Health care systems coverage and cost: A comparative analysis of European Health care systems

1
Health care systems coverage and cost A
comparative analysis of European Health care
systems

• Bruno Palier, Ph.D.
• Chargé de recherches du CNRS
• Centre dÉtude de la Vie Politique Française
  (CEVIPOF)
• Visiting Scholar at Northwestern University

2
We will discuss 3 questions

• I. How did European health care systems extend
  coverage?
• II. How do various health care systems work?
• III. Is universal coverage more costly?

3
The message

• The most universal and egalitarian Health care
  systems are also
• the cheapest!
• And (under certain conditions)
• the most cost-efficient!!!
• But you need to be a patient patient

4
I. Towards universal coverage

• History of the purposes of health care policies
• 1. To aid the sick on low incomes
• 2. To guarantee a substitute income for salaried
  workers suffering from illness
• 3. To ensure (equal) access to healthcare for all

5
I. Towards Universal coverage

• Two main solutions in Europe
• A unified, uniform Public Service
• - The British National Health Service (1948)
• - The Swedish progressive strategy (1955, 1969)
• Health insurance for all
• - The French case (19 different regimes CMU)

6
Two types of Universal Healthcare Systems

• The national health system
• (Sweden, Norway, Denmark, Finland, Great Britain,
  Italy, Spain, and in part Portugal, Greece,
  Canada, Australia and New Zealand)
• 2. The health insurance system
• (Germany, France, Austria, Belgium, Luxembourg,
  and to a lesser extent Japan, the Netherlands and
  certain countries in Central and Eastern Europe).
  
• A third type is not universal (perhaps not even a
  system!!!)
• 3. The liberal/residual healthcare system
• (that of the United States).

7
II. Different modes of functioning, different
problems

• Four dimensions
• Access
• The services
• The financing
• The organisation and regulation

8
Different modes of functioning, different
problems

• Access to the healthcare system
• Access to the system
• for all or for the insured Problems of
  exclusion in health insurance systems.
• Access to healthcare providers
• free circulation or control Problems of choice
  and waiting time in the NHS.

9
II. Different modes of functioning, different
problems

• 2. The services
• Public or private providers?
• Private supply in ambulatory sectors of health
  insurance systems, GP and specialists
• What costs are paid for by the system?

10
Share of public expenditure in total health care
expenditure, in 2004.
Source, OECD 2006.
11
II. Different modes of functioning, different
problems

• 3. The financing
• The financing of the systems.
• Tax, general income (redistribution) or local
  taxes (inequalities?)
• Social contribution and the problems of labour
  cost
• The co-payment and other user fees
• The financing of the providers
• Remuneration of doctors.
• The non incentive wages or flat rate
  remunerations
• The inflationary fee for service
• The funding of hospitals
• From fixed budgets to activity based
  financing.

12
II. Different modes of functioning, different
problems

• 4. The organisation and regulation of the system
• Three models of regulation
• - Regulation by the government (authoritative,
  limitative).
• - The negotiated regulation (inflationary)
• - Regulation by the market (inequalities, may be
  tough)

13
III. Different Performances

• Four main criteria
• for assessing Health Care Systems
• - Equality
• - Cost control
• - Health of the population
• - Users satisfaction (citizens, doctors,
  patients)

14
III. Different performances

• Social goals inequalities
• Same access for all versus choice
• Social inequalities of Health the role of
  co-payment.

15
III. Different performances

• Cost control two elements
• Total level of expenditure
• Expenditure development

16
Health Expenditure 2003/4.
Source, OECD 2006.
17
Development of health expenditure
Source, OECD 2003
18
III. Performances

• Cost efficiency
• The health of the population compared to the sums
  spent.
• Sweden spends the average, and has the best
  Health care system in the world!!!

19
Population health
Source OECD, 2006 Number of children below 1
year deceased for 1000 births. for 100,000
inhabitants.
20
Sweden has the best health results in the world
1.  The shaded area shows the middle two
quartiles (i.e. half the countries fall in this
range). 2.  The Potential Years of Life Lost is a
summary measure of avoidable or premature
mortality, providing an explicit way of weighting
deaths occurring at younger ages (before 70
years), that are in principle preventable. It is
measured as years lost per 100 000 people.
Source OECD Health Data 2004
21
Yes but

• The middle class does not want to have to wait
• The middle class wants to choose!

22
Citizens Satisfaction with their Health care
system
23
Public's satisfaction with health care system,
EU countries, 2002
Notes These results are based on the
following questions from a 2002 Eurobarometer
survey."Now, I will read you four statements
about the way health care system runs in
(COUNTRY). Which one comes closest to your own
point of view? (ONE ANSWER ONLY).1. On the
whole, the health care system in (OUR COUNTRY)
runs quite well. 2. There are some good things
in the way health care in (OUR COUNTRY) runs, and
only minor changes would make it work better. 3.
There are some good things in the way health care
in (OUR COUNTRY) runs, but only fundamental
changes would make it work better. 4. Health
care system in (OUR COUNTRY) runs so badly that
we need to rebuild it completely."Source
Eurobarometer, 2003.
24
The quadrilemna of healthcare reforms
Equality
financial Viability
Quality
Freedom, choice