There was a time when comparing health policies meant swapping stories about operations, or trading anecdotes about long waits in casualty departments. That all changed over breakfast on 16th January 2000, when Tony Blair made his now-famous pledge to David Frost to raise levels of health spending in this country to the EU average by 2006. Suddenly, a fact long known to policy experts and academics became the stuff of everyday conversation: Britain was trailing badly in the international league table of spending on health as a proportion of GDP. For weeks after the prime minister made his promise, you couldn't open a newspaper (even a Eurosceptic tabloid one) without seeing a bar chart about this country's relatively miserly spending on healthcare in comparison to other nations. The continent was no longer simply the place we looked to for inspiration in fashion or cuisine: it was now a source of national humiliation because of its apparently superb health systems.
Of course there was much exaggeration and brandishing of dubious statistics. Tony Blair was no doubt right that "a lot of nonsense" is talked about the French and German way of doing things. But, so far, nobody has done much to rectify the gap in public knowledge.
It is true that in the past two years, politicians from all the main parties have made at least cursory investigations into the models used elsewhere in the world and have been quizzing Swedish doctors, Dutch nurses and German health administrators on the secrets of their success. The risk is that this will turn out to be the faddish response of the political class to a perceived public anxiety, rather than the genuinely methodical inquiry that is needed to understand which best practices can be imported from overseas and which cannot.
As a contribution to that process-a crucial part of the modernisation of the 21st-century British state-this investigation is intended to be the most comprehensive journalistic survey of health systems to date for the general reader. It is an interim report, and will be fed into the health commission which the Social Market Foundation is undertaking this year.
There are many who believe that all such international comparisons are pointless. Policies, they say, cannot be cut out of specific historical, social and cultural contexts and pasted onto an entirely different domestic situation. The doubters argue that number-crunching and organisational analysis mask the meaning of systems. On this basis, it is folly to compare, say, this country's tax-funded system with the social insurance system which has proved so effective in Germany, because the two are the product of radically different cultural and historical contexts. It is certainly true that apparently similar things have different meanings in different settings: in Britain, a hospital is the local branch of a nationalised, centralised system funded by the Treasury and managed by a cabinet minister. In Germany, a hospital is a free-standing local institution, often affiliated to a church or a charity. It is run by doctors, not politicians, and settles its funding in annual negotiation with insurance companies. The extent of care offered by families differs radically from one nation to the next, as does the diet and lifestyle of citizens, even within Europe. Moreover, what people understand by the word health varies-in the US, for instance, it is now almost interchangeable with the notion of spiritual wellbeing.
It has long been a source of amazement to researchers that our health spending per head as a nation is less than half that of the US and a third less than the Germans, and yet the satisfaction levels reported by British patients do not reflect that gap. In fact our European neighbours often report greater dissatisfaction, whilst simultaneously enjoying higher spending per head, better survival rates and longer life expectancy. There's no pleasing some people, you might think. Or you might conclude that success breeds impatience with poor performance: where excellence is the norm, the occasional slip-up in service can create disproportionate anger in consumers. Conversely, a system which is under pressure-like the NHS-can breed deep loyalties and powerful feelings of gratitude when it does work against the odds.
For what it's worth, I subscribe to the theory that the NHS answered a need in the British people for a focus for their national pride when the sun finally set on the empire. It is an institutional expression of British solidarity, decency and responsibility which, 54 years after its foundation, still has overwhelming popular support. As a result, Bevan's system, staffed by angels, and free at the point of use, has been supported for decades by a spectrum of politicians so all-embracing that even Margaret Thatcher was compelled to declare it "safe in our hands." Nigel Lawson came close to the truth when he wrote in his memoirs that "the NHS is the closest thing the English have to a religion." Theology cannot be represented in graphs or pie charts. And those who challenge a religion must expect the charge of heretic.
