Comparing health policy: An assessment of the typologies of health systems

Author: Robert H. Blank
Submitted: Wednesday 2nd of November 2011 04:51:06 PM
Submitted by: egf
Language: English
Content type: Learning resource
Educational levels: expert, qc1, qc2, qc3


Despite widespread variation among health care systems, at their base they represent variants or combinations of a limited number of types. As with political systems, the comparative analysis of health policy often uses typologies of health systems to help capture the institutional context of health care and contribute to explaining health policies across different countries. Cross-country comparison generates an abundance of information, and ordering this information through typologies is central to utilizing comparison to build, review and revise explanations about policy emergence, policy making and policy cycles. While typologies can be valuable in simplifying a multifaceted set of cross-cutting dimensions, however, one must be cautious when interpreting them because they represent ideal types of specific macro-institutional characteristics. The real world of health care systems is considerably more complicated. The first part of this session will analyse a range of typologies that have been widely used to classify health care systems. The most used typology is a descriptive categorization of how health care is organized in different countries and reflects its specific origins in applied policy analysis. At one extreme is the potential for a completely free market system with no government involvement, while at the other extreme is a tax-supported government monopoly of provision and funding of all health care services. Though in reality neither of these extremes exists, along this continuum are three core types of health care systems: (1) the private insurance (or consumer sover¬eignty) model; (2) the social insurance (or Bismarck) model; and (3) the national health service (or Beveridge) model. Although Freeman observes that this OECD typology emerged from a search for better solutions to common problems, this situation changed with the wide use of this typology in the comparative analysis of health policy (Freeman, 2000; Scott, 2001). Together with the mounting interest in neo-institutionalism, this typology has been a facilitator for critical analyses of the health system as the insti¬tutional framework in which health policies are embedded and how the institutions of health care (among others) shape health policies (and poli¬tics). An overlapping scheme used to categorize health care systems is based on the dimension of the method and source of financing. At one extreme are systems fully dependent on private sources of funding and at the other are those fully funded by public sources. Based on this criterion, there are four main types of funding: direct tax/general revenues; social or state insurance; private insurance; direct payment by users. Within each type, however, there are many potential variants. For instance the direct tax might be levied by the central government, by sub¬units such as states or provinces, or by a combination of governments. Similarly, the social insurance system might be based on a single national scheme or on multiple insurance schemes more or less rigidly regulated or controlled by the government. Furthermore, there is a wide array of possible combinations both of basic types and their variants that are used often within a single health care system, such as in the US where only the elderly have social insurance. A similar classification of health systems, based on a distinction among institutions related to the governance of consumption, provision and production is offered by Moran (2000) who constructs four different types of health care states (3 of which are relevant here): (1) the command and control; (2) the corporatist; (3) the supply health care state. A final way of categorizing countries is to rank them on a single vari¬able considered appropriate for the comparisons being made. For instance, one measure of state involvement that is often used to compare countries is the extent to which health care is publicly funded. Another is the per cent of GDP devoted to health care. Such rankings can tell us nothing about whether one system is better or worse than another; they simply illus¬trate how the countries array themselves on a single dimension. Another use of these data, however, is to trace changes both for particular countries and collec¬tive patterns and to compare the comparative rankings over time. The second part of this presentation will critically discuss the usefulness of typologies and the importance of institutional embeddedness beyond the health system in a study of ten developed countries (Blank and Burau, 2010). A key issue here is whether the concept of the health system helps us to discover how countries vary (or are similar) in the health policies they adopt and whether we can gain insights into why these differences (or similarities) exist. The analysis will map out these countries using the typology of health systems as a basis, but also define in more detail different aspects of government involvement in the funding and provi¬sion of health care. Looking at the health systems in these countries across the different types and respective dimensions of governing health care, several find¬ings stand out. Only five out of the ten countries in the study well fit one of the three types of health system; the remaining countries are more or less only approximations of the individual ideal types. Most countries reflect mixes of characteristics in finance, provision and governance across the various types and there is variation across time and space within a single country. Consequently, within a country the two sets of institutions associated with the governance of funding may actually fit different types of health systems thus making categorization problematic. The specific configuration of any health care system, then, depends on a multitude of factors including the political system, the cultural framework, the demographic context, the distinctive histori¬cal background, specific events and social structures inherent to that country. Societal goals and priorities develop over time and shape all social institutions and values, which themselves are fluid and changeable. This underscores the fact that the institutional contexts of the governing of health care are more complex than suggested by the definition of the health system. The analysis suggests two things. First, the concept of the health system holds as an approximation of ‘real’ health systems. It is therefore a classical ideal type that is useful as a heuristic device that simplifies the complex real world of governing health care. Thereby, the concept of the health system helps to move the analysis beyond the specificity of individual cases and towards more generalized observations, overcoming a salient tension inherent in comparative enquiry (Goodin and Smitsman, 2000). The health system as an ideal type, therefore, does not need to fit the real types completely in order to be useful. Second, it is important to remember that it is primarily through the comparison and contrast with real types that explanations can be advanced (Arts and Glissen, 2002). The central question, then, is how to explain the extent to which ‘real’ health systems do or do not fit the ideal types. The different degrees of ‘misfits’ among these countries and the types of health systems presented in the analysis raises many such ‘why’ questions. Thus, the concept of the health system is only a starting point for a comparative analysis and must be complemented by additional, more specific, institu¬tional explanations. As the analysis of these few countries will suggest, governing health care is embedded in institutional contexts that are broader than those institutions making up the health system and often highly specific to each country and changeable over time. Therefore, more often than not, health policies follow trajectories that are highly complex and specific. Arts, W. and J. Glissen (2002) ‘Three Worlds of Welfare Capitalism or More? A State-of-the-Art Report’, Journal of European Social Policy 12: 137-48. Blank, R.H. and V. Burau (2010) Comparative Health Policy, 3rd Edition. Basingstoke: Palgrave. Freeman, R. (2000) The Politics of Health in Europe. Manchester: Manchester University Press. Goodin, R.E. and A. Smitsman (2000) ‘Placing Welfare States: The Netherlands as a Crucial Test’, Journal of Comparative Public Policy 2: 39-64. Moran, M. (2000) ‘Understanding the Welfare State: The Case of Health Care’, British Journal of Politics and International Relations 2 (2): 135-60. Scott, C.D. (2001) Public and Private Roles in Health Care: Experiences from Seven Countries. Buckingham: Open University Press.


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abstract Robert_Blank_20110829_5159.pdf

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Robert H. Blank. Comparing health policy: An assessment of the typologies of health systems. EUROGENE portal. November 2011. online:



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