Encyclopedia of Sociology

COMPARATIVE HEALTH-CARE SYSTEMS

development of health-care systems (Payer 1996).
For example, Starr (1982) has posed and explored
the question of why the United States ignored
national health insurance at the same time most
European countries were adopting such programs.
National insurance, he argues, was a form of social
protectionism and was, therefore, most likely to be
enacted by paternalistic regimes such as Germany
and only later by more liberal states such as France
and the United Kingdom. In addition, the United
States’ long history of rejecting national health
insurance reflects its decentralized government,
the relative lack of domestic unrest, and the failure
of major interest groups (labor, business, and
medicine) to provide support. Regarding the same
issue, Steinmo and Watts (1995) contend that the
structure of American political institutions creates
conditions that work against the adoption of na-
tional health insurance.

A final means of comparing health-care sys-
tems is on the basis of specific problems, including
assessments of citizen satisfaction (Donelan et al.
1999). Closely related comparisons focus on the
various strategies for reform that countries have im-
plemented in an attempt to address their prob-
lems (Graig 1993). Much can be learned by study-
ing and comparing which solutions seem to work
best for certain types of problems, as well as ob-
serving patterns of failure across multiple systems.

FRAMEWORKS FOR COMPARING HEALTH-

CARE SYSTEMS

While it is useful to compare health-care systems
on the basis of a series of characteristics, in-depth
understanding of the variation in systems requires
a more analytical approach. Most frameworks pro-
posed by comparative health-system researchers
can be characterized as typologies that, though
they add a conceptual basis for distinguishing
among systems, offer limited analytical complexity
or depth. These typologies typically emphasize
political or economic criteria, and several of the
more complex schemes attempt to integrate the
two. Graig (1993) organized the six countries she
analyzed on a continuum with public systems (e.g.,
the United Kingdom) at one end, private systems
(the United States) at the other, and mixed or
‘‘convergence’’ systems, such as Japan, Germa-
ny, and the Netherlands, in the middle. Roemer

(1991) developed a sixteen-cell typology that com-

bines political and economic elements, describ-

ing systems in relation to government policies

(entrepreneurial/permissive, welfare oriented, uni-

versal/comprehensive, and socialist/centrally

planned) as they intersect with economic condi-

tions (affluent, developing, poor and resource

rich). These and similar approaches offered by

Anderson (1989) and Light (1990) offer descrip-

tive distinctions, but do not emphasize the theo-

retical basis for the particular category schemes.

Mechanic (1996) hypothesizes that health-sys-

tems internationally are converging, based on the

idea that medicine forms a world culture in which

knowledge and health-care ideas are quickly dis-

seminated. He proposes six areas of convergence:

nations’ concerns with controlling cost and im-

proving the efficiency and effectiveness of health-

care, nations’ realization that population health

outcomes are largely a product of circumstances

outside the medical care system, nations’ concern

and attempts to address inequalities in health

outcomes and access to care, nations’ growing

interest in patient satisfaction and consumer choice,

and the increasing attention nations are placing

on the linkage between medical and social factors

in health-care, and the struggle all nations are

having between technology, specialization, and

the need to develop primary care. Field (1980) also

theorizes a progression of health-system develop-

ment with a scheme placing systems along a con-

tinuum according to the extent to which health-

care is seen as a social good. He identifies five

system types in order of their progression toward a

socialized system: anomic, pluralistic, insurance/

social security, national health service, and social-

ized health-care.

Elling (1994) takes issue with the notion of

‘‘automatic convergence’’ and with typologies that

posit unidirectional evolution or change, pointing

out that countries are involved in ongoing, dynam-

ic class struggles in the development of health-

systems. His neo-Marxist framework, influenced

by Wallerstein’s world-systems theory, allows for

countries to move back and forth among five

types: core capitalist (e.g., the United States and

Germany), core capitalist/social welfare (e.g., Cana-

da, Japan, Sweden, United Kingdom), industrial-

ized socialist-oriented (e.g., pre-1990s Soviet and