Health Care Systems in Europe and Asia

Christian Aspalter, Yasuo Uchida, Robin Gauld

• Publisher: Taylor & Francis
• Year: 2012
• eBook ISBN: 9781136587214
• Edition: 1
• Topic: Medicina
• Subtopic: Prestazione di assistenza sanitaria

This book addresses the global need for more comparative studies on health policy and health care systems, given the rise in recent decades of societal aging, modern mass diseases, economic globalization, and resulting permanent fiscal austerity of governments which have fundamentally altered the status quo of health care systems.

The book examines the healthcare experiences of the most developed countries in Asia (Japan, South Korea, Taiwan and Singapore) and compares these with four of the most important health care systems in Europe (UK, France, Germany and Italy). Focusing on the public health care systems the contributors discuss the rising need for reforms in health care and health insurance administration, delivery systems, financing and overall health care policy strategies, particularly in fast-aging societies in Asia, and highly aged societies in Europe.

This book will appeal to students and scholars of health care policy, health and social administration, social policy, public policy and social work. It will also provide a reference for professionals who need a view of the trajectory of public health financing in relation to changed and changing demographics and disease patterns.

1 Introduction

Robin Gauld, Christian Aspalter, and Yasuo Uchida

Health systems affect all of us in one way or another. The individual doctor operating in a solo practice that is their private business, whom we might visit with a health concern, works within a broader system. A referral for a laboratory test or to a specialist may be required, as may be a prescription for medicines. Depending upon how health care services are funded, the doctor may have contracts or billing arrangements with a range of funders including the government, a social insurance funder, or private insurers. The doctor may also have to fulfill various government policy goals, such as collecting data on patient characteristics and health risks, providing information to patients on specific diseases or government health priorities, and delivering certain services such as screening of at-risk patients and immunizations. Doctors and other health care professionals working in hospitals and allied services spend their working lives negotiating, and helping patients negotiate, the health system. They may see patients whose conditions could have been managed in community settings or averted with better primary care service access. They will also be beholden to funding arrangements, such as billing and reimbursement systems, and to issues of service coordination.

For the individual patient, how the health system is funded and organized can have significant ramifications. Payment at point of service may pose a barrier to accessing care in a timely manner or at the appropriate level of care. If an emergency department is free of charge but primary care medicine carries a cost, this has obvious implications for emergency services and moves the emphasis in the system away from preventive primary care. The extent to which the records kept by a patient’s primary care doctor follow a patient into more advanced hospital or specialist settings may impact on how coordinated the providers of care seem to be. Patients whose records have not followed them generally mean that tests and other diagnostic processes must be repeated. Of course, a patient referred from one part of the system to another – from primary care to a hospital, or between hospital departments – can easily perceive a lack of coordination and communication if robust processes for transfer are not in place. Such processes have been the focus of considerable policy and research activity in recent years, as discussed in further detail later in this chapter.

Those responsible for policy-making, for funding, and for planning and managing services are similarly affected by how the health system functions, but their concerns may be different again. Issues such as increasing public demand for services, changing demographics, limited capacity to provide services and shortages of health care professionals may dominate their activities. They may be concerned about how to attract, retain, and boost training opportunities for professionals, how to provide better preventive care and promote healthy behaviors, how to prioritize or ration services, and how to raise capital, spread the costs of health care provision, and provide incentives for improved clinical practice, while maintaining equity of patient access and outcomes.

Health systems are clearly complex and multi-faceted with wide ranging impacts. They consume vast sums of money, at an average of around 8.5 percent of gross domestic product (GDP) in the Organisation for Economic Co-operation and Development (34) member countries but less in countries such as South Korea and Singapore. They also have considerable potential to contribute to improved health care. Of course, poorly delivered health care can have the opposite effect, with great expense in terms of harmed patients or over-expenditure on treatments that are inappropriately delivered (Institute of Medicine, 2000; McGlynn et al., 2003; Department of Health, 2000; WHO, 2010).

