EUROPEAN PARLIAMENT DIRECTORATE GENERAL FOR RESEARCH WORKING PAPER HEALTH CARE SYSTEMS IN THE EU A COMPARATIVE STUDY Public Health and Consumer Protection Series SACO 101 EN This publication is available in the following languages: EN (original) DE FR The opinions expressed in this document are the sole responsibility of the author and do not necessarily represent the official position of the European Parliament. Reproduction and translation for non-commercial purposes are authorized, provided the source is acknowledged and the publisher is given prior notice and sent a copy. Publisher: EUROPEAN PARLIAMENT L-2929 LUXEMBOURG Author: Dr.med. Elke Jakubowski, MSc. HPPF, Advisor in Public Health Policy Department of Epidemiology and Social Medicine, Medical School Hannover Co-author: Dr.med. Reinhard Busse, M.P.H., Department of Epidemiology and Social Medicine, Medical School Hannover Editor: Graham R. Chambers BA Directorate-General for Research Division for Policies on Social Affairs, Women, Health and Culture Tel.: (00 352) 4300-23957 Fax: (00 352) 4300-27720 e-mail: [email protected] WITH SPECIAL GRATITUDE TO: James Kahan, Panos Kanavos, Julio Bastida-Lopez, Elias Mossialos, Miriam Wiley, Franco Sassi, Tore Schersten, Juha Teperi for their helpful comments and reviews of earlier drafts of the country chapters, and Manfred Huber for additional explanatory remarks on OECD Health Data. The manuscript was completed in May 1998. EUROPEAN PARLIAMENT DIRECTORATE GENERAL FOR RESEARCH WORKING PAPER HEALTH CARE SYSTEMS IN THE EU A COMPARATIVE STUDY Public Health and Consumer Protection Series SACO 101 EN 11-1998 Health Care Systems CONTENTS INTRODUCTION ........................................................... 5 PART ONE: A Comparative Outline of the Health Care Systems of the EU Member States ......................................... 7 Framework...................................................... 9 Need and Demand for Health Care .................................. 11 Finance and Organisation of Health Care ............................. 18 Health Care Resources and Utilisation ............................... 23 Current Issues in Health Care ...................................... 27 PART TWO: The Health care Systems of the Individual Member States ............ 29 Austria ........................................................ 31 Belgium....................................................... 37 Denmark....................................................... 43 Finland........................................................ 49 France......................................................... 55 Germany....................................................... 63 Greece ........................................................ 71 Ireland ........................................................ 79 Italy .......................................................... 85 Luxembourg .................................................... 91 Netherlands .................................................... 97 Portugal ...................................................... 105 Spain ........................................................ 111 Sweden....................................................... 117 United Kingdom ................................................ 123 Countries at-a-glance............................................ 129 GLOSSARY .............................................................. 131 REFERENCES ............................................................ 135 PE 167.403 Health Care Systems INTRODUCTION The following report provides essential facts on health and health care in the 15 EU Member States. This new study of the health care systems of the 15 European Union (EU) Member States replaces two existing studies carried out in 1990 and 1993. The 1991 Maastricht Treaty gave the Union new competences in public health and more scope for international cooperation. Joint action with the Member States was identified for health promotion and health protection, the subsidising of medical and health policy research, and the establishment of international information systems. The Commission has already developed specific policies in fields such as AIDS, tobacco and alcohol abuse, and environmental causes of ill-health. The 1997 Treaty of Amsterdam provides for a new direction of Community action towards illness and diseases, and alleviating sources of danger to human health. The single European market and increasing migration within the Union are encouraging further policy convergence and new routes for the exchange of medical technology, health services and manpower resources. However, health policy-making is firmly guided by the principle of subsidiarity. The harmonisation of national laws is specifically excluded in Article 129 of the European Union Treaty. Health care systems stem from specific political, historical, cultural and socio-economic traditions. As a result, the organisational arrangements for health care differ considerably between Member States - as does the allocation of capital and human resources. The principal forms of health care organisation in the European Union are the tax-financed national health service systems and those operating with social insurance in which insurance funds may be independent of the government. However, this fundamental division between the systems is weakening. Countries such as the United Kingdom have opened up their NHS to internal competition to diversify supply and increase purchasing power. In contrast, in some traditional social insurance systems sickness funds are being merged and cost control increased on the part of the central government. This trend towards convergence is an attempt to retain the relative advantages of each system. Health care in the EU is at a cross-roads between challenges and opportunities. The Member States are facing common challenges in delivering equal, efficient and high quality health services at affordable cost in times when the amount of care to be delivered is starting to exceed the resource base. The demand for health care in Europe - as elsewhere among industrialised countries - is growing as a result of ageing populations and rising public expectations. The combination of demographic changes and technological developments increases the cost of provision. In consequence, the systems face the same problems of rationing services in order to cut costs owing to an increasing demand and a decreasing tax base to pay for that demand. At the same time, it is increasingly difficult to develop widely accepted health policies and maintain public consent. On the other hand, there are new opportunities to secure substantial improvements in health. There is growing interest in disease prevention and health promotion, clinical advances are enabling more 5 PE 167.403 Health Care Systems effective and efficient use of resources, and information on health and health care can be circulated more rapidly. Strategies employed by the Member States to meet the challenges and opportunities in health differ. For one thing they reflect substantial differences in the organisational framework in which health services are financed and delivered. Furthermore, definitions of what constitutes health and health care differ from country to country and different levels in health outcomes reflect different problems to be tackled. Each system has its own strengths and weaknesses and none of the systems provides a wholly successful solution. Hence each has something to learn from the experience of the other fourteen. In essence, the fifteen health care systems in the EU reflect a variety of different philosophies and approaches and retain their own peculiarities. Comparative studies of these systems aid the process of learning from one another to improve the health of all citizens of the Union. This report aims to provide up to date comparable information on health care systems in the European Union. Part 1 provides an overview of the key components of the health care systems studied and major trends in challenges to health and health care. Part 2 gives a detailed account of the health care system in each of the fifteen Member States. The synoptic table in the final section aims to summarise the main characteristics of the systems at a glance and the glossary provides for short definitions of technical terms. Methodological Issues Comparisons of data on health and health care between the Member States are generally hindered due to the different methods of data collection and interpretation employed. Thus, conclusions from comparative statistical data have to be drawn with great caution. This applies to information on health status, health care costs and resources, including their utilisation. The standardisation of data definitions and methods of data collection has not yet been fully realised, though subject to substantial international effort. In the detailed account of the health systems in the Member States, use is made of EU average values. These estimates are presented inside brackets to compare particular indicators. The fundamental source of statistical information used in this study is "OECD Health Data 98(97)", the data are those available at the end of May 1998. Whenever possible, OECD data have been compared with a second data source, most frequently derived from the WHO "Health for All" database. Differences between the two sources exceeding 10% are presented in angular brackets. This comparison with a second data source is limited because of a lack of