Changing Healthcare System Types
S OCIAL P OLICY & A DMINISTRATION ISSN 0144–5596
DOI: 10.1111/spol.12061
VOL. 48, NO. 7, DECEMBER 2014, PP. 864–882
Changing Healthcare System Types
Claus Wendt
Department of Sociology, University of Siegen, Germany
Abstract
This article classifies Organisation for Economic Co-operation and Development (OECD)
healthcare systems based on data from and . It shows that European countries are
clustered in different types of healthcare systems and that traditional typologies are only partially
represented in the four types of healthcare systems identified in this study. Type represents
countries with low total health expenditure (THE), high public financing, and low out-of-pocket
payment (OOP). In-patient healthcare is higher and out-patient healthcare lower than the OECD
average. General practitioners (GPs) are paid by capitation, and patients’ access to healthcare is
strictly regulated. Type represents countries with an average level of THE, high public financing,
above-average OOP, and high in-patient and out-patient healthcare. GPs receive a salary, and
access regulation is strict. Type is characterized by very low THE, low public financing, and
very high OOP. Both in-patient and out-patient healthcare is well below average, and GPs are
paid a salary. Type includes systems with the highest THE, the highest public financing, and
the lowest direct payments by patients. In-patient healthcare is below the OECD mean and
out-patient healthcare is well above it. GPs are paid by fee-for-service, and most countries offer free
choice of medical doctors. The clusters for the years and are quite robust. During this
time period, THE increased, and patients’ access to medical doctors has since become more
regulated.
Keywords
Healthcare systems; Typology; Comparison; Cluster analysis; Organisation for Economic
Co-operation and Development; Access to healthcare
Introduction
Healthcare systems have experienced major changes in recent decades. In
Central and Eastern Europe (CEE), socialist healthcare systems have been
replaced by Western European types. Scandinavian countries and the UK
have experimented with internal markets and Western European countries
with strong corporate actors in the healthcare arena have entered a period
with both more competition and stronger state intervention. Moreover, the
USA has intensively debated and partly improved its healthcare system’s
Author Email: [email protected]
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
coverage (Freeman and Moran ; Rothgang et al. ; Marmor and
Wendt , ; Montanari and Nelson ). However, information about
different modes of regulation, financing and service provision do not yet
provide a clear picture regarding similarities and differences among healthcare systems in modern societies. In particular, the measurement of regulation
remains challenging when comparing a larger number of countries (Rothgang
et al. ). Furthermore, the direction of change which goes beyond trends in
healthcare expenditure and financing remains unclear. As emphasized by
Freeman and Moran (: ), in British and Swedish health policy, ‘competition has turned relatively quickly into collaboration between larger units’.
A few recent articles have started to characterize healthcare systems by not
only concentrating on expenditure, financing and modes of governance, but
also by including healthcare provision and patients’ access to healthcare
providers (Rico et al. ; Wendt ; Reibling ). These studies,
however, only cover European countries and do not comprehensively analyze
healthcare system change.
This article will go one step further by analyzing and classifying
Organisation for Economic Co-operation and Development (OECD) healthcare systems in and . The main purpose is to identify similarities and
differences among OECD healthcare systems by clustering countries into
types of healthcare systems. We do not expect to identify ‘frozen types’; rather,
we expect to see that healthcare system types have experienced change, and
that some countries may even shift from one type to another. Such knowledge
is relevant since demographic developments, growing demand, and scarce
resources have increasingly put healthcare systems under pressure and politicians have begun to respond to these changes with structural reforms.
Regarding health policy measures, however, it is important to know whether
otherwise similar healthcare systems operate better in certain respects and are,
for instance, more successful at controlling costs, have higher levels of healthcare providers, and place lower financial burdens on the individual patient
when compared with other healthcare systems. The typology may also serve
as a tool for future studies which analyze such issues as the relationship
between healthcare system types and inequalities in health, access to healthcare and trust in healthcare systems.
Furthermore, concepts for analyzing healthcare systems have been hitherto
poorly equipped to analyze healthcare system change (Béland ). Much
like welfare state typologies (Esping-Andersen ; Arts and Gelissen ;
Scruggs and Allen ), earlier healthcare system typologies suggested what
could be interpreted as ‘frozen types’ (see e.g. Field ; OECD ; Moran
). However, by simultaneously applying the role of three groups of actors
(state, private non-profit, private for-profit) and three healthcare policy areas
(financing, healthcare provision, regulation), Wendt et al. () arrived at
types of healthcare systems, including three ideal types: a state healthcare
system, a societal healthcare system, and a private healthcare system. By
referring to Hall’s () concept of first-, second- and third-order change, this
model suggests three forms of change: a ‘system change’ (from one ideal type
to another), an ‘internal system change’ (only one dimension changes its
dominant form, e.g. the provision of healthcare shifts from public to private
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
actors), and an ‘internal change of levels’ (a shift of levels in one or more
dimensions but without changing the dominant form). Based on this conceptual framework, Wendt, Frisina and Rothgang () suggested that CEE
countries are more similar to state-based healthcare systems than to Western
social health insurance schemes, though this suggestion was not empirically
measured. This model could also help to improve the understanding of the US
healthcare system, which, when including tax exemptions, today receives
more than per cent of its financing from public money but has not achieved
sufficient public administrative capacities for controlling costs (Rothgang et al.
; Schmid et al. ).
In this article, we employ the trilogy of financing, provision and regulation
suggested above, but we change the perspective. It is not the changing role of
the state which we are mainly interested in, but rather the question of how
modes and levels of financing and healthcare provision are related to institutional regulations concerning patients’ access to medical care.
By classifying OECD healthcare systems, we expect to improve the
knowledge about the characteristics of various types of healthcare systems and
to thereby support the formulation of hypotheses for ongoing research on the
importance of these types for inequalities in health, healthcare utilization and
satisfaction with the healthcare system. In the following section, we provide an
overview of healthcare system typologies and develop our hypotheses on this
basis. Second, we provide information on the data and methods used for
comparing healthcare systems. Third, we identify different types of healthcare
systems as well as their main characteristics, and analyze healthcare system
change.
Typologies of Healthcare Systems
The history of healthcare system classification has been described in much of
the literature (Burau and Blank ; Wendt et al. ; Freeman and Frisina
). The OECD () study Financing and Delivering Health Care distinguished
three basic models: the National Health Service (NHS) model, the social
insurance model and the private insurance model. However, according to
Freeman and Frisina (), we cannot expect to learn anything new about
healthcare systems and how they work on the basis of this typology. Classifying countries from CEE as social health insurance systems and Southern
European countries as NHS systems, for instance, may not capture the
systems’ most important characteristics. After the transformation from socialist healthcare systems to social health insurance schemes, CEE countries seem
to have maintained a higher level of state regulation, as is typical of social
health insurance in Western Europe (Wendt et al. ). NHS systems
from Southern Europe, on the other hand, still seem to lack administrative
capacities and infrastructures, and have higher shares of private financing
compared with NHS systems in the Scandinavian countries and the UK
(Moran ). Another case which has proven difficult to classify is the
Netherlands, which is traditionally classified as a social health insurance
system with strong access regulation to medical care. In , the responsibility for financing was transferred to private insurance companies, which has
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
been interpreted by some authors as a privatization of the Dutch healthcare
system. As emphasized by Okma et al. (), however, private plans in the
Netherlands are strictly regulated and, therefore, do not represent a private
health insurance model.
Moran’s (, ) work represents one of the first attempts at combining
the dimensions of funding, service provision and governance in healthcare.
Using the three governing arenas of ‘consumption’, ‘provision’ and ‘production’, Moran constructed four types of ‘healthcare states’: the ‘entrenched
command and control state’, the ‘supply state’, the ‘corporatist state’ and the
‘insecure command and control state’. Based on Moran’s typology, Wendt
et al. () combined the involvement of state actors, non-governmental
actors and the market with the dimensions of ‘financing’, ‘service provision’
and ‘regulation’, and identified a taxonomy of healthcare systems, three
of which being ‘ideal types’. Both typologies contribute to the analysis of the
role of the state in healthcare, and capturing the healthcare systems’ main
characteristics and how they work has not been their main focus.