Another problem is that most of the comparative studies which have been rushed out so far have failed to compare like with like. You can look at inputs, such as the amount of money spent or the aim of a policy; or at institutional questions, such as the organisation and delivery of health care; or at outcomes, such as life expectancy or satisfaction levels. But these are all very different factors. So what should we seek to compare? According to Julian Le Grand, one of the leading experts in this field, there are six main criteria to try to monitor: equity of finance, universality of access, efficiency, health outcomes, patient satisfaction, and finally choice and responsiveness.
Amidst all the data it is easy to forget the patients. As Jack McConnell, first minister of Scotland, recently argued, a favourable legislative and fiscal regime can be implemented by government, but improvements in health levels rely just as much on individuals reforming their diet or taking up exercise. In other words, no amount of upheaval in health policy will work without the partnership and understanding of the people it is intended to help.
Whether or not this country radically alters its system of health care, the question is not going to go away. The Sharron Storer incident during the election and the Rose Addis case earlier this year show how health now dominates the political agenda-and the Labour government has, perhaps rashly, asked the electorate to judge it on its performance in improving the NHS. Yet we stand at a difficult phase in the development of popular sentiment where people's expectations of healthcare delivery are rising but their visceral attachment to the NHS seems undimmed. The result is that people are simultaneously demanding change, and recoiling from its consequences-whether "top-up" payments from the better off, social insurance, tax breaks for health insurance, and so on.
There are reasons to believe that international comparison in health policy is now more meaningful than ever before. As real as the differences remain, there are genuine convergences occurring in global society, meaning that values and expectations in Tokyo and London and Stockholm are much closer than they were 30 years ago. You don't have to be in favour of the wholesale import of a system to argue that it is worth looking at, and to conclude that some of its components might be applicable in your own country. If Japanese teenagers wear American clothes and listen to British rock, why shouldn't we study the health policies their parents pay for?
It is also possible to exaggerate the uniqueness of the NHS. Many people believe that our system is the most egalitarian in the western world because it is funded out of general taxation and free at the point of delivery. If it was funded purely out of income tax it would be more redistributive than a social insurance system-where, say, the employer and employee both pay a small proportion of an employee's annual salary into an insurance fund. But income tax now constitutes only a little over one quarter of tax revenues-and much of the rest, especially VAT and customs and excise, is actually regressive. Nor, strictly speaking, has British health care been free at the point of delivery since 1951, when Bevan resigned over Hugh Gaitskell's charges for dentures, spectacles and prescriptions.
The most obvious lesson of these tables is that no system is perfect. If the NHS is going to reduce its waiting lists the British are going to have to pay more tax or will have to supplement a tax-funded NHS with various extra payments (for doctor visits, for example, as in Sweden). On the other hand, if they embrace a social insurance system of the German variety, they may end up paying even more as well as imposing job-killing burdens on business.
There is something in this "at a glance" guide for both NHS reformers and traditionalists. Reformers will stress the much higher levels of private/public mix in both the provision and funding of care, even in societies which are considered rather egalitarian, such as the Netherlands. Traditionalists will point to the NHS's relative underfunding and the fact that most countries spend more per head on health than Britain, (although reformers, in turn, will respond that this is because funding is held down because it is tied to general taxation). The point is that we should undertake this investigation armed with the facts.
UNTIED KINGDOM
Amount spent on health per person: US$1,418
Total health expenditure as a % of GDP: 6.7
Public expenditure on health as % of GDP: 5.6
Private expenditure on health as % of GDP: 1.1
Public: Private ratio: 84:16
Hospital beds per 1,000 population: 4.2
Practising physicians per 1,000 population: 1.7
Practising nurses per 1,000 population: 5
Life expectancy at birth in years: 75.13(M) 79.99(F)
Infant mortality (per 1,000 live births): 5.78
History
Until mid-way through the 20th century, health care was provided by the voluntary and private sectors. During the second world war, hospitals were in effect nationalised. The 1948 NHS Act made this permanent and extended the principle to primary care providers, including GPs, to create a system delivering universal care free at the point of need. Consultants remained independent and continued to see private patients within NHS hospitals.
