other because they share the same objectives, namely high-quality health care that is accessible to all, affordable health systems that meet patients’ needs and good value for money.