A major goal of healthcare systems can be seen in their provision of patients
with access to necessary healthcare services, and two typologies have recently
been introduced which cover patients’ access in European countries. Reibling
() used the criteria of gatekeeping, cost-sharing, provider density and
medical technology, and Wendt () classified healthcare systems on
the basis of the following eight criteria: total healthcare expenditure, the
public-private mix of healthcare financing, private out-of-pocket payment
(OOP), out-patient healthcare provision, in-patient healthcare provision,
entitlement to healthcare, remuneration of medical doctors, and patients’
access to healthcare providers.
This study makes use of the concepts provided by Reibling and Wendt, and
extends the scope of healthcare system typology by covering a larger number
of countries (including non-European countries) and by analyzing healthcare
system change. However, there is a payoff between the necessary work of
aggregation and simplification on the one hand, and the accuracy of the
representation of individual cases on the other hand (Freeman and Frisina
), and we should, therefore, remain cautious in our use of the results of
classification. Accordingly, when comparing OECD healthcare systems,
we do not aim at a better understanding of a particular case but rather at an
analysis of the following hypotheses on country groups, the extension of earlier
typologies, and healthcare system change:
H In contrast to earlier typologies, this article provides the opportunity
to contrast European and non-European countries. Due to the early
development of welfare states and healthcare systems in Europe combined with the process of European Integration (Taylor-Gooby ;
Montanari and Nelson ), we may identify more similarities among
European healthcare systems compared with countries of other world
regions.
H Modes of financing and organization, which are the main dimensions
for distinguishing NHS systems and social health insurance, may still
represent the dominant features of modern healthcare systems. We will,
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
therefore, test whether the traditional typology of NHS, social insurance
and private insurance (Kokko et al. ; Hassenteufel and Palier ;
Hassenteufel et al. ) remains valid when comparing healthcare
systems or if CEE countries and Southern European countries demonstrate major differences compared with social health insurance and
NHS systems, respectively.
H The intensity of healthcare reforms has increased over the past decades
(Freeman and Moran ), and a number of healthcare systems have
undergone more recent structural reforms (Rothgang et al. ), which
has not been studied by earlier typologies. Due to structural reforms, we
expect to identify healthcare system change in the s.
Data and Methods
Healthcare expenditure and financing, provision and regulation are captured
by data taken from the OECD Health Data (OECD ), as well as
with data collected by the author as part of a research project focusing on the
years up to (see tables and ). For analyzing healthcare system change,
data for and are included. In the next section, healthcare system
types are calculated by cluster analysis, and both the quantitative data on
expenditure and provision as well as the information on regulation are,
therefore, expressed as numerical data.
Total healthcare expenditure can be measured as a percentage of gross domestic
product or in monetary units per head of the population. Calculating healthcare expenditure per capita provides us with information on the actual
resources invested in healthcare. This typology focuses on how healthcare
systems work (including patients’ access). Since we are mainly interested in the
healthcare system’s financial capacity to provide the population with access to
necessary healthcare and not in a given society’s willingness to pay, we use the
indicator total health expenditure (THE) per capita measured in US$ per head of
the population by using purchasing power parities (PPP/general deflator).
The share of public healthcare financing, measured in public health expenditure
(PHE) as a percentage of THE, is used as an indicator to capture the role of
the state in the healthcare arena. A strong role of the state can be used for
controlling healthcare costs and for reducing inequalities.
The share of patients’ co-payments, measured as private OOP as a percentage
of THE, is used to capture the financial burden placed on the individual
patient in the case of sickness. Even if exemptions from co-payments are to be
considered, higher private OOPs generally increase the difficulty for those
with lower incomes and lower health statuses to access necessary healthcare.
Healthcare provision is more difficult to assess than expenditure and
financing, which can be measured in monetary units. Total health employment does not differentiate between healthcare providers with different levels
of qualification and overestimates the level of healthcare provision in countries with a high number of low-skilled personnel. Using the number of
doctors as an indicator for the level of total healthcare provision, on the
other hand, over-estimates the level in countries where a high number of
doctors collaborates with a lower number of other healthcare givers. We,
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Healthcare system characteristics,
Healthcare financing
and private payment
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Japan
Korea
Luxembourg
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
Turkey
UK
USA
Healthcare provider
indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private
OOP in
% of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access
regulation
index
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Sources: OECD ; Reibling and Wendt ; Rothgang et al. ; country chapters of the WHO Health in
Transition Series (WHO n. d.).
Notes: = THE: total health expenditure; = PHE: public health expenditure; = OOP: out-of-pocket payments;
= see construction of indices in Wendt ; = coding for remuneration: fee-for-service = ; capitation = ;
salary = ; = coding for index construction: free choice of GP = ; patients have to register with a GP = ; free
choice of specialists = , skip & pay = , referral to specialist = .
therefore, use two healthcare provider indices to estimate the level of healthcare provision: an in-patient index and an out-patient index. These indices provide
information on whether healthcare systems rely more on in-patient or on
out-patient healthcare. We calculated the healthcare provider indices by:
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Healthcare system characteristics,
Healthcare financing and
private payment
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Japan
Korea
Luxembourg
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
Turkey
UK
USA
Healthcare provider
indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private
OOP in
% of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access
regulation
index
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Sources: OECD ; Reibling and Wendt ; Rothgang et al. ; country chapters of the WHO Health in
Transition Series (WHO n. d.).
Notes: = THE: total health expenditure; = PHE: public health expenditure; = OOP: out-of-pocket payments;
= see construction of indices in Wendt ; = coding for remuneration: fee-for-service = ; capitation = ;
salary = ; = coding for index construction: free choice of GP = ; patients have to register with a GP = ; free
choice of specialists = , skip & pay = , referral to specialist = .
. using the raw values of the included indicators, expressed per ,
people;
. recalculating the value as a percentage of the average of OECD
countries; and
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
. calculating the respective index as the average value of the two healthcare
provider indicators (specialists and nurses for in-patient healthcare; GPs
and pharmacists for out-patient healthcare).
Lastly, two indicators are included to measure the degree of regulation in
healthcare systems (see tables and ). Healthcare systems have established
different concepts of paying medical doctors, and these concepts contain
incentives for both the level and quality of service provision. The remuneration
of GPs is particularly important since GPs are often the primary caregiver and
may guide the patient through the healthcare system. Decisions, however,
may depend on the mode of remuneration. Whereas a fee-for-service
payment may set an incentive for doctors to see their patients as often as
possible, a reimbursement per capita or a fixed salary might create an incentive for reducing the workload (Rice and Smith ). For this analysis,
remuneration has been coded as follows: fee-for-service = ; capitation = ;
salary = , with ‘’ representing the lowest level and ‘’ the highest level of
regulation.
For analyzing patients’ access to healthcare provision, we calculated an
access regulation index. This index captures whether patients have a free choice
of doctors or whether they have to sign onto a GP’s list for a longer period
(‘gatekeeping’) (Reibling and Wendt ; Rico et al. ). Furthermore,
patients have several options when visiting healthcare specialists. They may:
. have a free choice of and direct access to specialists;
. need a referral by a GP to access specialist healthcare; or
. skip the referral system by accepting additional co-payment (skip&pay).
In order to construct healthcare system types, these indicators are combined into an access regulation index, which ranges from no regulation at the
one end to strict ‘gatekeeping’ at the other. This strict ‘gatekeeping’ requires
patients to sign up on a GP’s list and necessitates a referral to specialist
healthcare. The index makes use of a scale which ranges from to : free
choice of GPs = ; signup on a GPs list = ; free choice and direct access to
specialists = ; skip&pay = ; and referral by a GP to access a specialist = . To
give GPs and specialists the same importance, we selected the same value (‘’)
in both areas for the strongest access regulation.
