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Health care systems are highly complex organizations, with many interdependent components. Traditionally, health systems in the developed world have been classified by their type of financing—i.e., either predominantly tax-funded (such as the National Health Service in England and publicly operated regional care systems in the four European Nordic countries) or predominantly statutory social health insurance (SHI)-funded (such as in Germany, the Netherlands, and France). Over the last decade, however, there has been structural convergence in the technical characteristics of both funding arrangements, and also in the associated delivery systems, making analytic observations about the differences across national systems more difficult.
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A second confounding factor has been that former Soviet Bloc countries have, since 1991, replaced their former Soviet-style Semashko models (a top-down, national government–controlled structure with a parallel Communist Party apparatus) with various hybrid arrangements built on government-run SHI financing. Distinctions across health systems, especially in Europe, have been further compressed by the continuing negative impact of the 2008 global financial crisis on public revenues in many countries.
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This chapter focuses on the individual patient care system: on the financing and delivery of individual clinical and preventive services. The individual patient care system is composed of the financing and delivery of necessary services to prevent death or serious harm (“rule of rescue”); to maintain quality of life; and to manage, reduce, and/or prevent the burden of illness on individual patients. While the technical dimensions of most clinical services are similar across countries, their organizational, social, and economic characteristics differ markedly. Health systems in different countries exhibit substantial differences, for example, in access to care; in the design and reliance on quality assurance and provider payment mechanisms; in the relationship of primary care to hospital services; in the coordination of health care with home care and nursing home services; in the design and use of provider management strategies; in the way physicians work and are paid; in the decision-making roles of politically elected officials and of national, regional and municipal governments; and in participation of both citizens and patients. These differences reflect differing country contexts (geographical, social, economic and political), differences in national culture (consisting of prioritized norms and values), and substantial variation in how health sector institutions are structured.
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FINANCING INDIVIDUAL PATIENT CARE SERVICES
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Funding for individual care services in developed countries comes from the particular national mix among four possible sources of revenue: national, regional and/or municipal taxes; mandatory social health insurance; private health insurance; and out-of-pocket payments. Most countries have one preponderant payer, which then defines its funding arrangements and serves to frame the structure of its delivery system as well.
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The Organization for Economic Co-operation and Development (OECD) data from 2015 (adjusted for purchasing power parities) show that total health care expenditures in developed countries vary across a considerable range, tied to health system structure as well as national history and culture. Total ...