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Noort, B. A., van der Vaart, T...
HEALTH PURCHASING
& SUPPLY CHAIN READINGS
1 – BÖ HM ET AL. (2013)
FIVE TYPES OF OECD HEALTHCARE SYSTEMS- EMPIRICAL RESULTS OF A
DEDUCTIVE CLASSIFICATION
3 Types of Dimensions of the Healthcare System: 3 Types of Actors
Regulation State
Financing Societal
Service provision Private
in that hierarchy! Superior dimension restricts the in that hierarchy! Dominant actor at
nature of the subordinate dimensions higher level restricts potential range of
Five Health care System Types: actors at subordinate level
1. National Health Service (NHS)
2. Social Health Insurance (SHI) OECD classification arrives at these 3 types that are
used regularly by researchers
3. Private Health System (PHI)
4. National Health Insurance (NHI)
5. Etatist Social Health Insurance
HEALTHCARE SYSTEMS CLASSIFICATION
EXISTING TYPOLOGIES
NHS Model SHI Model PHI model
universal coverage combines univeral private insurance only
funding from general taxt coverage with funding (also major funding
revenue coming mainly from source)
public ownership of the contributions & public/
health infrastructure private delivery
When classifications are made, need to looks at delivery of services and their financing as core di-
mensions especially with respect to the extent to which the state intervenes in healthcare and with re-
spect to the public/ private mix
Regulation includes professional autonomy, eligibility, coverage/ access, administration of financing
THE ROTHGANG-WENDT TYPOLOGY
attempts a deductive construction of healthcare system types more precise classification of
healthcare systems
Health care system is defined by 3 functions processes
1. Service provision
Trichotomous concept: public, societal & private providers
2. Financing
a. general & earmarked tax revenues reflect state financing does not result I dir-
ect entitlements of health services
b. private insurance and out-of-pocket payments occur in the private sector
1
, 3. Regulation
relationship between providers of service, beneficiaries & financing institutions which have
to be regulated (= 3. regulation dimension)
Basically: healthcare systems are about delivery of health services for which someone has to raise
the money
Question for classifying the regulation dimensions arises: “Who is in charge of regulating & controlling
these relationships?”
HIERARCHY OF HEALTHCARE ACTORS & FUNCTIONS
PLAUSIBLE HEALTHCARE SYSTEM TYPES (+ HIGHLIGHTING ONES FOUND)
NHS: dominant role of state in all 3 dimensions
NHI: services are contracted out to for-
profit providers
Etatist Social Health Insurance: state
holds the regulatory power but grants
privileges for the financing & provision of
health services to societal actors (e.g.
sickness funds with their own health fa-
cilities).
SHI: societal actors have competences
to regulate & finance the health system
but where most service providers per-
form for profit
PHI: financing must rely either on private
insurance or out-of-pocket payments &
health services are likely performed by
for-profit providers
RESULTS
2
,DISCUSSION
NATIONAL HEALTH SERVICE (NHS)
e.g. Nordic countries, UK, Spain, Portugal
State has the responsibility to govern the relation between the main actors in health-care
Private actor decisions only play a role with respect to access of patients to services since in most
systems there is some leeway for choice of providers
Public provision through state-owned hospitals & salaried physicians in public facilities is the prevail-
ing modality
CHARACTERISTICS
NHS reflects social democratic values of universal coverage,
Necessary require-
equal access to services and beliefs in the efficiency of public services
ments for NHS
Low number of veto points in the political institutional system
NATIONAL HEALTH INSURANCE TYPE (NHI)
e.g. Anglo-Saxon countries (Australia, Canada, Ireland, NZ) + Italy
= NHS regulatory structures & tax financing + private service provision
( private provision main differentiator from NHS)
3
, If public agencies contract private providers, universal free care can be guaranteed without forcing
doctors into public service
CHARACTERISTICS
Points to achieve NHS system have not been achieved by the countries implementing NHI
NHI systems express political preferences for more private involvement under state
control, particularly in the provision of health services
SOCIAL HEALTH INSURANCE (SHI)
E.g. DACH + Luxemburg
Dominant role of societal actors in healthcare regulation & financing
Mainly provided by private for-profit providers
CHARACTERISTICS
More veto-ridden SHI countries picked the path of incremental inclusion in order to cover
their entire population during the period of welfare state expansion
Strong federalism proved to be a stronghold for corporatist actors against direct state in-
volvement. When the tide turned towards retrenchment, policymakers lost confidence in the
ability of societal actors to contain costs and organize service provision efficiently.
PRIVATE HEALTH SYSTEMS (PHI)
e.g. USA
Core features: coordination by market actors, private financing sources & for-profit providers
System deficiency: provide affordable access to healthcare for the elderly, chronically ill & poor
State need to amend privately covered core provision with several public programmes in order
to include significant parts of the population in the health system
CHARACTERISTICS
Veto-ridden political system
State-sceptic public opinion
Weak labour movement
Powerful opposition by physicians and the private insurance industry
ETATIST SOCIAL HEALTH INSURANCE (ETATIST SHI)
11 countries use this system most common!
only completely mixed healthcare type
CHARACTERISTICS
Clear hierarchy of 3 dimensions:
1. State is responsible for regulating the system
2. Financing is organized by societal actors
3. Provision has been delegated to private hands
LIMITATIONS
1. Assumed hierarchy of dimensions & actors is a simple functional model that on its own cannot
explain the existence of a particular healthcare system type in a given country
needs to be supplemented by institutional theories
2. Less differentiated conceptualizing of regulation only allows for the archetypical combinations
of modes of interaction & corresponding actors
3. Concentration of ownership in the service provision dimension fails to account for formal/ func-
tional privatization
4
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