With few exceptions, all countries for which data are available in the
OECD Health Data (OECD ) have been included. Chile and
Mexico have been excluded due to difficult access to information on regulation. The countries included in the analysis represent countries from
Western and Northern Europe (Austria, Belgium, Denmark, Finland, France,
Germany, Iceland, Ireland, Luxembourg, the Netherlands, Norway, Sweden,
Switzerland, the UK), four countries from Southern Europe (Greece, Italy,
Portugal, Spain), six countries from CEE (the Czech Republic, Estonia,
Hungary, Poland, the Slovak Republic, Slovenia), two countries from North
America (Canada, the USA), two countries from Asia (Japan, Korea), two
countries from the Australia and Oceania region (Australia, New Zealand), as
well as both Israel – which belongs geographically to Asia but has a political
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
association agreement with the EU – and Turkey – which bridges Europe and
Asia and is an associate member of the EU.
The data are summarized in tables () and (). Quantitative data
on expenditure, financing, and service provision are taken from the OECD
Health Data (OECD ). Information on regulation is taken from
secondary literature and in particular from the WHO Health in Transition
Series (WHO n.d.).1
The data summarized in tables and demonstrate vast country differences in all dimensions. In , the level of THE ranged from US$ per
head in Turkey to US$, in the USA; the share of public financing ranged
from . per cent of THE in the USA to . per cent in the Czech Republic;
private OOP ranged from . per cent of THE in Luxembourg to . per
cent in the Republic of Korea; the in-patient index ranged from . in
Turkey to . in Iceland; and the out-patient index ranged from . in the
Netherlands to . in Belgium. GPs are paid on the basis of fee-for-service
in countries, on a capitation basis in another countries, and with a fixed
salary in eight countries. In , ten countries had no access regulation,
countries had implemented strong access regulation, and the remaining ten
countries lay in-between.
By , the situation had changed and the amount of resources invested in
healthcare had increased. THE now ranged from US$ in Turkey to
US$, in the USA; public financing as a percentage of THE ranged from
. per cent in the USA to . per cent in Luxembourg; private OOP as a
percentage of THE ranged from . per cent in the Netherlands to . per
cent in Greece; the in-patient index ranged from . in Turkey to . in
Norway; and the out-patient index ranged from . in the Netherlands to
. in Belgium. Remuneration of GPs hardly changed: countries relied
on fee-for-service, on capitation, and seven on a fixed salary. Access
regulation to medical care became somewhat stricter, with nine countries
being in the category with no access regulation, countries in the category
with the strongest access regulation, and the remaining eight between the two
extreme poles.
We performed cluster analyses for and in order to model healthcare system types and classify countries (see Powell and Barrientos ;
Jensen ; Wendt ; Reibling ). Cluster analysis aims to group cases
by simultaneously taking a number of selected characteristics into account.
We used agglomerative hierarchical clustering techniques, starting with a
cluster for each country and then gradually merging similar countries into
clusters until finally all countries form one cluster. Since we used a mixture of
binary and continuous data, the clusters were constructed using the Gower
dissimilarity coefficient (Everitt et al. ). Once a country has been allocated
to a cluster, it remains within this initial cluster. Other procedures were used
(single- and complete linkage, ward method and waverage linkage; see Everitt
et al. ) in order to check the stability of cluster solutions. All procedures
created four identical clusters. The development of the level of homogeneity
(as expressed in the distance coefficient or similarity coefficient) within country
groupings suggested that four clusters best represent the structure of the
data. Furthermore, the robustness of this solution was checked with k-means
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
.4
.3
.2
Australia
Italy
Denmark
Ireland
Slovenia
United Kingdom
Netherlands
Czech Republic
Slovak Republic
Estonia
Hungary
Poland
Finland
Portugal
Spain
Iceland
Sweden
Greece
Israel
Turkey
Austria
Belgium
New Zealand
Canada
Japan
Germany
Luxembourg
France
Switzerland
United States
Norway
Korea
.1
0
Gower dissimilarity measure
Average linkage 01
clustering (Powell and Barrientos ; Jensen ). With this method, the
number of clusters is set by the researcher, and cases are thus selected and
re-combined to form the optimal solution regarding homogeneity within
clusters in the a priori set number of clusters. Again, the four-cluster solution
reached by these algorithms shows the highest degree of homogeneity and
proves stable when using k-means clustering.
Results: Classifying Healthcare Systems and
Analyzing Change
OECD countries are grouped in four types of healthcare systems in both
and . However, some countries cannot be classified for either year (see
figures and , as well as tables , and ).
In , Cluster represents the largest group of countries and includes
healthcare systems conventionally known as NHS systems (Australia,
Denmark, Ireland, Italy, the UK), social health insurance systems from CEE
countries (the Czech Republic, Estonia, Hungary, Poland, the Slovak Republic, Slovenia), and the Western European social health insurance system of the
Netherlands. Cluster covers NHS countries from Scandinavia and Southern
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
.4
.3
.2
AU
EE
IT
HU
SK
PL
SL
DK
IE
UK
NL
CZ
FI
PT
ES
IS
SE
AT
DE
CA
JP
NZ
LU
BE
FR
US
GR
CH
KR
NO
IL
TR
.1
0
Gower dissimilarity measure
.5
Average linkage 07
Table
Four-cluster solution,
Type
Type
Type
Type
Not classified
Australia
Czech Republic
Denmark
Estonia
Hungary
Ireland
Italy
Netherlands
Poland
Slovak Republic
Slovenia
UK
Finland
Iceland
Portugal
Spain
Sweden
Greece
Israel
Turkey
Austria
Belgium
Canada
France
Germany
Japan
Luxembourg
New Zealand
Korea
Norway
Switzerland
USA
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Four-cluster solution,
Type
Type
Type
Type
Not classified
Australia
Czech Republic
Denmark
Estonia
Hungary
Ireland
Italy
Netherlands
Poland
Slovak Republic
Slovenia
UK
No change
Finland
Iceland
Portugal
Spain
Sweden
Israel
Turkey
Austria
Belgium
Canada
France
Germany
Japan
Luxembourg
New Zealand
Greece
Korea
Norway
Switzerland
USA
No change
(minus Greece)
No change
(plus Greece)
Europe (Finland, Iceland, Portugal, Spain, Sweden). Cluster includes Greece,
Israel and Turkey. Cluster includes mainly Western European social health
insurance countries (Austria, Belgium, France, Germany, Luxembourg) as
well as both Japan’s social health insurance system and the mainly taxfinanced systems of Canada and New Zealand. It has not been possible to
classify Korea, Norway, Switzerland, or the USA.
We do not see major changes in the number of clusters or the classification
of countries between and . The countries in Cluster , Cluster , and
Cluster remain the same. Greece no longer groups together with Turkey
and Israel in , leaving five countries which cannot be classified into any of
the four healthcare clusters. Although the number of clusters remains the
same in both years, we detect some changes over time when analyzing the
main characteristics of the four clusters.
In , the identified healthcare system types can be described as follows
(see table ):
Type represents countries with a low level of THE per capita, a high
share of public financing, and below-average private OOP. The level of
in-patient healthcare is higher than the OECD mean, and the level of
out-patient healthcare is much lower than this measure. GPs are remunerated on a capitation basis in all countries in this cluster, and the level
of access regulation is very high (at the highest level in eight countries and
at a somewhat lower level in four countries).
– Type represents countries with a level of THE at the average of OECD
countries, a high share of public financing, above-average OOP, and
above-average levels of in-patient and out-patient healthcare. The control
of doctors’ remuneration is even stricter than in Type , with GPs being
–
© John Wiley & Sons Ltd
Table
Healthcare system characteristics in and
Healthcare provider indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private OOP
in % of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access regulation
index
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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.
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.
.
.
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.
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.
.
.
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.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
Type
Type
Type
Type
© John Wiley & Sons Ltd
Norway
Norway
Korea
Korea
Switzerland
Switzerland
USA
USA
Mean
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Healthcare financing and private payment
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
paid on a salary basis. Access regulation is strict, but Iceland and Sweden
are exceptions with lower levels of access regulation.