Anxieties about inefficiency and lagging performance grew in the 1970s and 1980s and major reorganisations were attempted by the Thatcher and Major governments. The private sector was introduced for cleaning and catering in hospitals, and private health care was encouraged with tax breaks for the old. In 1991, purchaser/provider splits were introduced which made hospitals independent of district health authorities but gave the latter more freedom to choose from which hospitals it would buy services (such as operations). Some GPs were also given fundholder status to buy services for their patients. After 1997, Labour left most of these market-type reforms in place (especially the purchaser/provider split in England) but changed the rhetoric from competition to collaboration. Labour also combined the fundholders and health authorities into a new purchasing body-a primary care trust.
Funding
Britain's healthcare spending has risen steadily in the past few decades but it has risen more slowly than most comparable countries-and it has poorer outcomes in premature deaths and low survival rates for cancer and heart disease to show for it. This is mainly because it is funded by general taxation; countries like Denmark which pay for health from general tax have similarly lagged in spending. The total spent on the NHS is now about ?60 billion a year. After small annual increases in the late 1990s, when Labour was pledged to stick to Tory spending plans, the NHS is now in the middle of a four year period of annual real increases in spending of between 6 and 8 per cent. This money is supposedly linked to efficiency reforms, and the private sector is heavily involved in hospital building.
The health department is allocated an annual sum for the NHS by the Treasury. A small amount is from charges, in particular for prescriptions, but only 20 per cent of the population pay the full fee of ?6.10 per prescription. GPs are funded on a capitation basis plus incentive payments. Hospital patients incur no charges, although some hospitals charge for things like private rooms. Medical care for the elderly is free but social care is subject to means- testing and delivered by local authorities.
Organisation
Hospitals are administered by NHS Trusts. GPs remain the gatekeeper to most health care and retain the power to make referrals to specialists. However, new services using telephone and internet channels have recently been developed in response to demands for more flexible sources of advice. Like many other countries, Britain reflected the "end of the hospital" thinking of the 1980s and 1990s and reduced hospital bed capacity to reflect the big increase in day care surgery. The other big capacity constraint is doctors-Britain does not train enough of them.
Strengths
Relatively egalitarian, universal access.
Low administrative costs. Around 5 per cent of total health spending goes on administration compared to roughly 20 per cent in the US.
Publicly available performance comparisons.
Weaknesses
Under-investment in buildings, equipment and doctors has left the system struggling to attain the levels demanded by an increasingly affluent population.
Lack of choice for patients and lack of competition means there is insufficient incentive for NHS providers to respond to consumer demand or improve the experience of patients. Perversely, when the system fails, most notably manifested in long waiting lists, it becomes better placed to attract more government funding.
With insatiable demand for health care-driven by demography, new technology, increased expectations and the fact that it is "free"-rationing occurs through waiting lists. This fosters a crisis atmosphere.
NETHERLANDS
Amount spent on health per person: US$2,070
Total health expenditure as a % of GDP: 8.5
Public expenditure on health as % of GDP: 6.0
Private expenditure on health as % of GDP: 2.5
Public: Private ratio: 70:30
Hospital beds per 1,000 population: 11.3
Practising physicians per 1,000 population: 2.6
Practising nurses per 1,000 population: N/A
Life expectancy at birth in years: 75.43(M) 80.61(F)
Infant mortality (per 1,000 live births): 5.23
History and funding
State involvement was limited until the 1960s. The Netherlands now operates a social insurance system but also has the highest levels of private health insurance in Europe. It excludes higher income earners, around a third of the population, from the statutory insurance system.
For primary and acute secondary care, individuals can choose to join one of 30 competing sickness funds; contributions are paid by employer and employee. Long-term care is funded by a mandatory insurance scheme.
Of the richer citizens who are excluded from the state schemes, 98 per cent buy private health insurance. These premiums are usually risk-adjusted rather than income related. Private insurance offers a more luxurious level of service, although not better medical care and it does not allow for queue jumping over other types of insurance.
