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INTRODUCTION

Health care systems are highly complex organizations, with many interdependent components. In developed countries, health systems have traditionally 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 past several decades, however, there has been structural convergence in the technical characteristics of both funding arrangements and in the associated delivery systems, making analytic observations about differences across national systems more difficult.

A second confounding factor has been that former Soviet Bloc countries in Central and Eastern Europe, including the Russian Federation, have, since 1991, replaced their former Soviet-style Semashko models (a top-down, national government–controlled funding and delivery structure with a parallel Communist Party administrative apparatus) with various hybrid arrangements built on national government–run SHI financing. Distinctions across developed country health systems, especially in Europe, have been further compressed by inadequate resources in many publicly funded systems in an era of rapid clinical and technological change, triggering increased private sector funding and provision.

In middle-income developing countries, institutional structures in the health sector typically reflect the country’s preindependence administrative framework. Mexico, for example, has a Spanish-derived configuration with health insurance as part of social insurance for formally employed workers (via Instituto Mexicano del Seguro Social), supplemented by tax-funded health services (Seguro Popular) provided for those with informal employment and all other citizens, as well as a separate program (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado) for public employees. Countries such as India and Egypt, reflecting British influence, have predominantly tax-funded and publicly operated health systems. China is an exception, with an internally generated system that is publicly funded and operated, although recent Communist Party policy has been to introduce SHI-based insurance with individual medical savings accounts (patterned after Singapore), promote private insurance, and expand private hospitals.

In lower-income developing countries, health services are typically provided by tax-funded public institutions, often with considerable inadequacies and sometimes with substantial copayments. It is important to note that governmentally organized systems in nearly all developing countries, as well as in former Soviet bloc countries and, to a lesser degree, in tax-funded developed countries, are supplemented to varying extents by a mix of private and/or employer-paid insurers and providers.

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 range widely. Health systems in ...

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