– Type represents healthcare systems with both a very low level of THE
(about per cent of the OECD average) and a low share of public
financing. Both in-patient and out-patient healthcare are well below the
average, and GPs are remunerated on a salary basis. However, patients’
access to medical doctors is hardly controlled by instruments of regulation.
– Type represents healthcare systems with the highest level of THE, the
highest share of public financing, and the lowest direct payments by
patients. In-patient healthcare is below the average OECD level, and
out-patient healthcare is well above the level of other OECD healthcare
systems. GPs are remunerated on a fee-for-service basis, and most countries offer free choice of medical doctors.
Taking these characteristics into account, Korea shows similarities to
Type with its low level of THE, low public financing, very high private
co-payment, and low levels of in-patient and out-patient healthcare.
However, instead of a fixed salary, Korea’s GPs are paid on a fee-for-service
basis, and formal access regulation is somewhat higher than in Type .
Norway shares important characteristics with Iceland and Sweden, both
grouped in Type . However, due to Norway’s prosperous economic condition, THE is much higher (ranked number – behind the USA and Switzerland), and doctors’ income is less regulated than in Type . The US and
Switzerland share with Type countries the high level of THE, GPs’ fee-forservice payment, and doctors’ free choice. However, the share of public
financing is even lower than in Type , and private OOP is much higher
in Switzerland. Interestingly, the US and Switzerland share a preference
for in-patient care opposed to out-patient care, which is the case with Type
countries.
Between and , the clusters and country groupings proved to be
robust. However, at the same time major changes took place. Overall in
OECD countries, THE per capita increased by more than per cent, the
share of public financing remained at a level of per cent, and private OOP
also turned out to be quite stable (at average below per cent). No changes
took place with respect to the main form of GP remuneration. However,
access to medical doctors became more regulated than it was at the beginning
of the s. When analyzing within-cluster changes, some important healthcare policy developments can be detected. In Type , THE increased by almost
per cent and, therefore, to a higher extent than the OECD average. The
share of public financing, private OOP, and in-patient and out-patient healthcare remained stable. Access regulation to medical care became even stricter
than before. Type countries also increased THE to a greater extent than the
OECD average. The share of public financing increased slightly while the
relative amount of private co-payments decreased. In-patient and out-patient
healthcare remained at a high level, and there were also no changes in
doctors’ remuneration (salary) or in the high level of access regulation. Comparing Type ’s average levels in and is not very meaningful since
Greece no longer grouped with the other two countries in . In Israel and
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Turkey, however, public financing remained at a low level, private OOP
remained very high, and in-patient and out-patient healthcare continued to
be much lower than the average in the OECD world. Salary payment was also
combined with free formal access to medical care. Type , finally, controlled
and stabilized THE somewhat more than Type and Type countries. Public
financing and private co-payments continued to be at the highest and lowest
levels, respectively, and service provision concentrated on out-patient healthcare while the level of in-patient healthcare remained below the OECD mean.
GPs continued to be mainly remunerated on a fee-for-service basis, and while
patients had free choice of doctors in most of the Type countries, access
regulation slightly increased in countries such as Germany and France
(Reibling and Wendt ). Norway and Korea still showed similarities to
Type and Type , respectively. Switzerland and the USA, finally, demonstrated parallels to Type , but both countries paid much more for healthcare
while their share of public financing remained low. In contrast to Type , the
main focus in the USA and in Switzerland was not on out-patient but on
in-patient healthcare.
Our results do not support the hypothesis that European healthcare
systems have more in common than do healthcare systems of other world
regions or that they even form a European healthcare model (H). European
countries are classified in different types of healthcare systems. Furthermore,
non-European countries do not form their own type but join different clusters
(or, as with Korea and the USA, cannot be classified at all). Australia is
grouped into Type ; Canada, Japan, and New Zealand into Type ; and
Turkey and Israel (in together with Greece) form their own type.
The hypothesis that healthcare systems can still be best classified as NHS,
social health insurance, and private health insurance has, to a certain extent,
been confirmed (H). Almost all Western social health insurance countries are
grouped into Type (the Netherlands being an exception). The social health
insurance scheme of Japan is also grouped into this type. Although Canada
and New Zealand are mainly tax financed and no social insurance companies
are involved in (self-)regulation, the two countries seem to share more similarities with Western social health insurance systems than with tax-financed
NHS schemes. The largest group of countries (Type ), however, represents a
combination of NHS systems, CEE social insurance schemes, and the Dutch
social health insurance scheme. The level of access regulation and the capacity
to control costs, therefore, seem to reinforce more important similarities than
the NHS or the social insurance model. Furthermore, other established NHS
systems (Finland, Iceland, Sweden) do not join the same group as the UK,
Ireland, Italy and Denmark. Lastly, countries such as Switzerland and the
USA, whose private healthcare market is of great importance, do not seem to
have much in common and do not form their own private health insurance
model.
We have found some evidence for the hypothesis of healthcare system
change (H). However, institutions like healthcare systems change slowly; they
are ‘elephants on the move’ (Hinrichs ). THE has increased to a high
extent. However, Type countries with an already high THE have been more
successful in controlling costs than have countries with lower expenditure
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
levels. One of the main focuses of health policy change has been on access
regulation, and we only see changes in the direction of higher access regulation and not in the direction of lower access regulation (possibly also to
support cost control measures). The payment of medical doctors often represents a mixture of different methods of remuneration, and this mixture has
changed in a number of countries. Germany, for instance, has recently introduced a capitation-based component of GPs’ income (Rothgang et al. ;
Schmid et al. ). The main mode of remuneration, however, remained
unchanged in the period under study.
Discussion
In this article, we identify robust cluster solutions with four types of healthcare
systems in and , and only one country changed clusters within this
period.
Our results do not confirm the concept of a European healthcare model
(H). On the contrary, European healthcare systems are classified into different clusters, and with only one exception, the clusters represent a mix of
European and non-European countries. When comparing NHS-type countries with social health insurance countries, these two organizational and
financial patterns still seem to represent the core of two different types of
healthcare systems (H). Social insurance countries are mainly grouped into
Type , whereas certain NHS type countries are grouped into Type .
However, our results support the assertion by Wendt et al. () that social
health insurance systems in CEE countries do not share major characteristics
of Western social health insurance schemes. Instead, CEE healthcare systems
seem to be more similar to the NHS systems of the UK, Ireland, Italy and
Denmark, possibly due to the weak position of corporate actors and a stronger
role of the state in CEE countries compared with Western social health
insurance countries (Kaminska ; Wendt et al. ).
Healthcare system change (H) has been identified mainly in the areas of
healthcare expenditure and access regulation. Patterns of public financing,
private co-payments, healthcare provision and doctors’ remuneration, in contrast, have proven rather stable.
Comparing our findings with earlier typologies (OECD ; Moran ;
Burau and Blank ; Wendt et al. ; Wendt ; Reibling ), we
can corroborate the existence of two types of healthcare system. Type
confirms the ‘healthcare-provision-oriented type’ suggested by Wendt ().
Due to the almost unregulated access to medical care, Type also shows
similarities to the ‘financial incentives states’ proposed by Reibling ().
Type countries are characterized by the unquestioned importance of access
to medical care expressed in low access regulation and high levels of outpatient healthcare. All other features, such as low direct private payments and
fee-for-service payment of medical doctors, seem to follow this overarching
health-policy goal.