Attention to the study of health systems has increased in recent years, partly in response to the sorts of issues outlined above. Attention has also been bolstered by the World Health Organization (WHO)’s World Health Report 2000: Health Systems: Improving Performance (WHO, 2000). This noted the important place of health systems in the overall effort for better health care. It emphasized the need for performance monitoring and improvement in order to provide for better health care and outcomes. The WHO’s starting point was to define “health system,” which, in keeping with the above, encompasses a range of organizational forms, funding arrangements and service types. The WHO used the following definition: “Health systems consist of all the people and actions whose primary purpose is to improve health” (p. 1). Controversially, the report ranked the world’s health systems against one another across a set of criteria that included the different dimensions considered by the WHO to be important to a high-performing system. These were responsiveness to the population, equity of access in terms of financial contribution across different groups within the population, expenditure levels, and health outcomes measured in disability adjusted life years (DALYs).

But back to the WHO’s definition. In a short sentence this spelled out the potential scope of a health system. It could include public and private sectors, along with the spectrum of funders and providers that might be involved in improving health. The full range of organizational forms is likely to be evident in any developed world health system, perplexing those who seek simplicity. Patients and providers will interact with and be affected by large bureaucracies such as government health ministries as well as hospitals. Networks may straddle various service areas around issues such as care of diabetes or cancer, or to coordinate the activities of providers with common interests (for example, all providers of community-based primary medical care) who practice in different locations. Many small independently owned businesses will also be evident, including private medical clinics, pharmacies, and various other allied services.

The advent of studies showing that a range of social and economic factors such as housing, education, working conditions, and levels of inequality in a society impact on population health has expanded the reach of health systems (Pickett and Wilkinson, 2007; Wilkinson, 2005). Indeed, the “new public health” philosophy sees a health system intertwined with other social systems, suggesting health policymakers need to consider the broader context of people’s lives, and act on issues affecting them, if health is to be improved (Baum, 2008). The WHO Commission on Social Determinants of Health went as far as to suggest that governments should direct efforts toward altering the power structures within society if better health for all is the goal (Commission on Social Determinants of Health, 2008).

Comparing health care systems in Europe and Asia

Underpinning this book is a comparative approach to the study of health systems, which is useful for a variety of reasons. As implied above, comparisons can be important for gaining an understanding of how well a health system performs against others. Of course, the choices over what is compared and the relative importance placed on each of these factors will have a bearing on comparative performance. If one were interested, for example, in capacity to deliver universal and equitable access to health care, the UK, with its tax-funded National Health Service that is relatively free of patient charges, would rank highly. For such reasons, comparative studies are often the center of much debate, especially amongst leaders of high-income countries whose rankings show them in poorer light than comparators.

The comparative approach is particularly useful for exploring the policy choices of governments and how services are configured and delivered, given the multiple options and combinations available to policymakers. As governments search for ways of improving health systems and services and dealing with the various pressures confronting health systems today, considerable lessons can be gained from comparisons. How different countries deal with common problems can have numerous benefits.

How and what to compare are important issues in comparative studies and will depend on what the aims of comparison are. Comparisons can be drawn in differing ways and at different levels of a health system: national, regional, organizational, or by policy issue. Comparative approaches also differ by method. Quantitative methods underpin the WHO rankings and various OECD member-country studies, drawing on routinely collected country data, although the OECD has produced in-depth discussions of arrangements in member countries (OECD, 2010). Various other studies look at quite specific issues, such as risk-adjusted mortality rates (Nolte and McKee, 2008). Quantitative approaches often lack consideration of contextual issues such as political influences, policy frameworks, or management processes. Other comparative studies employ qualitative case-based methods in providing in-depth individual country health system descriptions (Blank and Burau, 2010; Marmor et al., 2009; Okma, 2010). Usually, such studies feature a common framework for comparison. Organizations such as the Commonwealth Fund and European Union (EU) Observatory on Health Systems offer a mix of these two approaches. The Commonwealth Fund, for example, regularly surveys doctors and patients from multiple countries about their perceptions of and experiences with the health system, with an overall aim of emphasizing how well different types of health system perform (Schoen et al., 2009a,b). Routinely, they find that the US health system has considerable scope for improvement over comparators as an “outlier” in being a market-oriented system (Davis et al., 2010). The underlying message is that the United States can draw important lessons from other high-income country systems when it comes to delivering high-quality health care accessible to all.

