COMPARATIVE HEALTH-CARE SYSTEMSindependent insurance plans. The plans fall into
three major groups, each enrolling about a third
of the population: large-firm employees, small-
firm employees, and self-employed persons and
pensioners. In the case of the first two plans, as is
the case with the German sickness funds, the
employer pays approximately half of the premium
and the employee pays the remaining portion. The
similarity to the German system is no accident;
Japan has consciously patterned its health-care
syatem after Germany’s, dating back to its mod-
ernization in the late nineteenth and early twenti-
eth centuries (Lassey, Lassey, and Jinks 1997).
Despite these similarities, Japan’s health-care sys-
tem presents some unique and somewhat startling
features compared to the other systems dis-
cussed here.
Compared to other systems with a significant
private component, the Japanese system costs con-
siderably less (Andersen and Poullier 1999). In
1997, for example, per capita health-care spending
in Japan was $1741, less than in the United States,
Canada, France, Germany, and many other Euro-
pean countries. Of the nations discussed here,
only the austere British system ($1347 per capita)
and efficiency-conscious Finnish system ($1492
per capita) spent less. Japan’s economical approach
to delivering health-care raises two paradoxes.
First, the low levels of spending would seem to
contradict the fact that Japan currently has the
longest life expectancy and the lowest infant mor-
tality in the world. In addition, utilization rates in
Japan are high, which some would argue indicates
a sicker rather than a healthier population. Specifi-
cally, the Japanese visit physicians two to three
times more frequently, stay in the hospital three to
four times longer, and devote considerably more
health spending to pharmaceuticals than the other
nations discussed here. How can these contradic-
tions be explained? Ikegami and Campbell (1999)
argue that, in part, the paradox can be explained
by the country’s much lower incidence of social
problems related to health, such as crime, drug
use, high-speed motor vehicle accidents, teen-age
births, and HIV infections. Less aggressive medi-
cine and lower hospital staffing and amenities also
are thought to keep down costs in Japan.
Health-care arrangements in nations where
the political economy is neither ‘‘advanced’’ nor a
stronghold of capitalistic democracy can also be
instructive. During the latter part of the twentieth
century and until today, both China and Russia
have been faced with the monumental challenge
of providing health-care with very limited financial
resources to huge, diverse populations, many of
which live under poor social conditions. Their
health-care systems, however, are quite different
and their current problems reflect the distinctive
political and economic trajectories of the two coun-
tries. Russian health-care at the dawn of the twen-
ty-first century is a system in crisis. Based on
socialist principles of universal and free access, the
old Soviet system included a primary care network
of local clinics (‘‘polyclinics’’) typically connected
to a general hospital, as well as more specialized
hospitals. This means that a regional city might
have separate hospitals for emergencies, materni-
ty, children, and various infectious diseases (Albrecht
and Salmon 1992). Funding came directly from
the central government until 1993 when a new
health insurance law was approved, shifting the
source of financing to employer payroll deduc-
tions. There are major questions, however, as to
whether such a system can be effective during the
current period of resource scarcity and instability
in major social institutions (Lassey, Lassey, and
Jinks 1997).Chinese health-care, for most Westerners,
evokes images of acupuncture and other forms of
Eastern medicine, as well as the idealized ‘‘bare-
foot doctors’’ of the 1960s and 1970s, practition-
ers with basic medical training who provided pri-
mary care in rural areas. In reality, traditional
Chinese medicine exists alongside an increasingly
dominant Western medical establishment, and the
barefoot doctors have all but disappeared. Since
new leadership took over the Communist Party in
the late 1970s, China has encouraged privatization
and decentralization in health-care. By the 1990s,
nearly half of all village health-care was provided
by private practitioners (Lassey, Lassey, and Jinks
1997). These changes reportedly have been ac-
companied by a decline in preventive care and
public health efforts in rural areas. At the same
time, the situation in urban areas seems to have
improved. China’s revolutionary-era network of
local and regional clinics and hospitals has been
modernized, although resource shortages contin-
ue to limit the level of technological advancement.
The most significant change in China is the grow-
ing impact of privatization, which appears to be
bringing China many of the same problems that