Type bears a striking resemblance to the ‘gatekeeping and low-supply
type’ suggested by Reibling (), and also to Wendt’s () ‘universal
coverage-controlled access type’ and Moran’s () ‘entrenched command
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
and control state’. Interestingly, CEE countries included in this analysis are all
grouped in this cluster. The label ‘gatekeeping and low-supply’ (Reibling
), however, requires some modification since supply in the in-patient
sector is higher than the OECD mean, and only out-patient healthcar
DOI: 10.1111/spol.12061
VOL. 48, NO. 7, DECEMBER 2014, PP. 864–882
Changing Healthcare System Types
Claus Wendt
Department of Sociology, University of Siegen, Germany
Abstract
This article classifies Organisation for Economic Co-operation and Development (OECD)
healthcare systems based on data from and . It shows that European countries are
clustered in different types of healthcare systems and that traditional typologies are only partially
represented in the four types of healthcare systems identified in this study. Type represents
countries with low total health expenditure (THE), high public financing, and low out-of-pocket
payment (OOP). In-patient healthcare is higher and out-patient healthcare lower than the OECD
average. General practitioners (GPs) are paid by capitation, and patients’ access to healthcare is
strictly regulated. Type represents countries with an average level of THE, high public financing,
above-average OOP, and high in-patient and out-patient healthcare. GPs receive a salary, and
access regulation is strict. Type is characterized by very low THE, low public financing, and
very high OOP. Both in-patient and out-patient healthcare is well below average, and GPs are
paid a salary. Type includes systems with the highest THE, the highest public financing, and
the lowest direct payments by patients. In-patient healthcare is below the OECD mean and
out-patient healthcare is well above it. GPs are paid by fee-for-service, and most countries offer free
choice of medical doctors. The clusters for the years and are quite robust. During this
time period, THE increased, and patients’ access to medical doctors has since become more
regulated.
Keywords
Healthcare systems; Typology; Comparison; Cluster analysis; Organisation for Economic
Co-operation and Development; Access to healthcare
Introduction
Healthcare systems have experienced major changes in recent decades. In
Central and Eastern Europe (CEE), socialist healthcare systems have been
replaced by Western European types. Scandinavian countries and the UK
have experimented with internal markets and Western European countries
with strong corporate actors in the healthcare arena have entered a period
with both more competition and stronger state intervention. Moreover, the
USA has intensively debated and partly improved its healthcare system’s
Author Email: [email protected]
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
coverage (Freeman and Moran ; Rothgang et al. ; Marmor and
Wendt , ; Montanari and Nelson ). However, information about
different modes of regulation, financing and service provision do not yet
provide a clear picture regarding similarities and differences among healthcare systems in modern societies. In particular, the measurement of regulation
remains challenging when comparing a larger number of countries (Rothgang
et al. ). Furthermore, the direction of change which goes beyond trends in
healthcare expenditure and financing remains unclear. As emphasized by
Freeman and Moran (: ), in British and Swedish health policy, ‘competition has turned relatively quickly into collaboration between larger units’.
A few recent articles have started to characterize healthcare systems by not
only concentrating on expenditure, financing and modes of governance, but
also by including healthcare provision and patients’ access to healthcare
providers (Rico et al. ; Wendt ; Reibling ). These studies,
however, only cover European countries and do not comprehensively analyze
healthcare system change.
This article will go one step further by analyzing and classifying
Organisation for Economic Co-operation and Development (OECD) healthcare systems in and . The main purpose is to identify similarities and
differences among OECD healthcare systems by clustering countries into
types of healthcare systems. We do not expect to identify ‘frozen types’; rather,
we expect to see that healthcare system types have experienced change, and
that some countries may even shift from one type to another. Such knowledge
is relevant since demographic developments, growing demand, and scarce
resources have increasingly put healthcare systems under pressure and politicians have begun to respond to these changes with structural reforms.
Regarding health policy measures, however, it is important to know whether
otherwise similar healthcare systems operate better in certain respects and are,
for instance, more successful at controlling costs, have higher levels of healthcare providers, and place lower financial burdens on the individual patient
when compared with other healthcare systems. The typology may also serve
as a tool for future studies which analyze such issues as the relationship
between healthcare system types and inequalities in health, access to healthcare and trust in healthcare systems.
Furthermore, concepts for analyzing healthcare systems have been hitherto
poorly equipped to analyze healthcare system change (Béland ). Much
like welfare state typologies (Esping-Andersen ; Arts and Gelissen ;
Scruggs and Allen ), earlier healthcare system typologies suggested what
could be interpreted as ‘frozen types’ (see e.g. Field ; OECD ; Moran
). However, by simultaneously applying the role of three groups of actors
(state, private non-profit, private for-profit) and three healthcare policy areas
(financing, healthcare provision, regulation), Wendt et al. () arrived at
types of healthcare systems, including three ideal types: a state healthcare
system, a societal healthcare system, and a private healthcare system. By
referring to Hall’s () concept of first-, second- and third-order change, this
model suggests three forms of change: a ‘system change’ (from one ideal type
to another), an ‘internal system change’ (only one dimension changes its
dominant form, e.g. the provision of healthcare shifts from public to private
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
actors), and an ‘internal change of levels’ (a shift of levels in one or more
dimensions but without changing the dominant form). Based on this conceptual framework, Wendt, Frisina and Rothgang () suggested that CEE
countries are more similar to state-based healthcare systems than to Western
social health insurance schemes, though this suggestion was not empirically
measured. This model could also help to improve the understanding of the US
healthcare system, which, when including tax exemptions, today receives
more than per cent of its financing from public money but has not achieved
sufficient public administrative capacities for controlling costs (Rothgang et al.
; Schmid et al. ).
In this article, we employ the trilogy of financing, provision and regulation
suggested above, but we change the perspective. It is not the changing role of
the state which we are mainly interested in, but rather the question of how
modes and levels of financing and healthcare provision are related to institutional regulations concerning patients’ access to medical care.
By classifying OECD healthcare systems, we expect to improve the
knowledge about the characteristics of various types of healthcare systems and
to thereby support the formulation of hypotheses for ongoing research on the
importance of these types for inequalities in health, healthcare utilization and
satisfaction with the healthcare system. In the following section, we provide an
overview of healthcare system typologies and develop our hypotheses on this
basis. Second, we provide information on the data and methods used for
comparing healthcare systems. Third, we identify different types of healthcare
systems as well as their main characteristics, and analyze healthcare system
change.
Typologies of Healthcare Systems
The history of healthcare system classification has been described in much of
the literature (Burau and Blank ; Wendt et al. ; Freeman and Frisina
). The OECD () study Financing and Delivering Health Care distinguished
three basic models: the National Health Service (NHS) model, the social
insurance model and the private insurance model. However, according to
Freeman and Frisina (), we cannot expect to learn anything new about
healthcare systems and how they work on the basis of this typology. Classifying countries from CEE as social health insurance systems and Southern
European countries as NHS systems, for instance, may not capture the
systems’ most important characteristics. After the transformation from socialist healthcare systems to social health insurance schemes, CEE countries seem
to have maintained a higher level of state regulation, as is typical of social
health insurance in Western Europe (Wendt et al. ). NHS systems
from Southern Europe, on the other hand, still seem to lack administrative
capacities and infrastructures, and have higher shares of private financing
compared with NHS systems in the Scandinavian countries and the UK
(Moran ). Another case which has proven difficult to classify is the
Netherlands, which is traditionally classified as a social health insurance
system with strong access regulation to medical care. In , the responsibility for financing was transferred to private insurance companies, which has
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
been interpreted by some authors as a privatization of the Dutch healthcare
system. As emphasized by Okma et al. (), however, private plans in the
Netherlands are strictly regulated and, therefore, do not represent a private
health insurance model.
Moran’s (, ) work represents one of the first attempts at combining
the dimensions of funding, service provision and governance in healthcare.
Using the three governing arenas of ‘consumption’, ‘provision’ and ‘production’, Moran constructed four types of ‘healthcare states’: the ‘entrenched
command and control state’, the ‘supply state’, the ‘corporatist state’ and the
‘insecure command and control state’. Based on Moran’s typology, Wendt
et al. () combined the involvement of state actors, non-governmental
actors and the market with the dimensions of ‘financing’, ‘service provision’
and ‘regulation’, and identified a taxonomy of healthcare systems, three
of which being ‘ideal types’. Both typologies contribute to the analysis of the
role of the state in healthcare, and capturing the healthcare systems’ main
characteristics and how they work has not been their main focus.