Comparative studies of health systems and policies tend to be regional or across countries that share similar characteristics (Blank and Burau, 2010). The predominant focus is high-income Western countries such as those covered by the Commonwealth Fund and the EU Observatory, although the latter extends to other parts of the world to generate lessons for EU policymakers. Health policy comparisons are often across a small number of jurisdictions, such as the United States, Canada and the UK (Tuohy, 1999; Moran, 1999). There is an emerging literature comparing Asian health systems and policies, as well as social policy studies that include health care (Okma, 2010; Aspalter, 2007; Gauld et al., 2006; Gauld, 2005; Ramesh, 2004; Holliday and Wilding, 2003; Ramesh and Holliday, 2001; Tang, 2000). Few studies have sought to compare European and Asian health systems, despite, as this book shows, the considerable potential for analysis and lesson drawing. Several of the Asian systems covered in the following chapters have foundations that were borrowed from European countries. Japan, for instance, was influenced by the German social insurance model; Singapore’s roots were laid when it was a British colony. Yet European and other Western countries today might garner many lessons from the Asian systems in terms of how they have configured funding arrangements and service provision.

Pressures facing high-income country health systems

Health systems face multiple challenges today to which no high-income country is immune. Options for what to do about these challenges are not necessarily easily identifiable nor likely to provide a full solution. Again, this is where comparative studies can be useful. The health systems covered in this book each face a similar set of challenges, albeit to differing degrees and in different contexts, which this section overviews.

First is the changing age and demographic structure in societies. Data show that many high-income countries face dramatic change due to a combination of population aging and low total fertility rates. As a general rule, a natural fertility rate of 2.1 children per woman is required for population replacement. None of the countries featured in this book is achieving this rate. The United Kingdom had the highest rate in 2008 at 1.96 births per woman; at the lower end were Singapore and South Korea, both with average rates of around 1.1 births per woman, that is, the average for all women aged 15 to 49 (OECD, 2009a). For all of the eight countries the overall population faces decline in the absence of immigration. In addition, populations are aging, with people living longer and living longer in retirement. Across OECD countries, average life expectancy has increased by more than 10 years since the 1960s. Meanwhile, men who reach 65 years of age can expect to live a further 17 years and women a further 20 years, around three to four years longer than in 1970 (OECD, 2009b). The implication of these two trends is two-fold. There is a declining number of children moving into adulthood, lowering the potential tax base and funding to help pay for public services such as health care, but also fewer family members to help provide care for one another and for older people in society. Coupled with this is an expansion in the numbers of older people, potentially driving up health care costs.

Second, service demand and health care expenditure are ever-increasing. OECD data from 1997 to 2007 show average member-country increases of 4.1 percent per annum, more than double the general inflation rate (OECD, 2009b). This is of concern to policymakers as the proportion of GDP expenditure on health care is growing. Where government is a significant contributor of health care funding, this is placing pressure on other areas of the government budget.

In societies with social insurance or other funding forms, it inevitably means increasing contributions are required. The growth in expenditure is attributed to new technology and therapies, a demand for more services from the population to treat a range of previously untreatable conditions, population aging, and the demand to increase remuneration of health professionals in an internationally competitive market place (Zurn and Dumont, 2008). Chronic disease is seen as a particular pressure for health funders, with conditions such as heart disease and diabetes on the rise. All high-income countries are therefore looking for ways to control expenditure. Many are looking at methods to ration and prioritize services and patients, at methods for improving the planning of services and controlling fees paid to providers, and at ways of promoting better health behaviors in the population. Improving system efficiency is also at the core of such debates.

Third, following the above but also in response to the increasing complexity of health care provision, many countries are seeking to improve health system performance. In many countries, there is evidence that this is less than satisfactory. Studies show that a significant proportion of hospitalized patients will be victims of an avoidable error in the process of treatment, with considerable costs associated (Vincent et al., 2001; Thomas et al., 2000). Other studies show that unsatisfactory treatment contributes to hospital readmissions. Processes of care for patients with complex conditions or w...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• List of Boxes
• List of Contributors
• Preface
• 1 Introduction
• 2 The health care system in the United Kingdom
• 3 The health care system in Germany
• 4 The health care system in France
• 5 The health care system in Italy
• 6 The health care system in Japan
• 7 The health care system in South Korea
• 8 The health care system in Taiwan
• 9 The health care system in Singapore
• 10 European and Asian health care systems in comparative perspective
• Index