Organisation
Hospitals contract with both social and private insurers. Fees are determined by the National Health Tariffs Authority. Most hospitals are not-for-profit, and many are run by the church-as many as 60 per cent in the 1980s, but this is becoming less common. Doctors are organised like GPs in Britain. They are paid per patient for the sickness fund patients and through a fee for service from the privately insured patients, with nationally negotiated fees.
Strengths
Choice encourages competition and increases efficiency. Services are technologically advanced, especially for cancer treatment.
Effective preventive programmes have been put in place and have successfully engaged traditionally hard-to-reach groups such as immigrants or deprived families.
Weaknesses
Different parts of the system enjoy considerable autonomy, which causes difficulties for cost control.
As with all insurance schemes where employers have to contribute it raises the price of labour and costs jobs.
Waiting lists are increasing.
UNITED STATES
Amount spent on health per person: US$3,950
Total health expenditure as a % of GDP: 13.0
Public expenditure on health as % of GDP: 5.8
Private expenditure on health as % of GDP: 7.2
Public: Private ratio: 45:55
Hospital beds per 1,000 population: 3.7
Practising physicians per 1,000 population: 2.7
Practising nurses per 1,000 population: 8.3
Life expectancy at birth in years: 73.04(M) 79.75(F)
Infant mortality (per 1,000 live births): 6.67
History
From Roosevelt's New Deal, via the Great Society programmes in the 1960s, to Hillary Clinton's middle way proposals in the early 1990s, health policy has often dominated the US domestic agenda. One reason is that the US private insurance model has excluded many people from basic cover. In the mid-1960s the government created Medicare and Medicaid which have provided a ragged safety net. Bill Clinton tried to introduce more state involvement and extend coverage to more citizens but the initiative stalled in 1994. George W Bush is introducing a system of tax credits to help low-income people become less dependent on state support. But it is still estimated that over 2m Americans lost their health coverage in 2001, due to rising unemployment and insurance costs.
Funding
Americans spend more than twice per capita British levels on health, but alone amongst the countries profiled here most of the spending (55 per cent) is in the private sector. The money for Medicare (covering 39m people) for the over 65s and Medicaid (covering 36m) for the poor comes 56 per cent from the federal government and 44 per cent from states. There have been attempts to curb the increasing costs of private health care. For example, the setting up of health maintenance organisations (HMOs) in 1973, which meet health needs for a prepaid annual fee. This initiative has proved popular, with 30m members, but some providers have gone bankrupt. In 1989 Oregon tried extending Medicaid to all people below the federal poverty level. Costs were kept down by limiting cover to a basic package. The number of uninsured people fell sharply.
Organisation
Primary health services are delivered mostly by private doctors. Over 60 per cent of hospital and nursing home beds are privately owned, although only 15 per cent are for-profit. The 40 per cent of hospitals owned by federal, state or local government are seen as a last resort. Doctors working for the government have recently seen their fees, linked to US GDP, drop by 5 per cent. Those feeling the pinch are scaling back Medicare work to concentrate on private practice. The prime source of public doctors is ex-medical students paying off college fees.
Strengths
For those who can afford it, there is a substantial degree of choice and high-quality health care. The US is a world class centre for research and patients can benefit from cutting edge technology.
Whilst American health care is largely dependent on market forces, doctors and hospitals are heavily regulated.
Weaknesses
15 per cent of Americans have no access to either public or private insurance and can get only a limited service.
The cost of private health schemes is considerable and forms a significant budget item for families and business.
Private insurance has led to an emphasis on quantifiable hospitalisation rather than preventative medicine.
Cuts in doctors pay, an ageing population and rising demand is placing a big strain on public programmes.
The methods of payment for healthcare-private, employer or government-funded insurance schemes-have helped fuel a system that has led to spiralling health costs.