A major goal of healthcare systems can be seen in their provision of patients
with access to necessary healthcare services, and two typologies have recently
been introduced which cover patients’ access in European countries. Reibling
() used the criteria of gatekeeping, cost-sharing, provider density and
medical technology, and Wendt () classified healthcare systems on
the basis of the following eight criteria: total healthcare expenditure, the
public-private mix of healthcare financing, private out-of-pocket payment
(OOP), out-patient healthcare provision, in-patient healthcare provision,
entitlement to healthcare, remuneration of medical doctors, and patients’
access to healthcare providers.
This study makes use of the concepts provided by Reibling and Wendt, and
extends the scope of healthcare system typology by covering a larger number
of countries (including non-European countries) and by analyzing healthcare
system change. However, there is a payoff between the necessary work of
aggregation and simplification on the one hand, and the accuracy of the
representation of individual cases on the other hand (Freeman and Frisina
), and we should, therefore, remain cautious in our use of the results of
classification. Accordingly, when comparing OECD healthcare systems,
we do not aim at a better understanding of a particular case but rather at an
analysis of the following hypotheses on country groups, the extension of earlier
typologies, and healthcare system change:
H In contrast to earlier typologies, this article provides the opportunity
to contrast European and non-European countries. Due to the early
development of welfare states and healthcare systems in Europe combined with the process of European Integration (Taylor-Gooby ;
Montanari and Nelson ), we may identify more similarities among
European healthcare systems compared with countries of other world
regions.
H Modes of financing and organization, which are the main dimensions
for distinguishing NHS systems and social health insurance, may still
represent the dominant features of modern healthcare systems. We will,
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
therefore, test whether the traditional typology of NHS, social insurance
and private insurance (Kokko et al. ; Hassenteufel and Palier ;
Hassenteufel et al. ) remains valid when comparing healthcare
systems or if CEE countries and Southern European countries demonstrate major differences compared with social health insurance and
NHS systems, respectively.
H The intensity of healthcare reforms has increased over the past decades
(Freeman and Moran ), and a number of healthcare systems have
undergone more recent structural reforms (Rothgang et al. ), which
has not been studied by earlier typologies. Due to structural reforms, we
expect to identify healthcare system change in the s.
Data and Methods
Healthcare expenditure and financing, provision and regulation are captured
by data taken from the OECD Health Data (OECD ), as well as
with data collected by the author as part of a research project focusing on the
years up to (see tables and ). For analyzing healthcare system change,
data for and are included. In the next section, healthcare system
types are calculated by cluster analysis, and both the quantitative data on
expenditure and provision as well as the information on regulation are,
therefore, expressed as numerical data.
Total healthcare expenditure can be measured as a percentage of gross domestic
product or in monetary units per head of the population. Calculating healthcare expenditure per capita provides us with information on the actual
resources invested in healthcare. This typology focuses on how healthcare
systems work (including patients’ access). Since we are mainly interested in the
healthcare system’s financial capacity to provide the population with access to
necessary healthcare and not in a given society’s willingness to pay, we use the
indicator total health expenditure (THE) per capita measured in US$ per head of
the population by using purchasing power parities (PPP/general deflator).
The share of public healthcare financing, measured in public health expenditure
(PHE) as a percentage of THE, is used as an indicator to capture the role of
the state in the healthcare arena. A strong role of the state can be used for
controlling healthcare costs and for reducing inequalities.
The share of patients’ co-payments, measured as private OOP as a percentage
of THE, is used to capture the financial burden placed on the individual
patient in the case of sickness. Even if exemptions from co-payments are to be
considered, higher private OOPs generally increase the difficulty for those
with lower incomes and lower health statuses to access necessary healthcare.
Healthcare provision is more difficult to assess than expenditure and
financing, which can be measured in monetary units. Total health employment does not differentiate between healthcare providers with different levels
of qualification and overestimates the level of healthcare provision in countries with a high number of low-skilled personnel. Using the number of
doctors as an indicator for the level of total healthcare provision, on the
other hand, over-estimates the level in countries where a high number of
doctors collaborates with a lower number of other healthcare givers. We,
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Healthcare system characteristics,
Healthcare financing
and private payment
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Japan
Korea
Luxembourg
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
Turkey
UK
USA
Healthcare provider
indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private
OOP in
% of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access
regulation
index
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Sources: OECD ; Reibling and Wendt ; Rothgang et al. ; country chapters of the WHO Health in
Transition Series (WHO n. d.).
Notes: = THE: total health expenditure; = PHE: public health expenditure; = OOP: out-of-pocket payments;
= see construction of indices in Wendt ; = coding for remuneration: fee-for-service = ; capitation = ;
salary = ; = coding for index construction: free choice of GP = ; patients have to register with a GP = ; free
choice of specialists = , skip & pay = , referral to specialist = .
therefore, use two healthcare provider indices to estimate the level of healthcare provision: an in-patient index and an out-patient index. These indices provide
information on whether healthcare systems rely more on in-patient or on
out-patient healthcare. We calculated the healthcare provider indices by:
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Healthcare system characteristics,
Healthcare financing and
private payment
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Japan
Korea
Luxembourg
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
Turkey
UK
USA
Healthcare provider
indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private
OOP in
% of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access
regulation
index
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Sources: OECD ; Reibling and Wendt ; Rothgang et al. ; country chapters of the WHO Health in
Transition Series (WHO n. d.).
Notes: = THE: total health expenditure; = PHE: public health expenditure; = OOP: out-of-pocket payments;
= see construction of indices in Wendt ; = coding for remuneration: fee-for-service = ; capitation = ;
salary = ; = coding for index construction: free choice of GP = ; patients have to register with a GP = ; free
choice of specialists = , skip & pay = , referral to specialist = .
. using the raw values of the included indicators, expressed per ,
people;
. recalculating the value as a percentage of the average of OECD
countries; and
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
. calculating the respective index as the average value of the two healthcare
provider indicators (specialists and nurses for in-patient healthcare; GPs
and pharmacists for out-patient healthcare).
Lastly, two indicators are included to measure the degree of regulation in
healthcare systems (see tables and ). Healthcare systems have established
different concepts of paying medical doctors, and these concepts contain
incentives for both the level and quality of service provision. The remuneration
of GPs is particularly important since GPs are often the primary caregiver and
may guide the patient through the healthcare system. Decisions, however,
may depend on the mode of remuneration. Whereas a fee-for-service
payment may set an incentive for doctors to see their patients as often as
possible, a reimbursement per capita or a fixed salary might create an incentive for reducing the workload (Rice and Smith ). For this analysis,
remuneration has been coded as follows: fee-for-service = ; capitation = ;
salary = , with ‘’ representing the lowest level and ‘’ the highest level of
regulation.
For analyzing patients’ access to healthcare provision, we calculated an
access regulation index. This index captures whether patients have a free choice
of doctors or whether they have to sign onto a GP’s list for a longer period
(‘gatekeeping’) (Reibling and Wendt ; Rico et al. ). Furthermore,
patients have several options when visiting healthcare specialists. They may:
. have a free choice of and direct access to specialists;
. need a referral by a GP to access specialist healthcare; or
. skip the referral system by accepting additional co-payment (skip&pay).
In order to construct healthcare system types, these indicators are combined into an access regulation index, which ranges from no regulation at the
one end to strict ‘gatekeeping’ at the other. This strict ‘gatekeeping’ requires
patients to sign up on a GP’s list and necessitates a referral to specialist
healthcare. The index makes use of a scale which ranges from to : free
choice of GPs = ; signup on a GPs list = ; free choice and direct access to
specialists = ; skip&pay = ; and referral by a GP to access a specialist = . To
give GPs and specialists the same importance, we selected the same value (‘’)
in both areas for the strongest access regulation.
