HEALTH CARE SYSTEMS IN THE EU A COMPARATIVE STUDY

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: gchambers@europarl.eu.int

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

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