FRANCE
Amount spent on health per person: US$2,102
Total health expenditure as a % of GDP: 9.4
Public expenditure on health as % of GDP: 7.3
Private expenditure on health as % of GDP: 2.1
Public: Private ratio: 77:23
Hospital beds per 1,000 population: 8.1
Practising physicians per 1,000 population: 3.3
Practising nurses per 1,000 population: 4.97
Life expectancy at birth in years: 75.02(M) 82.72(F)
Infant mortality (per 1,000 live births): 4.58
History
The revolution of 1789 first laid down the idea of a social support system, but France has adopted the basic principles of the German social insurance system. The present system came into being in 1945, concentrating primarily on workers and their families. Compulsory health insurance was extended to farmers in 1961 and to the self-employed in 1966. Employers have to pay around 12 per cent of their payroll costs to a health fund for each employee and, following recent reforms, the individual now pays a social contribution of about 7.5 per cent of total income. Controlling costs is a constant battle. There are plans to fine doctors who over-prescribe and to remove many drugs from the approved list.
Funding
Patients pay in advance for treatment which is then reimbursed. Insurance funds pay for around 80 per cent of the cost of treatment; the difference is made up by the patient either out of pocket or, more frequently, from the top-up fund they have joined. These supplementary schemes, known as mutuelles, can also be used to pay for luxuries during treatment such as a private room. (Refunds can be as high as 100 per cent for a major operation or as low as 40 per cent for less essential care. GP consultations are reimbursed at 70 per cent.) For the 6m people who cannot afford a mutuelle the state funds a safety net. The government contributes from the proceeds of motor insurance premiums and taxes on alcohol, tobacco and drug advertising.
Organisation
About 65 per cent of hospitals are public; of the private hospitals about half are non-profit. As in Germany and the Netherlands, hospitals are run by a range of organisations from local authorities to universities and churches.
Strengths
The World Health Organisation rates the French system the best in the world. There are no waiting lists.
Patients get a choice of doctor and can select a private or public hospital. Patients can consult physicians as often as they like and can see a specialist without GP referral.
Good co-operation between public and private sector
A thorough system of regulation and inspection exists with 4,000 physicians employed for this role.
France has, according to the OECD, the lowest years of potential life lost to heart or lung disease.
Weaknesses
The French system is one of the most expensive in the world with high administration costs and unrestrained demand. The bureaucracy generates over one billion claim forms a year, 12m of which take over three months to be paid. The patient has to pay in advance causing problems for those who have no spare funds.
The high cost of the system to employers contributes to France's high unemployment.
There is no incentive to ration treatment or drugs. The French are Europe's biggest consumers of anti-depressants and sleeping pills. As they get paid per visit, doctors have an incentive to see as many patients as possible.
Health scandals, such as the blood transfusion/HIV case, have led to doubts about the system's safety.
JAPAN
Amount spent on health per person: US$1,844
Total health expenditure as a % of GDP: 7.5
Public expenditure on health as % of GDP: 5.9
Private expenditure on health as % of GDP: 1.6
Public: Private ratio: 78:22
Hospital beds per 1,000 population: 16.5
Practising physicians per 1,000 population: 1.9
Practising nurses per 1,000 population: 7.8
Life expectancy at birth in years: 77.13(M) 83.45(F)
Infant mortality (per 1,000 live births): 4.05
History
The government has provided assistance for the ill, disabled and old since the 1920s when a series of welfare programmes, based on European models, were established. In April 1961, universal medical insurance and pension systems were introduced. Big changes were implemented in September 1997. Salaried workers who previously had to pay 10 per cent of their total medical fees are now required to pay 20 per cent. Furthermore, the fixed premium paid by the elderly has been raised. Further changes will mean patients, hospitals and insurers paying a bigger share of the cost in a period of economic decline with a growing proportion of old people in the population. Geriatric care now represents nearly one third of all health costs.
Funding
The system has two parts: those employed in private corporations or as public servants are enrolled in one of the various employee health insurance plans (EHIP), where their dependents are also eligible for benefits. Those who are self-employed or retired are enrolled in the National Health Insurance Plan (NHIP), run by local authorities. Both schemes are underwritten by central government.
For those covered by EHIP, premiums are fixed on an income related basis, for the NHIP there is a flat rate provision. The patient pays for treatment at point of contact but is later reimbursed, as in France. For those who are insured on an income-related basis they are later reimbursed for 80 per cent of treatment costs. Those who are insured with the flat rate provision through their local authority are reimbursed for 70 per cent of the total cost.