With few exceptions, all countries for which data are available in the
OECD Health Data (OECD ) have been included. Chile and
Mexico have been excluded due to difficult access to information on regulation. The countries included in the analysis represent countries from
Western and Northern Europe (Austria, Belgium, Denmark, Finland, France,
Germany, Iceland, Ireland, Luxembourg, the Netherlands, Norway, Sweden,
Switzerland, the UK), four countries from Southern Europe (Greece, Italy,
Portugal, Spain), six countries from CEE (the Czech Republic, Estonia,
Hungary, Poland, the Slovak Republic, Slovenia), two countries from North
America (Canada, the USA), two countries from Asia (Japan, Korea), two
countries from the Australia and Oceania region (Australia, New Zealand), as
well as both Israel – which belongs geographically to Asia but has a political
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
association agreement with the EU – and Turkey – which bridges Europe and
Asia and is an associate member of the EU.
The data are summarized in tables () and (). Quantitative data
on expenditure, financing, and service provision are taken from the OECD
Health Data (OECD ). Information on regulation is taken from
secondary literature and in particular from the WHO Health in Transition
Series (WHO n.d.).1
The data summarized in tables and demonstrate vast country differences in all dimensions. In , the level of THE ranged from US$ per
head in Turkey to US$, in the USA; the share of public financing ranged
from . per cent of THE in the USA to . per cent in the Czech Republic;
private OOP ranged from . per cent of THE in Luxembourg to . per
cent in the Republic of Korea; the in-patient index ranged from . in
Turkey to . in Iceland; and the out-patient index ranged from . in the
Netherlands to . in Belgium. GPs are paid on the basis of fee-for-service
in countries, on a capitation basis in another countries, and with a fixed
salary in eight countries. In , ten countries had no access regulation,
countries had implemented strong access regulation, and the remaining ten
countries lay in-between.
By , the situation had changed and the amount of resources invested in
healthcare had increased. THE now ranged from US$ in Turkey to
US$, in the USA; public financing as a percentage of THE ranged from
. per cent in the USA to . per cent in Luxembourg; private OOP as a
percentage of THE ranged from . per cent in the Netherlands to . per
cent in Greece; the in-patient index ranged from . in Turkey to . in
Norway; and the out-patient index ranged from . in the Netherlands to
. in Belgium. Remuneration of GPs hardly changed: countries relied
on fee-for-service, on capitation, and seven on a fixed salary. Access
regulation to medical care became somewhat stricter, with nine countries
being in the category with no access regulation, countries in the category
with the strongest access regulation, and the remaining eight between the two
extreme poles.
We performed cluster analyses for and in order to model healthcare system types and classify countries (see Powell and Barrientos ;
Jensen ; Wendt ; Reibling ). Cluster analysis aims to group cases
by simultaneously taking a number of selected characteristics into account.
We used agglomerative hierarchical clustering techniques, starting with a
cluster for each country and then gradually merging similar countries into
clusters until finally all countries form one cluster. Since we used a mixture of
binary and continuous data, the clusters were constructed using the Gower
dissimilarity coefficient (Everitt et al. ). Once a country has been allocated
to a cluster, it remains within this initial cluster. Other procedures were used
(single- and complete linkage, ward method and waverage linkage; see Everitt
et al. ) in order to check the stability of cluster solutions. All procedures
created four identical clusters. The development of the level of homogeneity
(as expressed in the distance coefficient or similarity coefficient) within country
groupings suggested that four clusters best represent the structure of the
data. Furthermore, the robustness of this solution was checked with k-means
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
.4
.3
.2
Australia
Italy
Denmark
Ireland
Slovenia
United Kingdom
Netherlands
Czech Republic
Slovak Republic
Estonia
Hungary
Poland
Finland
Portugal
Spain
Iceland
Sweden
Greece
Israel
Turkey
Austria
Belgium
New Zealand
Canada
Japan
Germany
Luxembourg
France
Switzerland
United States
Norway
Korea
.1
0
Gower dissimilarity measure
Average linkage 01
clustering (Powell and Barrientos ; Jensen ). With this method, the
number of clusters is set by the researcher, and cases are thus selected and
re-combined to form the optimal solution regarding homogeneity within
clusters in the a priori set number of clusters. Again, the four-cluster solution
reached by these algorithms shows the highest degree of homogeneity and
proves stable when using k-means clustering.
Results: Classifying Healthcare Systems and
Analyzing Change
OECD countries are grouped in four types of healthcare systems in both
and . However, some countries cannot be classified for either year (see
figures and , as well as tables , and ).
In , Cluster represents the largest group of countries and includes
healthcare systems conventionally known as NHS systems (Australia,
Denmark, Ireland, Italy, the UK), social health insurance systems from CEE
countries (the Czech Republic, Estonia, Hungary, Poland, the Slovak Republic, Slovenia), and the Western European social health insurance system of the
Netherlands. Cluster covers NHS countries from Scandinavia and Southern
© John Wiley & Sons Ltd
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
.4
.3
.2
AU
EE
IT
HU
SK
PL
SL
DK
IE
UK
NL
CZ
FI
PT
ES
IS
SE
AT
DE
CA
JP
NZ
LU
BE
FR
US
GR
CH
KR
NO
IL
TR
.1
0
Gower dissimilarity measure
.5
Average linkage 07
Table
Four-cluster solution,
Type
Type
Type
Type
Not classified
Australia
Czech Republic
Denmark
Estonia
Hungary
Ireland
Italy
Netherlands
Poland
Slovak Republic
Slovenia
UK
Finland
Iceland
Portugal
Spain
Sweden
Greece
Israel
Turkey
Austria
Belgium
Canada
France
Germany
Japan
Luxembourg
New Zealand
Korea
Norway
Switzerland
USA
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Table
Four-cluster solution,
Type
Type
Type
Type
Not classified
Australia
Czech Republic
Denmark
Estonia
Hungary
Ireland
Italy
Netherlands
Poland
Slovak Republic
Slovenia
UK
No change
Finland
Iceland
Portugal
Spain
Sweden
Israel
Turkey
Austria
Belgium
Canada
France
Germany
Japan
Luxembourg
New Zealand
Greece
Korea
Norway
Switzerland
USA
No change
(minus Greece)
No change
(plus Greece)
Europe (Finland, Iceland, Portugal, Spain, Sweden). Cluster includes Greece,
Israel and Turkey. Cluster includes mainly Western European social health
insurance countries (Austria, Belgium, France, Germany, Luxembourg) as
well as both Japan’s social health insurance system and the mainly taxfinanced systems of Canada and New Zealand. It has not been possible to
classify Korea, Norway, Switzerland, or the USA.
We do not see major changes in the number of clusters or the classification
of countries between and . The countries in Cluster , Cluster , and
Cluster remain the same. Greece no longer groups together with Turkey
and Israel in , leaving five countries which cannot be classified into any of
the four healthcare clusters. Although the number of clusters remains the
same in both years, we detect some changes over time when analyzing the
main characteristics of the four clusters.
In , the identified healthcare system types can be described as follows
(see table ):
Type represents countries with a low level of THE per capita, a high
share of public financing, and below-average private OOP. The level of
in-patient healthcare is higher than the OECD mean, and the level of
out-patient healthcare is much lower than this measure. GPs are remunerated on a capitation basis in all countries in this cluster, and the level
of access regulation is very high (at the highest level in eight countries and
at a somewhat lower level in four countries).
– Type represents countries with a level of THE at the average of OECD
countries, a high share of public financing, above-average OOP, and
above-average levels of in-patient and out-patient healthcare. The control
of doctors’ remuneration is even stricter than in Type , with GPs being
–
© John Wiley & Sons Ltd
Table
Healthcare system characteristics in and
Healthcare provider indices
Regulation
THE per
capita, US$
PHE in %
of THE
Private OOP
in % of THE
In-patient
index
Out-patient
index
Remuneration
of GPs
Access regulation
index
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
( except.)
( except.)
.
.
.
.
.
.
.
.
.
.
Type
Type
Type
Type
© John Wiley & Sons Ltd
Norway
Norway
Korea
Korea
Switzerland
Switzerland
USA
USA
Mean
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Healthcare financing and private payment
S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
paid on a salary basis. Access regulation is strict, but Iceland and Sweden
are exceptions with lower levels of access regulation.
