Changing Healthcare System Types
Claus Wendt
Department of Sociology, University of Siegen, Germany
Abstract
This article classifiesOrganisation for Economic Co-operation and Development (OECD) healthcare systems based on data fromand. 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. Typerepresents 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. Typeis 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. Typeincludes 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 yearsandare 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 In Central and Eastern Europe (CEE), socialist healthcare systems have been replaced by Western European types.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:wendt@soziologie.uni-siegen.de DOI: 10.1111/spol.12061
VOL. 48, NO. 7, DECEMBER2014,PP. 864–882
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 health-care 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, ‘com-petition 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) health-care systems inand. 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 poli-ticians 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 health-care 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 health-care and trust in healthhealth-care 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), Wendtet 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
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 concep-tual 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 thanper cent of its financing from public money but has not achieved sufficient public administrative capacities for controlling costs (Rothganget al.
; Schmidet 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 institu-tional 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; Wendtet al.; Freeman and Frisina
). The OECD () studyFinancing and Delivering Health Caredistinguished 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. Classify-ing 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 social-ist 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 responsi-bility for financing was transferred to private insurance companies, which has
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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 ‘produc-tion’, 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 com-bined 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,
therefore, test whether the traditional typology of NHS, social insurance and private insurance (Kokkoet al.; Hassenteufel and Palier; Hassenteufel et al. ) remains valid when comparing healthcare systems or if CEE countries and Southern European countries dem-onstrate 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 (Rothganget al.), which has not been studied by earlier typologies. Due to structural reforms, we expect to identify healthcare system change in thes.
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 tablesand). For analyzing healthcare system change, data forand 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 expenditurecan be measured as a percentage of gross domestic product or in monetary units per head of the population. Calculating health-care 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 indicatortotal health expenditure(THE) per capita measured in US$ per head of the population by using purchasing power parities (PPP/general deflator).
Theshare 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.
Theshare 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 employ-ment does not differentiate between healthcare providers with different levels of qualification and overestimates the level of healthcare provision in coun-tries 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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therefore, use two healthcare provider indices to estimate the level of health-care provision: anin-patient indexand anout-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:
Table
Sources:OECD; Reibling and Wendt; Rothganget 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
Sources:OECD; Reibling and Wendt; Rothganget 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=.
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. 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. Theremuneration of GPsis 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 incen-tive 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 com-bined 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 regula-tion. 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
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 differ-ences 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 incountries, on a capitation basis in anothercountries, 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 forandin order to model health-care 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 (Everittet 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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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 thea 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 figuresand, 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 Repub-lic, Slovenia), and the Western European social health insurance system of the Netherlands.Clustercovers NHS countries from Scandinavia and Southern
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
Figure
Dendrogram resulting from hierarchical cluster analysis (using average linkage),
Europe (Finland, Iceland, Portugal, Spain, Sweden).Clusterincludes Greece,
Israel and Turkey.Clusterincludes 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 tax-financed 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 betweenand. 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 remu-nerated 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).
– Typerepresents 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
Table
No change No change (minus Greece) No change (plus Greece)
Healthcare system characteristics inand
Healthcare financing and private payment Healthcare provider indices Regulation
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 coun-tries 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 condi-tion, THE is much higher (ranked number– behind the USA and Switzer-land), and doctors’ income is less regulated than in Type . The US and Switzerland share with Typecountries the high level of THE, GPs’ fee-for-service 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.
Betweenand, 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 ofper cent, and private OOP also turned out to be quite stable (at average belowper 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 thes. When analyzing within-cluster changes, some important health-care policy developments can be detected. InType, 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 health-care remained stable. Access regulation to medical health-care became even stricter than before.Typecountries 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. Com-paringType ’s average levels inandis not very meaningful since
Greece no longer grouped with the other two countries in. In Israel and
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 Typeand Typecountries. Public financing and private co-payments continued to be at the highest and lowest levels, respectively, and service provision concentrated on out-patient health-care while the level of in-patient healthhealth-care 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, demon-strated 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 (intogether 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 simi-larities 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, Typecountries with an already high THE have been more successful in controlling costs than have countries with lower expenditure
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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 regula-tion and not in the direcregula-tion of lower access regularegula-tion (possibly also to support cost control measures). The payment of medical doctors often repre-sents a mixture of different methods of remuneration, and this mixture has changed in a number of countries. Germany, for instance, has recently intro-duced a capitation-based component of GPs’ income (Rothganget 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 inand, 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 differ-ent clusters, and with only one exception, the clusters represdiffer-ent a mix of European and non-European countries. When comparing NHS-type coun-tries with social health insurance councoun-tries, 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 Wendtet 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; Wendtet 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 con-trast, have proven rather stable.
Comparing our findings with earlier typologies (OECD; Moran; Burau and Blank ; Wendtet 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 (). Typecountries are characterized by the unquestioned importance of access to medical care expressed in low access regulation and high levels of out-patient 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
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 healthcare provision is much lower. ‘Command and control’ (Moran) suits this type of healthcare system due to the strict access regulation and control of doctors’ income chances through capitation payment. The other two clusters identified in this article specify (and even disagree with) earlier typologies. Typeshows signs of the ‘insecure command and control state’ proposed by Moran (). However, today the characteristics of this type (particularly low administrative capacity and low supply) do not seem to exist solely in the healthcare systems of Southern Europe, but (with the exception of Greece in) can also be found in Turkey and Israel. Type, lastly, represents a combination of strict access regulation and control of doctors’ income chances with high levels of healthcare provision in the in- and out-patient sectors. This is the case for Finland, Iceland and Sweden, but Spain and Portugal also increased their levels of in-patient healthcare. ‘Low budget – restricted access’ (Wendt), therefore, does not describe the main characteristics of this type of healthcare system since regulation is not primarily used for controlling costs but rather for achieving high levels of healthcare provision. Future research relying on data afterwill show whether countries such as Spain and Portugal are able to guarantee high healthcare provision in times of economic crisis or whether they will fall back to a low expenditure and low provision type as represented by Israel, Turkey and (in) Greece. The position of the USA is charac-terized by high costs, low public financing, average healthcare provision, and low regulation of patients’ access to healthcare providers. The USA and Switzerland, which revealed some signs of forming their own ‘private insur-ance’ type in, are now more distinct from each other and from any other of the four healthcare system types identified in this study.
Note
. Data on remuneration and access regulation are taken from secondary literature (see tablesand), and have been cross-validated by contacting country experts in this field.
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