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A health care delivery system is the organized response of a society to the health problems of its inhabitants. Longitudinally, widespread kinship-based arrangements for survival were gradually supplemented and replaced by collective arrangements. This culminated in a demographic transition consisting of the reduction of a population’s fertility. In modern societies it was no longer imperative to have many children as a provision against old-age poverty. In the course of this modernization process, the epidemiological transition took place that reflected a gradual shift from the sheer necessity to overcome infectious diseases (mainly affecting infants) toward dealing with chronic diseases (primarily affecting the late middle aged and elderly). Modern health care delivery systems require extensive financial resources which only advanced economies are able to put aside. Evidently, there is a strong association between health and wealth. In low-income countries hygiene, sanitation, vaccination, nutrition, and immunization are the important objectives for health care. Modern societies, with higher average levels of income, largely have to cope with rising costs due to the increasing demand for chronic care, as a consequence of an aging population.
In typifying a nation’s health system the role of the state in funding is decisive:
- Largely absent: the state propagates non-interventionism, leaving room primarily for private insurance to fill this role.
- In-between: the state harmonizes the arrangements that developed between groups of citizens (e.g., employers, employees).
- Central: the state controls funding, with or without the provision of health care.
The free market model applies when the state conducts a policy of non-interventionism and restricts its interference in health care matters to the bare essentials, leaving all other expenses to private funding and corporate provision (HMOs). This is the typical situation in the USA, except for Medic-aid (indigent) and Medicare (elderly) state interventions. Private insurance fills the gap to some degree, however, leaving about 15 percent of the US population uninsured for health care costs or loss of income due to illness and disability.
In the social insurance system patients pay an insurance premium to a sickness fund which has a contract with first-line (GP) and second-line (hospital and specialist) providers. The role of the state is confined to setting the overall terms of contracts between patients, providers, and insurers. Founded in Germany, the social insurance system still exists in a modified fashion in Germany, the Netherlands, Belgium, France, Austria, Switzerland, Luxembourg, and Japan.
The third model, typically found in the UK, is the tax-based National Health Service (NHS) model. It was first introduced in 1948, is also centralized and is funded by means of taxation, while the state is responsible for the provision of institution-based care (hospitals). The medical profession has a rather independent position. Self-employed GPs are the gatekeepers in primary health care. Currently the NHS model applies to the UK, Ireland, Denmark, Norway, Sweden, Finland, Iceland, and outside Europe to Australia and New Zealand. Four Southern European countries (Spain, Italy, Portugal, and Greece) have also adopted this tax-based model.
The fourth, most centralized health care delivery system model, the Soviet model, dates from 1920. It is characterized by a strong position of the state, guaranteeing full and free access to health care for everyone. This is realized by state ownership of health care facilities, by funding from the state budget (taxes), and by geographical distribution and provision of services throughout the country. Health services are fully hierarchically organized. They are provided by state employees, planned by hierarchical provision, and organized as a hierarchy of hospitals, with outpatient clinics (poly-clinics) as lowest levels of entrance. Among the nations that, at least until recently, had a health care system based on the Soviet model were Russia, Belarus, the Central Asian republics of the former USSR, and some countries in Central and Eastern Europe. Many former Soviet Republics, however, are in a process of transition toward a social insurance-based system. Outside Europe the socialized Cuban health-care system remained largely intact, due to the government’s support and grassroots organizations-based networks of solidarity. Also China used to have the now largely extinct twentieth-century communist health care system but moved to a private one (and its typical failures).
The four models make up a continuum in terms of their ”system” character, with state interven-tionism and centralized health care at one end, and non-interventionism at the other. Centralized systems provide the best mechanisms for cost control, while absence of state intervention does not appear to be fruitful, as soaring costs in the USA evidently show. The four health delivery system models also reflect stages and outcomes of a historical process. Consequently, system models that came into existence in highly developed economies in the first half of the twentieth century can now still provide useful options to choose from in low-income countries or transitional economies like in Eastern European societies.
Contingencies like increasing health care costs, an aging population, changing disease patterns, technological developments, growing public demand, and so forth impose a common logic in terms of institutional performance and the structuring of modern health care. Yet the convergence of modern health care delivery systems is not undisputed. Differences exist in degree and similarity of these developments. National health delivery systems are the outcome of a dialectical tension between universal aspects of technology and medicine on the one hand, and particularistic cultural characteristics of each nation on the other. Health care institutions are still largely country specific. Such country specific elements would include social, economic, institutional, and ideological structures, the dominant belief system, the role of the state versus the market, patterns of health care coverage, and centralization or decentralization of political authority.
- Stevens, F. C. J. and van der Zee, J. (2008) Health system organization models (including targets and goals for health systems). In: Heggenhougen, K. and Quah, S. (eds.), International Encyclopedia of Public Health, vol. 3. Academic Press, San Diego, CA, pp. 247—56.
- Stevens, F. C. J. (2009) The convergence and divergence of modern health care systems. In: Cockerham, W. C. (ed.), The New Blackwell Companion to Medical Sociology. Wiley-Blackwell, Oxford.
- Van der Zee J., Boerma, W. G. W., and Kroneman, M. W. (2004) Health care systems: understanding the stages of development. In: Jones, R., Britten, N., Culpepper, L., et al. (eds.), Oxford Textbook of Primary Medical Care, vol. 1. Oxford University Press, Oxford, pp. 51—5.
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