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1 Europäische Gesundheitssysteme im Vergleich Perspective européenne comparée des systèmes de santé et des assurances sociales Reinhard Busse, Prof. Dr. med. MPH FFPH Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management), Charité Universitätsmedizin Berlin & European Observatory on Health Systems and Policies

2 1. Actors and organisation: are Bismarck s and Beveridge s grandchildren look-alikes? 2. Financing 3. Ensuring access and quality 4. Services, costs and reimbursement 5. Contribution to health and wealth Prof. Dr. Reinhard Busse Berlin,

3 Third-party Payer Providers Prof. Dr. Reinhard Busse Berlin,

4 Collector of resources Third-party payer Providers Prof. Dr. Reinhard Busse Berlin,

5 Resource pooling & allocation Collector of resources Mobilizing resources/ funding Coverage: Who? What? How much? Steward/ regulator Regulation Third-party payer Financing providers: reimbursement/ purchasing/ contracting Access to Providers and provision of services Functions Prof. Dr. Reinhard Busse Berlin,

6 Resource pooling & allocation Collector of resources Mobilizing resources/ funding Coverage: Who? What? How much? Steward/ regulator Regulation System typology Prof. Dr. Reinhard Busse Berlin, Third-party payer Financing providers: reimbursement/ purchasing/ contracting Access to Providers and provision of services - 6 -

7 Mobilizing resources/ funding Third-party payer Social insurance contributions & sickness funds = social health insurance (SHI) BISMARCK Taxes & health authorities = national health service (NHS) BEVERIDGE System typology Prof. Dr. Reinhard Busse Berlin,

8 Classical integrated NHS-type systems General taxation Central government Limited choice NHS = payer & provider Public providers Prof. Dr. Reinhard Busse Berlin,

9 General taxation NHS Central government Purchaser provider split Limited choice Public providers Prof. Dr. Reinhard Busse Berlin,

10 General taxation NHS Central government Purchaser provider split Limited choice Public autonomous providers Prof. Dr. Reinhard Busse Berlin,

11 General taxation NHS Central government Purchaser provider split Limited more choice (money follows patient) Public autonomous providers Prof. Dr. Reinhard Busse Berlin,

12 Central Regional governments General taxation NHS Purchaser provider split Limited more choice Public autonomous providers Prof. Dr. Reinhard Busse Berlin,

13 General taxation NHS Regional governments Purchaser provider split Limited more choice Public autonomous and private providers Prof. Dr. Reinhard Busse Berlin,

14 Social Health Insurance (SHI) systems SHI contributions Sickness funds Purchaser provider split Choice Public autonomous and private providers Prof. Dr. Reinhard Busse Berlin,

15 Social Health Insurance (SHI) systems SHI contributions Sickness funds Observation 1: Basic configuration of actors Purchaser provider split is now similar across EU member states. Choice Public autonomous and private providers Prof. Dr. Reinhard Busse Berlin,

16 Third-party Payer prepaid Taxes Social Health Insurance contributions Voluntary insurance Out-of-pocket Providers Prof. Dr. Reinhard Busse Berlin,

17 Third-party Payer Taxes Social Health Insurance contributions Voluntary insurance Out-of-pocket 75% public 71% 5% 2% Providers 18% 26% EU new EU members

18 Third-party Payer USA Taxes Social Health Insurance contributions Voluntary insurance Out-of-pocket 75% public 71% 5% 2% Providers 18% 26% 14% 45% 37%

19 Third-party Payer CIS (ex-soviet Union) Taxes Social Health Insurance contributions Voluntary insurance Out-of-pocket 50% 75% public 71% 5% 2% Providers 18% 26% 14% 45% 46% 1% 37%

20 South-East Asia Third-party Payer Taxes Social Health Insurance contributions Voluntary insurance Out-of-pocket 50% 53% 75% 45% public 71% 5% 2% 1% Providers 18% 26% 14% 40% 46% 1% 37%

21 Third-party Payer Taxes Social Health Insurance contributions America (without USA) Voluntary insurance Out-of-pocket 75% 50% public 71% 9% 5% 2% 1% Providers 53% 45% 56% 18% 26% 35% 14% 40% 46% 1% 37%

22 16 Total health expenditure as % of gross domestic product (GDP), WHO estimates EU new EU East. Mediteranean USA America West. Pacific South-East Asia Africa CIS Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

23 16 Total health expenditure as % of gross domestic product (GDP), WHO estimates Observation 2: East. Mediteranean USA There is a distinct European way America West. Pacific EU new EU South-East Asia Africa CIS of financing health care. Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

24 Needs-based access? health status (need) Human resources Technologies Financial resources Patients: demand, access Structures and organisation Fair and sustainable funding? Personnel well qualified? Institutions of high standards? Technologies effective? Environment Nutrition/ agriculture Other sectors Process Health care outcome: satisfaction, complications etc. Health care system Patients receiving appropriate services? High-quality results? Health gain/ Outcome How much? Is it worth it?

