COMPARATIVE HEALTH-CARE SYSTEMSinvolves describing the range of health-care services
in populations or societies, particularly their or-
ganization and functioning. By far the most com-
mon type of research, descriptive studies, brings
together statistical indicators and factual explana-
tions about how various national systems operate
(van Atteveld et al. 1987). Some of this work
incorporates an analytical dimension by categoriz-
ing systems in terms of conceptual schemes or
typologies. Less attention has been paid to the
second type of research, which looks more closely
at the dynamics of how health-care systems be-
have. The intent in this type of research is to
analyze the patterns among system characteristics,
especially with the idea of anticipating the out-
comes that are likely with specific types of system
arrangements. Still in its infancy, this work promis-
es an in-depth yet practical understanding of how
health-care can be organized and financed to
achieve desirable levels of both quality and access.
Interest in cross-national studies of health-
care systems increased dramatically in the early
1990s as a result of national debates over reorgan-
izing American health-care. Rapidly aging popula-
tions in many advanced, capitalistic countries, in
combination with the expanding scope of high
technology medicine, resulted in increased public
demand for health-care. At the same time, poverty
and other forms of social inequality as well as
ineffective societal institutions created major pub-
lic health problems in many developing countries,
such as hazardous water, inadequate or harmful
food supplies, poor air quality, unsafe homes and
workplaces, and the swift spread of infectious
diseases. In both cases, health-care systems have
been severely challenged and often cannot meet
the needs of citizens. Because of these problems
and also due to enhanced global cooperation,
social scientists and policy makers are increasingly
turning their attention to the experience of other
countries.
KEY CHARACTERISTICS FOR THE
COMPARISON OF HEALTH-CARE SYSTEMSDrawing on the work of Anderson (1989) and
Frenk (1994), a health-care system can be defined
as the combination of health-care institutions, sup-
porting human resources, financing mechanisms,
information systems, organizational structures that
link institutions and resources, and management
structures that collectively culminate in the deliv-
ery of health services to patients. Within this broad
framework, the methodology for comparing health-
care systems can vary widely. A standard approach
would include some or all of the dimensions out-
lined below.
The most fundamental comparative dimen-
sion is the organization, financing, and control of a
health-care system. This involves comparing which
health services are provided; how they are paid for;
how they are configured, planned, and regulated;
and how citizens gain access to them. Among
countries with advanced economies, health-care
services today look much the same to the casual
observer; however, the financing arrangements
and policy-making mechanisms that underlie them
vary widely. The role of government is perhaps the
most significant organizational variable in interna-
tional health-care. All governments, with the nota-
ble exception of the U.S. government, accept re-
sponsibility for the health-care of citizens (Evans
1997). Some governments take it upon themselves
to actually provide health services and, therefore,
own their own clinics and hospitals and hire their
own physicians and staff—examples are Sweden
and Denmark. Within the U.S., the Veteran’s Ad-
ministration operates its own healthcare system
this way. In a variation of this model, the govern-
ment acts as the purchaser (but not the owner) of
health-care services, obtaining services from pri-
vate providers on behalf of patients, such as in
Canada or the reformed health-care system in
Britain. In Finland, local governments can pur-
chase from either public or private providers. In
another model, illustrated by Germany and Japan,
the government avoids acting as the major payer,
and instead takes the role of an overseer, setting
mandates for health coverage, including the type
and level of coverage, and regulating the terms of
what is largely a private system. Due to economic
pressures, national governments in both Germany
and Japan provided increasing subsidies to sup-
port their systems in the 1990s.It is important also to compare health-care
systems in terms of physician characteristics and
provider arrangements for primary care and preven-
tion. The supply of medical personnel (e.g., the
number of physicians per unit of population) is a
key comparative indicator. Interestingly, there is
significant variation in the number of physicians in
advanced economy nations, ranging per 10,000