How is health care financed in European countries

Health policy

Thomas Gerlinger

Prof. Dr. Dr. Thomas Gerlinger is professor at AG 1: Health Systems, Health Policy and Health Sociology at the Faculty of Health Sciences at Bielefeld University

Renate Reiter

Dr. Renate Reiter, Institute for Political Science at the FernUniversität in Hagen

In many countries of the world there are systems with which the health care of the population is to be ensured. However, the structures and functional principles of the various national health systems differ significantly. 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, an international comparison is repeatedly sought in order to work out the advantages or disadvantages of individual systems. This learning tour uses the example of five European countries - Great Britain, the Netherlands, Sweden, Switzerland and France - to illustrate which differences, but also which similarities, different national health systems have.

The comparison of health systems

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Health systems are usually very complex structures. They have a large number of institutions and actors that have diverse and complex relationships. One of the reasons for this is that the health systems we know today have gone through a long and changeable historical development. The origins of the national systems are in the 19th century or even older. They arose due to specific social, health, political and economic problems.

Health policy is often the result of conflicts between social actors with different interests, problem perceptions and objectives. The supply systems have been continuously developed since their inception. Sometimes this happens in small steps, sometimes there are far-reaching structural reforms that place 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.

If one wants to compare health systems with one another, one is faced with the question of which criteria should be used to do this. There are three levels:

On the one hand, there is the question of who pays for the services of the health system. The financing can be based on a wide variety of providers:
  • What is the significance of state tax revenues?
  • What do public or private insurance companies do?
  • How much are companies, employees and, last but not least, private households involved in the financing of the health system?
On the other hand, health systems are differentiated according to who provides the actual medical, nursing, preventive and rehabilitative services. The supply can also be organized very differently.
  • Who are the providers of the service?
  • What role do public and private service providers play?
  • Are they for-profit or non-profit?
Finally, regulation of the health system is an important feature:
  • Who sets the rules that apply to the various actors in the system?
  • How are the relationships between the funding agencies, service providers and users of the health system designed?
  • What is the significance of state regulatory mechanisms?
  • What do the social actors themselves decide?
  • What role do market and competition mechanisms play?
The different importance of state, social and private actors in the individual systems has led to a division into three ideal types of health systems. The first type is the state health service, in which the financing is guaranteed through taxes, the service is provided through public utilities and the rules of the system are set by the actors of the state or politics.


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 raised, for example, by the 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 work alongside public providers. The regulation of social security systems is characterized by the fact that non-state actors can, to a certain extent, organize their relationships on their own (principle of self-administration).

Finally, private or private-sector systems represent the third ideal type. In private systems, the state largely withdraws from the financing, organization and control of the health system and leaves these tasks to private actors. Financing is mainly provided through private insurance and household expenses. Care is based on private providers competing with other service providers and the regulation of the system is left to a considerable extent to the mechanisms of the market.

Since the statutory health insurance for workers introduced in the German Reich under Chancellor Bismarck in 1883 was the world's first social insurance, social insurance systems are also referred to as "Bismarck systems". In contrast, government health services are also referred to as "Beveridge systems", named after the economist William Henry Beveridge, who is considered to be the "architect" of the British National Health Service (NHS) from 1946.

However, if you look at individual health systems, you will find that they never fully correspond to one of the three ideal types. In state health services, too, there are financing shares that do not come from tax revenues, as well as private service providers. And systems that are predominantly organized in the private sector - such as in the USA, for example - have a not inconsiderable share of state funding, service provision and regulation. In reality we find mixed systems in which elements of the various ideal types are combined with one another. Nevertheless, due to a certain basic structure, they can be assigned to one or the other type.

The health systems in Europe

In the member states of the European Union, state health services and social security systems predominate. This learning tour describes the health systems in five European countries that are repeatedly used as (positive or negative) comparison models in the 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 basic knowledge of the characteristics of the various systems. The illustration gives an insight into the financing systems, the organization of the provision of services and the mechanisms of regulation. In addition to the basic structures of the health systems, the recent changes in health policy are presented, and readers are given an insight into current health policy reform debates. On the one hand, there are important structural differences that make it difficult to transfer reform measures to other systems. On the other hand, despite the system differences, numerous similarities can be observed in the discussed problem perceptions and reform models.

The program of this learning tour

Five different European health systems will be presented during this learning tour.
  • the health system in Sweden
  • the UK healthcare system
  • the health system in Switzerland
  • the health system in the Netherlands
  • the health system in France
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The following learning objectives can be achieved with the module:
  • The users of the learning tour should be introduced to different types of health systems. With the systems of Switzerland, the Netherlands, Great Britain, Sweden and France, health systems are presented which have "model character" beyond their own borders.
  • The users receive information about central differences and similarities that characterize health care in the Bismarck and Beveridge systems. For this purpose, both quantitative and qualitative system features should be explained.
  • The presentation of the more recent changes in health policy in the five countries is intended to enable a better understanding of current problem constellations and reform strategies.
  • The comparison with developments in other European countries should make it easier for users of the learning tour to place developments and discussions about the German health system in a larger context and to form their own opinion about current reform projects.

Bibliography

Rothgang, Heinz (2006): The Regulation of Health Systems from a Comparative Perspective: On the Way to Convergence? In: Wendt, Claus / Wolf, Christof (ed.): Sociology of health. Cologne journal for sociology and social psychology, special issue 46.Wiesbaden, pp. 298-319