Contenu du sommaire : Reforms and regulation of health care systems in Europe

Spending on health in OECD countries continues to rise and now accounts for around 9% of GDP, on average. The high cost of health systems and the strain on the public purse mean that financial sustainability is high on the policy-makers' agenda. Paramount among the key factors pushing up health expenditure over recent years have been the advances in medical technology, population ageing and increasing public expectations vis-à-vis their health systems. Drawing on data for the 30 OECD member countries, the authors examine the main trends in health spending over recent decades and present variations across countries. First they examine the growth in health spending in relation to the economy as a whole, before reviewing the various funding mechanisms in place across the OECD. They then go on to look at differences in how the money is spent, regarding various types of goods and services, with a particular focus on the situation in France.

This article reviews the main modes of regulating health systems in Europe and industrialised countries. Regulation aims to reconcile four contradictory objectives: securing the best possible quality at reasonable expense, whilst ensuring fair distribution and encouraging innovation. Equity is frequently taken to be beyond consideration; only countries with a decreasing allocation of resources consider it a full-blown problem. But regulation is mainly concerned with reconciling quality and overall cost. Two approaches may be distinguished: the first treats health providers as factors of production managed by the regulator, whereas the second, on the contrary, treats providers as suppliers operating in a market and encourages them to behave in an optimal manner, providing effective care without spending too much. The market may either be stimulated by a central planner or genuinely established by letting buyers – i.e. patients – select the producers offering the best quality at the best price (patients not always being the best placed to do so, however). Regulation via the market requires the introduction of intermediary players between final consumers and producers. Finally, the article lists (contradictory) arguments justifying the different types of intervention by the regulator in terms of innovation.

This paper provides an overview of the health baskets and benefit catalogues in nine EU member states (Denmark, France, Germany, Hungary, Italy, the Netherlands, Poland, Spain and England. Health baskets can be considered as more or less comprehensive in all studied countries. However, the degree of explicitness of benefit catalogues varies among countries and within the same country among health care sectors. A number of different catalogues and substitutes are in place, such as remuneration schemes, guidelines and contracts. At present, an EU-wide harmonisation of benefit baskets does not seem realistic in the short or the medium term. However, the need for a minimum European common-core health basket should be openly debated, and an in-depth classification of existing differences between countries is urgently required.

Regulating the demand for out-of-hours (OOH) services is, in most European countries, the subject of some consideration and even sizeable reforms, aiming to address new developments in medical practice and reduce inefficiencies in the current delivery of OOH services. The purpose of this contribution is to enquire into the possible convergence of alternative models of demand regulation in some of the countries listed: Germany, Spain, France, Italy, the United Kingdom and Sweden. The article outlines, on the one hand, the characteristics and limitations of the traditional models of organising OOH services delivery and, on the other, the new forms of demand regulation for OOH services. A common model seems to be emerging in the form of a single call centre; the emergence of this model is supported not only by new information and communication technologies but also by the ability of health systems to define new professional roles, empower health care demand and subject its operation to regular economic assessment.

In all countries in Europe, the underlying concern in the reform of primary care is the achievement of a better match between supply and demand with a view to rationalising, if not improving, access. The proportion of doctors in the community, their geographical distribution and the productivity of general practitioners, whose role as gatekeepers is being developed, constitute key criteria in determining supply regulation policies. This article provides an overview of the current organisation of health care provision by general practitioners in several European countries, i.e. Germany, Spain, France, Italy, the United Kingdom and Sweden. Three main aspects of the system giving access to primary care are considered: the geographical distribution of doctors, the rules governing access to health care and those governing payment of general practitioners.

The health care systems that have been developed in the EU share common values and principles which constitute the “European social model”. They are structured upon the logic of Bismarckian or Beveridgean solidarity and cover the entire population. For two decades, they have been confronted with a strong growth in health care expenditure, given the evolution of medical practices, which are more and more costly, the growth in demand for care and demographic ageing. By adopting measures to control expenditure, European countries have increased patients' participation in costs, consequently increasing the need for complementary health insurance to cover the “remaining costs” or to access private care. Notwithstanding, private health care insurance only fulfils a secondary function. The scope of compulsory protection and the manner in which it is organised fundamentally determines the demand for and forms of private protection. Generally, this develops where there are gaps in social coverage. Commercial and non-commercial players have traditionally operated in different segments of the market. However, the widening of the field and the European integration process have modified their strategies. Tension has surfaced and conflicts have developed, creating a need for regulation. It appears that only the European Union is in a position to undertake this task at a time when many member states are devising scenarios for threetier protection within a context of fragmentation of social protection.

Implementation is often neglected in comparative analyses of the regulation of health care systems and expenditure. Taking this aspect into account reintroduces the national diversity of the reform paths, whereas approaches focused on the institutional models and financial data blur the differences and highlight international transfers of ideas and common economic constraints. This article compares the implementation of reforms aiming to regulate healthcare expenditure in countries with Bismarckian systems (France, Germany, the Netherlands), revealing unequal capacities to implement change, depending on the players and, in particular, the relationship between the state and health care insurance providers. The study distinguishes structural reforms, aimed at modifying the original architecture of the system to benefit new players, and management reforms, which try to depart from the previous opaque management style and promote a medico-economic approach combining managerial rigor with medical quality. Finally, it identifies three levels in the carrying out of reforms, each requiring specific conditions for their implementation: political arbitration between the financial and social spheres, the withdrawal of the state in favour of a regionalisation or privatisation of the systems' management and, finally, the introduction of new models of medico-economic management.