Organisation
The ministry of health is responsible for overall administration of health care, with an interventionist approach towards the elderly, the disabled and children, but it owns only 2,000 hospitals, compared to 8,000 private hospitals. The Japanese population is ageing faster than that of other developed states. The "golden plan" for care of the elderly places increased demands on local government to provide residential homes and home-based nursing care.
Strengths
Every citizen in Japan is insured for medical care, through either EHIP or NHIP.
There is an abundant supply of hospital beds and strong emphasis on hospital-based convalescent care. (This can mean a waste of resources when people stay too long.)
The Japanese enjoy close to the longest life expectancy and the lowest infant mortality rate in the world, despite the country's comparatively moderate health expenditure.
Weaknesses
The regulation of medical clinics and hospitals is relatively weak in Japan, because of the great strength of the medical profession. In recent years there have been many cases of gross negligence where nurses and doctors have made basic errors leading to fatalities.
The mixtures of public and some private funding have created complex pension and insurance systems; this means a long wait for patients to be fully reimbursed.
Even though beds are plentiful, the medical service is understaffed. For example, the number of hospital staff per 1,000 beds is 79, compared to 213 per 1,000 in the Netherlands and 335 per 1,000 in the US.
GERMANY
Amount spent on health per person: US$2,424
Total health expenditure as a % of GDP: 10.6
Public expenditure on health as % of GDP: 7.9
Private expenditure on health as % of GDP: 2.7
Public: Private ratio: 75:25
Hospital beds per 1,000 population: 9.3
Practising physicians per 1,000 population: 3.5
Practising nurses per 1,000 population: 9.6
Life expectancy at birth in years: 74.89(M) 81.02(F)
Infant mortality (per 1,000 live births): 4.54
History
Germany has the oldest system of social insurance in the world, introduced by Bismarck in 1883. In 1998, the government backed statutory health insurance system (SHI) covered 88 per cent of the population. Of these, all but 13 per cent are automatically enrolled because their incomes fall below a certain threshold. Those who earn the equivalent of over ?25,000 in western Germany and ?21,000 in eastern Germany have the choice of remaining in the statutory sector or opting out to private insurance; only one in three of those eligible choose this latter option. Dependants automatically receive health insurance through the head of household. The sickness funds, which are private bodies, have recently rationalised-the number falling from over 1,000 in the mid-1990s to about 400 now. Almost all individuals can now enrol into a sickness fund of their choice, rather than being segmented by their occupation as used to be the case.
Funding
Compulsory insurance provides essential health care and some "hotel" services and other luxuries unrelated to medical treatment. Premiums are set as a proportion of income, it is currently about 7 per cent of income for both employer and employee. There is a further levy of about 1.5 per cent of income to cover long term care for the elderly. Premiums for private health insurance are unregulated and are based on the individual risks of each member at the time of entry into the insurance plan. In addition, the government covers a small number of individuals who cannot afford insurance for themselves.
Organisation
Hospital capacity is split 50:50 between the private and public sector; within the private sector just over half is non-profit. States, cities, universities, churches, private companies all run hospitals. The government pays for the capital investment of public hospitals. All hospitals provide care under the SHI and hospital admissions are made though referrals from primary care doctors who act as gatekeepers. However, patients do not need a referral to see a specialist and can make their own appointments.
Doctors bargain collectively with the sickness funds over fees; hospital charges are mainly set by national regulation. Because the sickness funds must, by law, offer patients the choice of any doctor, it means they cannot reward those doctors who give better value for money. This is an obstacle to making the system more efficient.
Strengths
There is choice and flexibility for patients which has led to high satisfaction ratings and no waiting lists.
Citizens have a direct relationship with the health system because they can usually choose their own sickness fund or personal insurance arrangement
Weaknesses
Highly corporatised system that is expensive and difficult to reform.
Oversupply in both personnel and high-tech equipment leads to wastage and unnecessary treatments.
Citizens are vulnerable to increases in insurance premiums and the high cost to employers reduces job creation.
