COMPARATIVE HEALTH-CARE SYSTEMSpopulation from fifty-five in Italy to thirty-four in
Germany to twenty-six in the United States, which
is more typical, to seventeen in the United King-
dom (Anderson and Poullier 1999). Equally inter-
esting is that there is no apparent corresponding
variation in the health status of these populations.
A more complex issue is how different systems
organize and divide medical work between various
professions and occupations. In some countries,
such as Sweden, Finland, and the Netherlands,
midwives or nurse midwives have primary respon-
sibility for normal prenatal care and childbirth; in
others, such as the United States, physicians have
responsibility for these tasks and midwives are
relatively rare. Practice arrangements between gen-
eralist and specialist physicians are another point
of comparison. The United States is unique among
its peers because primary care physicians working
in ambulatory settings also have hospital privileg-
es, and, therefore, have the right to admit patients
and to treat hospitalized patients. In Britain, Swe-
den, Germany, and many other countries, on the
other hand, only specialists comprise the hospital
medical staff and only they can treat patients there.
Hospitals and long-term care arrangements consti-
tute another dimension in comparing health-care
systems. Countries vary widely in how they use
hospitals, as well as in how and where citizens
with chronic illnesses and other debilitating condi-
tions receive ongoing, nonacute care. Many West-
ern countries today are in the process of shift-
ing from institutional to community-based care.
There are many factors affecting this transition,
including whether alternatives to institutional care,
such as home health and support programs, are
readily available. In countries such as Japan and
Germany, that through the 1990s have relied on
informal family caregiving arrangements rather
than institutions or community-based services,
sociodemographic changes (elders living longer as
well as changes in the work force participation of
caregivers) are producing a long-term care crisis.
Health-systems also can be compared accord-
ing to the degree to which care is integrated and
coordinated between various sectors and levels of
services. Systems that have rigid boundaries be-
tween ambulatory and hospital services, or be-
tween general medical and mental health services
and that are so highly specialized that patients are
required to transfer among multiple providers,
illustrate arrangements where communication
across ‘‘borders’’ is vital for optimal patient care.
The Nordic countries, in particular, have been
highly conscious of gaps in the coordination and
continuity of care, and have developed reforms to
bridge them. Finland has adopted a model that
integrates the basic education of both health-care
and social care personnel, a strategy intended to
link the biomedical and social aspects of health
and health-care at the very beginning of profes-
sional education.Perhaps the most common basis for compar-
ing countries’ health-care systems is various out-
come statistics such as economic characteristics, per-
sonnel resources, utilization rates, and population health
status measures. The proportion of the population
covered by government-assured health insurance
stands as the indicator with the least international
variation. Of the twenty-nine countries analyzed
by the Organization for Economic Cooperation
and Development in 1998, governments in twenty-
four countries assured coverage to 99 percent to
100 percent of their population. The five excep-
tions were Germany with 92 percent coverage,
Mexico and the Netherlands with 72 percent, Tur-
key with 66 percent, and the U.S. with 33 percent
(Anderson and Poullier 1999). Other indicators in
the same report vary widely. In per capita health-
care spending, the United States spends just less
than $4,000, an amount that is substantially more
than for the other nations, which range from
Switzerland’s $2547 to Turkey’s $260. Contrary to
what one might think, the amount a country spends
on health-care is not reflected in the longevity of
its population. Men in twenty-one countries live
longer than do men in the United States (up to an
average of 77 years in Japan compared to 72.7 in
the United States). Similarly, women in nineteen
countries live longer than American women (up to
an average of 83.6 years in Japan versus 79.4 in the
United States). In fact, relatively few of the high-
spending countries appear among those with the
greatest longevity.Detailed comparisons of statistical character-
istics have limited value when neither issues of
measurement nor the contextual meanings associ-
ated with each measure are immediately clear.
Each country has its own distinctive set of sociohistorical
and cultural characteristics; these should be consid-
ered in comparative research, since they often play
an important role in explaining the origin and