– Type represents healthcare systems with both a very low level of THE
(about per cent of the OECD average) and a low share of public
financing. Both in-patient and out-patient healthcare are well below the
average, and GPs are remunerated on a salary basis. However, patients’
access to medical doctors is hardly controlled by instruments of regulation.
– Type represents healthcare systems with the highest level of THE, the
highest share of public financing, and the lowest direct payments by
patients. In-patient healthcare is below the average OECD level, and
out-patient healthcare is well above the level of other OECD healthcare
systems. GPs are remunerated on a fee-for-service basis, and most countries offer free choice of medical doctors.
Taking these characteristics into account, Korea shows similarities to
Type with its low level of THE, low public financing, very high private
co-payment, and low levels of in-patient and out-patient healthcare.
However, instead of a fixed salary, Korea’s GPs are paid on a fee-for-service
basis, and formal access regulation is somewhat higher than in Type .
Norway shares important characteristics with Iceland and Sweden, both
grouped in Type . However, due to Norway’s prosperous economic condition, THE is much higher (ranked number – behind the USA and Switzerland), and doctors’ income is less regulated than in Type . The US and
Switzerland share with Type countries the high level of THE, GPs’ fee-forservice payment, and doctors’ free choice. However, the share of public
financing is even lower than in Type , and private OOP is much higher
in Switzerland. Interestingly, the US and Switzerland share a preference
for in-patient care opposed to out-patient care, which is the case with Type
countries.
Between and , the clusters and country groupings proved to be
robust. However, at the same time major changes took place. Overall in
OECD countries, THE per capita increased by more than per cent, the
share of public financing remained at a level of per cent, and private OOP
also turned out to be quite stable (at average below per cent). No changes
took place with respect to the main form of GP remuneration. However,
access to medical doctors became more regulated than it was at the beginning
of the s. When analyzing within-cluster changes, some important healthcare policy developments can be detected. In Type , THE increased by almost
per cent and, therefore, to a higher extent than the OECD average. The
share of public financing, private OOP, and in-patient and out-patient healthcare remained stable. Access regulation to medical care became even stricter
than before. Type countries also increased THE to a greater extent than the
OECD average. The share of public financing increased slightly while the
relative amount of private co-payments decreased. In-patient and out-patient
healthcare remained at a high level, and there were also no changes in
doctors’ remuneration (salary) or in the high level of access regulation. Comparing Type ’s average levels in and is not very meaningful since
Greece no longer grouped with the other two countries in . In Israel and
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
Turkey, however, public financing remained at a low level, private OOP
remained very high, and in-patient and out-patient healthcare continued to
be much lower than the average in the OECD world. Salary payment was also
combined with free formal access to medical care. Type , finally, controlled
and stabilized THE somewhat more than Type and Type countries. Public
financing and private co-payments continued to be at the highest and lowest
levels, respectively, and service provision concentrated on out-patient healthcare while the level of in-patient healthcare remained below the OECD mean.
GPs continued to be mainly remunerated on a fee-for-service basis, and while
patients had free choice of doctors in most of the Type countries, access
regulation slightly increased in countries such as Germany and France
(Reibling and Wendt ). Norway and Korea still showed similarities to
Type and Type , respectively. Switzerland and the USA, finally, demonstrated parallels to Type , but both countries paid much more for healthcare
while their share of public financing remained low. In contrast to Type , the
main focus in the USA and in Switzerland was not on out-patient but on
in-patient healthcare.
Our results do not support the hypothesis that European healthcare
systems have more in common than do healthcare systems of other world
regions or that they even form a European healthcare model (H). European
countries are classified in different types of healthcare systems. Furthermore,
non-European countries do not form their own type but join different clusters
(or, as with Korea and the USA, cannot be classified at all). Australia is
grouped into Type ; Canada, Japan, and New Zealand into Type ; and
Turkey and Israel (in together with Greece) form their own type.
The hypothesis that healthcare systems can still be best classified as NHS,
social health insurance, and private health insurance has, to a certain extent,
been confirmed (H). Almost all Western social health insurance countries are
grouped into Type (the Netherlands being an exception). The social health
insurance scheme of Japan is also grouped into this type. Although Canada
and New Zealand are mainly tax financed and no social insurance companies
are involved in (self-)regulation, the two countries seem to share more similarities with Western social health insurance systems than with tax-financed
NHS schemes. The largest group of countries (Type ), however, represents a
combination of NHS systems, CEE social insurance schemes, and the Dutch
social health insurance scheme. The level of access regulation and the capacity
to control costs, therefore, seem to reinforce more important similarities than
the NHS or the social insurance model. Furthermore, other established NHS
systems (Finland, Iceland, Sweden) do not join the same group as the UK,
Ireland, Italy and Denmark. Lastly, countries such as Switzerland and the
USA, whose private healthcare market is of great importance, do not seem to
have much in common and do not form their own private health insurance
model.
We have found some evidence for the hypothesis of healthcare system
change (H). However, institutions like healthcare systems change slowly; they
are ‘elephants on the move’ (Hinrichs ). THE has increased to a high
extent. However, Type countries with an already high THE have been more
successful in controlling costs than have countries with lower expenditure
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
levels. One of the main focuses of health policy change has been on access
regulation, and we only see changes in the direction of higher access regulation and not in the direction of lower access regulation (possibly also to
support cost control measures). The payment of medical doctors often represents a mixture of different methods of remuneration, and this mixture has
changed in a number of countries. Germany, for instance, has recently introduced a capitation-based component of GPs’ income (Rothgang et al. ;
Schmid et al. ). The main mode of remuneration, however, remained
unchanged in the period under study.
Discussion
In this article, we identify robust cluster solutions with four types of healthcare
systems in and , and only one country changed clusters within this
period.
Our results do not confirm the concept of a European healthcare model
(H). On the contrary, European healthcare systems are classified into different clusters, and with only one exception, the clusters represent a mix of
European and non-European countries. When comparing NHS-type countries with social health insurance countries, these two organizational and
financial patterns still seem to represent the core of two different types of
healthcare systems (H). Social insurance countries are mainly grouped into
Type , whereas certain NHS type countries are grouped into Type .
However, our results support the assertion by Wendt et al. () that social
health insurance systems in CEE countries do not share major characteristics
of Western social health insurance schemes. Instead, CEE healthcare systems
seem to be more similar to the NHS systems of the UK, Ireland, Italy and
Denmark, possibly due to the weak position of corporate actors and a stronger
role of the state in CEE countries compared with Western social health
insurance countries (Kaminska ; Wendt et al. ).
Healthcare system change (H) has been identified mainly in the areas of
healthcare expenditure and access regulation. Patterns of public financing,
private co-payments, healthcare provision and doctors’ remuneration, in contrast, have proven rather stable.
Comparing our findings with earlier typologies (OECD ; Moran ;
Burau and Blank ; Wendt et al. ; Wendt ; Reibling ), we
can corroborate the existence of two types of healthcare system. Type
confirms the ‘healthcare-provision-oriented type’ suggested by Wendt ().
Due to the almost unregulated access to medical care, Type also shows
similarities to the ‘financial incentives states’ proposed by Reibling ().
Type countries are characterized by the unquestioned importance of access
to medical care expressed in low access regulation and high levels of outpatient healthcare. All other features, such as low direct private payments and
fee-for-service payment of medical doctors, seem to follow this overarching
health-policy goal.
Type bears a striking resemblance to the ‘gatekeeping and low-supply
type’ suggested by Reibling (), and also to Wendt’s () ‘universal
coverage-controlled access type’ and Moran’s () ‘entrenched command
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S OCIAL P OLICY & A DMINISTRATION, VOL. , NO. , DECEMBER
and control state’. Interestingly, CEE countries included in this analysis are all
grouped in this cluster. The label ‘gatekeeping and low-supply’ (Reibling
), however, requires some modification since supply in the in-patient
sector is higher than the OECD mean, and only out-patient healthcar