In Germany, health care is provided via the (publicly regulated) interplay of a multitude of non-profit sickness funds and a pluralistic set of providers with which these funds maintain contractual relations. With its Bismarckian tradition, the system relies on pay-as-you-go contributions shared by employers and employees – an institutional design that has recently been challenged, however. Moreover, a particular, and novel, characteristic of the German health care system is competitive governance in its administrative setting (s). This article explores both the evolution of the funding regime and developments in the governance structures of the system. It argues that there have been incremental changes in the former and more radical shifts in the latter. The current debate on health care reform tends to confirm this configuration; in spite of far-reaching proposals to modify medical financing, the old funding regime basically tends to persist while the governance structures show an in-built tendency towards ever more inter-agency competition. The result is a contradictory evolution revealing both institutional stability and path-breaking liberalisation – with an underlying differentiation of medical service provision and further social inequality as a likely outcome.

Reform of the Dutch health system, which began in 2006, is based on the introduction of competitive mechanisms within the general curative care compartment. On 1 January 2006, the distinction between public health funds and private insurance funds ended and health insurance became privatised. The Dutch freely chose their health insurer and pay a premium that is no longer income-based, but varies according to the insurers and the policy chosen. The public authorities, who are aware of the problems posed by a mechanism that could allow health insurers to practise risk selection, have implemented various measures intended to balance relationships between the different players: a risk equalisation system, a standard health basket, mandatory insurance for all and prohibition of the differentiation of premiums in relation to risk.Several issues remain, nonetheless: the effectiveness of tax measures taken to compensate the non-redistributive effects of a flat-rate premium that penalises even more on the poorest, the quality of information for the insured in order to allow them to make a clear choice and the effectiveness of turning insurers into health care operators capable of negotiating with professionals not only regarding rates, but also regarding quality.

The Swiss health insurance system is a halfway-house between a social insurance and a private health insurance system. Insurance is compulsory and managed by a range of non-profit private health insurance companies (sickness funds) which officially compete with each other and cover an identical benefit package. Insurance premiums do not depend on income and vary according to the canton in which the insured person lives and the average risk of the client base for the insurer (community rating). The model provides the citizen with total freedom in choosing the service provider and health insurer in the canton within which they live. Insurers may offer products with limited freedom of choice in return for a reduction in the insurance premium. An appraisal of the regulatory role of this complex insurance model, which represents a compromise between market mechanisms and state regulation, and which is subject to a regressive financing, has shown that the objective of equity in access to health care has been broadly achieved whereas that of bringing cost increases under control has not. Major reforms of the system are being discussed in Parliament, but their successful outcome may well be called into question by the differences in the objectives of the main stakeholders and by the federalism and direct democracy that characterise the Swiss constitutional landscape.

This paper describes the financial regulation of health care in England. It starts with a historical overview, and then summarises the current institutional structure. The main instruments of regulation in the system are then outlined, and the elements of the finance system described. The paper ends with some views on current reforms, suggesting that England offers a fertile source of ideas for other countries interested in options for restructuring their health care systems. However, the English health system is going through a very turbulent period of redesign with many of the arrangements in the process of being changed. As this makes evaluation of the impact of reform problematic, many of the authors' conclusions are necessarily very tentative.

The article attempts to shed light on recent developments in the Italian national health service, particularly the changes introduced by the reforms of the late 1990s. By strengthening the role of regional governments, these measures deeply affected the previous centre-regional balance of power. The article contrasts the co-operative approach adopted by the centre-left governments that originally introduced the relevant legislation with the confrontational style typical of the following centre-right majority. Given that health funding played a crucial role in the controversy between the national government and the regions, the article discusses the rationale of legislation on fiscal federalism and its implementation, but also the quantity and quality of health care services provided in the different parts of the country. As the article illustrates, northern and central regions continue to have a higher level of services compared to the south, thereby attracting a considerable number of hospital patients from ill-equipped southern areas. The last part of the article addresses this topical issue and the possibility that inter-regional conflicts might surface and complicate the situation further, especially in the light of the constitutional reform approved by the centre-right majority just before the end of the legislative process.

The authors review 60 years of health care reform in Portugal. The major reforms emerged after the 1974 revolution. The initial period, up to the 1ate 1980s, was a period of development of a very centralised national health service. From the 1990s on wards, concerns with decentralisation were reflected in a number of initiatives: the emergence of regional health authorities; internal health markets and contracting agencies; the purchaser-provider split; entrepreneurial management experiences; local services; vertical (local) integration; and regionalised networks of facilities. These efforts have ensured that health policy, including fiscal matters, remains centrally controlled, while service delivery has increasingly undergone decentralisation, mostly of two types: devolution and deconcentration. Privatisation has also experimented with but has led to recentralisation. Therefore, in Portugal, the search for a decentralised model has involved an ongoing re-balancing of national and sub-national decisionmaking roles. It is not expected that Portugal will see a major decentralisation drive in the near future.

In Western nations health reform has become a ceaseless quest in which myriad ameliorative strategies compete for policy prominence. Although health policy researchers and analysts mainly focus on measures to improve the workings of the health care system (for example, evidence based medicine and information technology) or to transform it (for instance, priority setting and managed competition), in practice, the reforms at center stage are those that sustain the system by pumping additional resources into it. The quaint discipline of public finance deserves fresh attention in debates about health reform.