25 Universal coverage; cost-sharing limits health status (need) Human resources Technologies Financial resources Professional (re-)certification Provider (re-)accredition Health Technology Assessment Concentration of services Patients: demand, access Structures and organisation Environment Nutrition/ agriculture Other sectors Process Health care outcome: satisfaction, complications etc. Health care system Do the thing right : Benchmarking/ league tables; registers Health gain/ Outcome Do the right thing : ex ante Guidelines/ disease management programmes/ reminders; ex post Review

26 Universal coverage; cost-sharing limits health status (need) Human resources Technologies Financial resources Professional (re-)certification Provider (re-)accredition Health Technology Assessment Concentration of services Environment Observation 3: Nutrition/ agriculture EU health care systems Other sectors face the same challenges Patients: are choosing demand, Health care access outcome: very similar Processanswers. satisfaction, complications etc. Structures and organisation Health care system Do the thing right : Benchmarking/ league tables; registers Health gain/ Outcome Do the right thing : ex ante Guidelines/ disease management programmes/ reminders; ex post Review

27 Costs and reimbursement of European hospitals: hip replacement Reimbursement (Euros) Denmark England France Germany Hungary Italy Netherlands Poland Spain Total cost (Euros) HealthBASKET project final report (presentation: Berlin, )

28 Costs and reimbursement of European hospitals: stroke 8000 Reimbursement (Euros) Denmark England France Germany Hungary Italy Netherlands Poland Spain Total cost (Euros) HealthBASKET project final report (presentation: Berlin, )

29 8000 Costs and reimbursement of European hospitals: stroke Reimbursement (Euros) Observation 4: Actual treatment and costs differ in the EU - but mainly within, 4000 not systematically between countries. Denmark England 3000 Why do countries pretend France Germany Hungary 2000 they need their ownitaly Netherlands 1000 Poland specific reimbursement systems? Spain Total cost (Euros) HealthBASKET project final report (presentation: Berlin, )

30 Life expectancy at birth, in years Life expectancy is visibly rising Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

31 Today we know that health care does improve health England & Wales USA France Japan Italy Sweden Netherlands Spain Time analysed Age groups included 5-64 y y y. Share medically amenable/ avoidable mortality of total mortality (cross-sectional analysis) % 15.8% 15.3% 33.3% 19.7% 15.8% % 1975/ % 6.3% 7.4% 19.6% 11.3% 7.1% 15.5% % % Change in mortality per year (longitudinal analysis) Medically amenable mortality -3.2% -3.6% -4.5% -5.6% -3.8% -4.2% -4.5% -6.5% Other mortality -0.2% -0.4% -1.0% -2.5% -0.8% -0.1% -1.1% -1.2% Total mortality -0.6% -0.9% -1.4% -3.4% -1.3% -0.6% -1.6% -1.8% Share of medically amenable mortality of change in total mortality 71% 59% 38% 46% 45% 78% 43% 41% Busse 2006

32 Rethinking investment in health: A virtuous cycle? Suhrcke M, McKee M, Sauto Arce R, Tsolva S, Mortensen J. The Contribution of Health to the Economy in the European Union. Brussels: European Commission, Prof. Dr. Reinhard Busse Berlin,

33 The return on investment Increase in GDP per capita Increase in total health income Increase in health expenditure Increase in health income attributable to health care Return on health expenditure France $5,200 $3,302 $676 $996 47% UK $6,000 $4,108 $630 $1, % Italy $5,420 $4,992 $403 $1, % Spain $5,180 $4,498 $506 $1, % Sweden $4,810 $4,732 $395 $1, % Prof. Dr. Reinhard Busse Berlin,

34 Y Y = 1.79X Spending vs. life expectancy Spain UK Italy Sweden France (Germany) X - Total health expenditure as % of gross domestic product (GDP), WHO estimates, Y - Life expectancy at birth, in years, Last available X Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

35 Y Y = 1.79X Spending vs. life expectancy Estonia Slovakia Romania Spain UK Italy Sweden France (Germany) X - Total health expenditure as % of gross domestic product (GDP), WHO estimates, Y - Life expectancy at birth, in years, Last available X Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom Observation 5: If health care increases wealth, then it is in our common EU interest that low-spending countries increase their health expenditure.

36 This presentation and more material can be found on the following website: Deutschsprachige Artikel zu Gesundheitssystemen international: Prof. Dr. Reinhard Busse Berlin,

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