ReviewFive types of OECD healthcare systems: Empirical results of a deductive classification
Introduction
Classifications have a long-standing tradition in the social sciences, given that processes of sorting, ordering, and comparing involved in classifying social, political, or economic entities are intrinsically scientific: “By making such classifications, generalizations regarding the members or properties of given categories are also made possible. In this way, we might think of classification as the foundation of all science” [2]. In the field of health system research, classification is a common business, too, and has resulted in the co-existence of numerous different classifications. Most of them are developed inductively on the basis of observations of existing healthcare systems. However, a systematic deduction of healthcare system types leading to a more coherent and robust taxonomy has hitherto been lacking. In response to this shortcoming, Wendt et al. [3] have elaborated a typology of healthcare systems developed by Rothgang et al. [1]. This typology distinguishes three dimensions that define healthcare systems: financing, service provision, and regulation. It is argued that each dimension can be dominated by state, societal, or private actors, technically yielding 27 distinct combinations.
So far, this typology (in the following labelled RW typology) has been used as a background, comparative framework for broad descriptions of the health systems in England, Germany, the US [4], [5], the Netherlands [6], and Italy [7] as well as for the quantitative clustering of health systems based on access to care and health service provision [8]. It has also guided the case selection and explanatory approaches to health system change [9], [10]. A systematic application of the RW typology to a larger country sample, however, has not been conducted until now.
In this paper, we argue that out of the 27 types the RW typology offers, only ten are logically plausible and thus expected to occur in the real world. Our argument is based on the assumption that there exists a hierarchy of dimensions (regulation – financing – service provision) and actors (state – societal – private). We assume that the dominant actor at the higher level restricts the potential range of actors at subordinate levels. In order to test our argument, we have classified 30 OECD healthcare systems. Healthcare systems in 29 of these countries belong to the ten types we considered logically possible. These countries cluster into five different types: the National Health Service (eight cases), the National Health Insurance (five cases), the Social Health Insurance (four cases), the Etatist Social Health Insurance (eleven cases), and the Private Health System (one case). Only Slovenia does not follow the hierarchy rule in one dimension and thus forms a healthcare system type precluded by our assumptions.
Our paper starts with a brief overview of existing typologies of healthcare systems, followed by a more detailed description of the RW typology (Section 2). We then apply our argument of the hierarchy of dimensions and actors and present the ten logically possible healthcare system types (Section 3). Section 4 describes our methods and data, while Section 5 constitutes the empirical core of the paper, namely the classification of OECD health systems. The presentation of results is followed by a discussion of the five existing healthcare system types and the special case of Slovenia (Section 6), and some conclusive remarks.
Section snippets
Existing typologies
There is no dearth of health system typologies. Field's [11], [12] early functional categorization examines the extent of public control over healthcare resources (funding, personnel, knowledge, and legitimacy) vis-à-vis professional autonomy. Terris [13] aims at a global classification based on the nature of the economic system, where the public assistance type corresponds to pre-capitalist systems, the insurance type complements capitalist systems, and health systems of the National Health
Hierarchy of healthcare actors and functions
The deductive model for healthcare system types leads to 27 possible combinations, but some appear inherently dysfunctional. For example, a model that combines the public provision of services with private financing seems implausible. The motive behind public provision is to guarantee equal access, which conflicts with predominantly private financing. Although Wendt et al. [3] already indicate that some combinations are more likely than others, they offer no rule on how to exclude unlikely
Methods and data
Health systems in industrialized countries are highly complex institutional constructs that differ widely between countries. For classification purposes it is therefore necessary to reduce complexity by focussing on certain aspects of reality and neglecting others. We have tried to do this by focussing on the “core” part(s) of each healthcare system. Many health systems do not consist of a unitary scheme, but of several segregated parts. With regard to vertically segregated health systems –
Results
The classification of 30 OECD health systems according to the three dimensions regulation, financing, and service provision leads to six country clusters, which are presented in Fig. 3. Five of these clusters correspond to healthcare system types that we characterized as plausible ones: the National Health Service, National Health Insurance, Social Health Insurance, Private System and Etatist Social Health Insurance type. Only the Slovenian healthcare system currently resembles a combination
Discussion
Our classification of OECD healthcare systems has revealed five types which correspond with our assumptions, and the special Slovenian case. For each of the five health care system types we shall now compare our classifications with earlier findings on healthcare typologies, examine how close the countries really match the respective health system type as well as the variance within types, and give tentative explanations for the observed characteristics. The discussion will also trace past
Conclusion
In this paper we refined the typology of health care systems developed by Rothgang and Wendt, the first strictly deductive approach to health care system classification, by proposing a hierarchy of actors and functions. This allowed us to reduce the number of types from 27 theoretically possible to 10 plausible ones. The empirical application of the RW typology on a dataset of 30 OECD countries confirmed our functional model: with the notable exception of Slovenia, which has been accounted for,
Acknowledgements
Data collection has been conducted within the context of the research project “Decision-making processes and distributive effects” (http://www.distributive-decisions.de/english/project) founded by the Volkswagen Foundation and based at the University of Mainz. We would like to thank Dorothea Klinnert and Marco Brehme for their extensive case work, Barbara Ehgartner and Vicky May for their careful editing, and two anonymous reviewers for their helpful comments. Furthermore, the authors are
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- 1
Johannes Gutenberg-University Mainz, Department of Political Science, D 55099 Mainz, Germany. Tel.: +49 6131 39 25541; fax: +49 6131 39 27199.
- 2
University of Bremen, Collaborative Research Center 597 “Transformations of the State”, Linzer Str. 9a, D 28359 Bremen, Germany. Tel.: +49 421 218 56631; fax: +49 421 218 98 56631.
- 3
University of Bremen, Collaborative Research Center 597 “Transformations of the State”, Linzer Str. 9a, D 28359 Bremen, Germany. Tel.: +49 421 218 56632; fax: +49 421 218 98 56632.
- 4
Johannes Gutenberg-University Mainz, Department of Political Science, D 55099 Mainz, Germany. Tel.: +49 6131 39 25572; fax: +49 6131 39 27199.