AUSTRALIA
Amount spent on health per person: US$1,980
Total health expenditure as a % of GDP: 8.5
Public expenditure on health as % of GDP: 5.9
Private expenditure on health as % of GDP: 2.6
Public: Private ratio: 69:31
Hospital beds per 1,000 population: 8.5
Practising physicians per 1,000 population: 2.5
Practising nurses per 1,000 population: 7.8
Life expectancy at birth in years: 77.49(M) 83.48(F)
Infant mortality (per 1,000 live births): 4.97
History
Until 1972, Australia was one of the few industrialised nations to lack a mandatory social insurance scheme for health care-in that year 15-20 per cent of the population remained uninsured. Bob Hawke's government in 1983 introduced a universal health care system, Medicare. The number paying for private cover fell from two-thirds to one third by 1996 but as it was the young and healthy who were staying away from the private market, premiums were driven up. In 1999 the government introduced incentives to tempt young people back into the private market, including a 30 per cent tax rebate on premiums as a carrot and a 2 per cent increase year-on-year in mandatory premiums as a stick. Membership is back to 50 per cent.
Funding
The core of the public system remains the Medicare scheme, which aims to provide health care to all who need it whilst promoting choice for the individual by offering substantial private sector involvement in terms of delivery and financing. When Medicare began in 1984, a levy to pay for the public health system was introduced to supplement general taxation. The levy revenue provides around 27 per cent of the funding for Medicare. Access is provided to public hospitals at no cost to patients, and free or subsidised treatment is available from GPs.
Organisation
Despite the resurgence of private health care, public services continue to make up most of patient care. Public hospitals provide 75 per cent of all acute hospital beds.
Strengths
Universal free treatment is available in public hospitals; drugs at a reasonable cost.
The boost to private health cover has been a great success and insurance premiums are showing signs of a decline. It demonstrates that political will and courage can bring about big changes in a short period.
Weaknesses
The public have recently begun to express disquiet about the true cost of private insurance.
Geography and funding means too few rural doctors.
SWEDEN
Amount spent on health per person: US$1,707
Total health expenditure as a % of GDP: 8.0
Public expenditure on health as % of GDP: 6.7
Private expenditure on health as % of GDP: 1.3
Public: Private ratio: 84:16
Hospital beds per 1,000 population: 3.8
Practising physicians per 1,000 population: 3.1
Practising nurses per 1,000 population: 8.2
Life expectancy at birth in years: 76.95(M) 82.18(F)
Infant mortality (per 1,000 live births): 3.56
History
After the second world war a welfare society based on compulsory insurance was built. By 1962, health care and sickness benefits were insured for the whole population. Charging for GP visits was introduced in 1970. The charge was not intended as a big revenue raiser, but rather as a device to minimise frivolous use of the health service. The charge, which has since risen to the equivalent of ?10, is linked to the cost of a cinema ticket.
Funding
The 26 county councils administer the hospital system and collect 75 per cent of the total finance through local tax. In addition employers and employees pay into a compulsory insurance system which covers drugs and health care services, plus compensation for income lost through illness.
Patients have recently been given greater choice in selecting health care providers. High prescription charges and fees for the first 15 visits to a GP, mean that direct payment comprises about 5 per cent of the funding mix.
Organisation
The system is very decentralised but there have been attempts to impose more central controls. Until recently private care was provided by only a few doctors and some private nursing homes, but demand is rising.
Strengths
Enviable health outcomes, in particular in relation to life expectancy and infant mortality. Closing of the health gap between social classes.
The high percentage of doctors that are salaried, rather than paid per consultation or treatment, has decreased the wastage in fees-per-service systems.
The rights of the consumer are exemplified by the fact that patients do not have to pay if they are kept waiting for more than 30 minutes in surgeries.
Weaknesses
The system is expensive, claiming 85 per cent of county council spending. The lack of gatekeeping by GPs means high demand on hospital beds and services.
One in five people claim to have been put off seeking care for financial reasons. The future of charging in Sweden is now under review.
