Claus Wendt

Mapping European healthcare systems: a comparative analysis of financing, service provision and access to healthcare

Healthcare systems have been institutionalized to provide healthcare for those in need. Therefore, comparisons should focus in particular on differences in healthcare provision and on how access to healthcare services is regulated. This article presents a typology of healthcare systems which simultaneously takes into account data on expenditures, financing, provision and access to healthcare in 15 European countries. On this basis, three types of healthcare system have been constructed using statistical cluster analysis: a health service provision-oriented type that is characterized by a high number of service providers and free access for patients to medical doctors; a universal coverage — controlled access type where healthcare provision has the status of a social citizenship right and equal access to healthcare is of higher importance than free access and freedom of choice; and a low budget — restricted access type where financial resources for healthcare are limited and patients’ access to healthcare is restricted by high private out-of-pocket payments and the regulation that patients have to sign up on a general practitioner’s list for a longer period of time.

Conceptual frameworks for comparing healthcare politics and policy

This literature review pursues two main objectives: first, it argues that research on health policy actors and healthcare systems need to be separated more thoroughly. Though there are important interactions between both fields, it is often advisable to separate analytically research on health policy actors and on healthcare systems. Second, concentrating not only on actors and institutions but also on outcomes, we suggest, is theoretically valuable, practically feasible, and policy relevant. Most studies discussed in this review concentrate either on health policy implementation or on healthcare system characteristics. Our emphasis is on extending the understanding about the outcomes of different national healthcare arrangements and whether policy reforms actually deliver their promised results. To do this, more attention to the measurement of success is required.

9 The changing role of the state in healthcare systems

This article focuses on two major questions concerning the changing role of the state in the healthcare systems of OECD countries. First, we ask whether major changes in the level of state involvement (in healthcare systems) have occurred in the past 30 years. Given the fact that three types of healthcare system, each of which is characterized by a distinct role of the state, evolved during the ‘Golden Age’, we discuss how this distinctiveness – or more technically, variance – has changed in the period under scrutiny. While many authors analysing health policy changes exclusively concentrate on finance and expenditure data, we simultaneously consider financing, service provision and regulation. As far as financing is concerned, we observe a small shift from the public to the private sphere, with a tendency towards convergence in this dimension. The few data available on service provision, in contrast, show neither signs of retreat of the state nor of convergence. In the regulatory dimension – which we analyse by focusing on major health system reforms in Germany, the United Kingdom and the United States – we see the introduction or strengthening of those coordination mechanisms (hierarchy, markets and self-regulation) which were traditionally weak in the respective type of healthcare system. Putting these findings together we find a tendency of convergence from distinct types towards mixed types of healthcare systems.

Translating Monetary Inputs into Health Care Provision: A Comparative Analysis of the Impact of Different Modes of Public Policy

Abstract This article investigates different modes of public policy in health care and their impact on health care financing and health service provision. In order to investigate the relationship between health expenditure and health service provision, we construct an “index of health care providers”. The empirical analysis of expenditure and this index demonstrates that there is only a weak correspondence between the level of total health expenditure and the number of health service providers in OECD countries. Different modes of health policy can help to explain why some countries are more successful in translating monetary inputs into health care personnel than other countries. Our results indicate that policies which favor self-regulation by non-governmental actors (as in Germany) lead in general to high levels of health care providers at above OECD average health expenditure. Policies which favor direct state control (as in the United Kingdom), on the other hand, are characterized by lower levels of health care providers and below average health expenditure. Policies which favor market elements are more difficult to categorize. However, it is noteworthy that especially countries that give market mechanisms higher priority than other countries (as the United States) offer below average numbers of health care providers at comparatively high total health care costs.

Bildungsniveau und Zugang zu Gesundheitsleistungen

Equal access to health care is a central goal of all European health-care systems. International studies, however, show that this goal has not been accomplished yet. The aim of this study is to investigate if there are inequalities across patients with different levels of education and if these differences vary with the institutional set-up of health-care systems. The test of this hypothesis is based on a comparison of eleven European countries using data from the SHARE survey (Survey of Health, Ageing and Retirement in Europe). Our results show that in countries with institutionalised gatekeeping systems differences of utilisation between educational groups are rather low. In countries with free access to specialists, patients with higher levels of education show a higher probability of specialist visits than their counterparts with lower levels of education.

Social Austerity versus Structural Reform in European Health Systems: A Four-Country Comparison of Health Reforms

Cost containment has captured the attention of health policymakers in most OECD countries, and deliberations about creating powerful financial incentives dominate health care politics. Some European health systems are now implementing hospital payment schemes that mirror the U.S. model of diagnosis-related groups (DRGs) and are raising premiums and copayment levels in an effort to limit public expenditures. Though financial incentives may indeed help rein in health expenditures, focusing predominantly on financial incentives hinders due consideration of needed structural reforms that improve the continuity, quality, and appropriateness of health care service delivery. This article focuses on the structural specifics of two legally enacted health insurance systems (Germany and Austria) and two national health systems (Great Britain and Denmark) to discuss the influence of structural characteristics on cost-containment efforts. Structural reform strategies discussed include increasing reliance on general practitioners, improving coordination of community and hospital-based specialty care, addressing the stark divide between ambulatory and hospital-based care that exists in some European health systems, and improving continuity of care by better integrating medical and social care sectors. Also discussed is the relative focus on financial incentives versus structural deficits in recent European health care reform strategies.

Confidence in receiving medical care when seriously ill: a seven-country comparison of the impact of cost barriers.

Objective  This paper examines how negative experiences with the health‐care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

Gatekeeping and provider choice in OECD healthcare systems

Gatekeeping and provider choice have become central in health policymaking within the last two decades. This article contributes to the debates in two ways: first, it provides an extended review of evidence on the impact of gatekeeping and provider choice on efficiency, costs, quality, equality and patient empowerment; and second, it empirically analyses regulations and identifies common trends in healthcare reforms in OECD countries since 1990. More than half of the countries analysed have established gatekeeping systems, while a smaller number provides free access to secondary care. The study discovers a trend towards strengthening gatekeeping regulations within free access countries. Free choice of provider is the standard in the OECD, where only a small number of countries restrict provider choice. The article identifies a diverging trend of reforms, with some traditionally restrictive countries offering more provider choice and other countries limiting the choice of providers as a result of managed care reforms.

Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health

Background: Economic crises constitute a shock to societies with potentially harmful effects to the mental health status of the population, including depressive symptoms, and existing health inequalities. Methods: With recent data from the European Social Survey (2006–14), this study investigates how the economic recession in Europe starting in 2007 has affected health inequalities in 21 European nations. Depressive feelings were measured with the CES‐D eight‐item depression scale. We tested for measurement invariance across different socio‐economic groups. Results: Overall, depressive feelings have decreased between 2006 and 2014 except for Cyprus and Spain. Inequalities between persons whose household income depends mainly on public benefits and those who do not have decreased, while the development of depressive feelings was less favorable among the precariously employed and the inactive than among the persons employed with an unlimited work contract. There are no robust effects of the crisis measure on health inequalities. Conclusion: Negative implications for mental health (in terms of depressive feelings) have been limited to some of the most strongly affected countries, while in the majority of Europe persons have felt less depressed over the course of the recession. Health inequalities have persisted in most countries during this time with little influence of the recession. Particular attention should be paid to the mental health of the inactive and the precariously employed.

The Palgrave international handbook of healthcare policy and governance

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