**3. European health system classifications: a historical perspective**

The European health systems have been classified in a variety of ways in the last 30 years. Depending on the author, on the purpose, on the criteria, and on the moment, a typology is created. In this work, the last 30 years are divided into two periods, before and after the 2000s. In the more recent period, different proposals are grouped according to the method used to classify health-care systems. The methods used to create the typologies may be non-analytical or analytical. The non-analytical is based on descriptive and/or qualitative analysis, while the analytical is sustained in statistical methods, such as principal component analysis and cluster analysis.

The diversity of proposals is relevant and provides value added on the general and analytical perspective about each health system. In **Table 1** of the Appendix, a synthesis of the set of typologies referred here is presented for a clear perspective of the 30 years of European health system classification. This table lists the author (year), type of analysis/methods, classifying criteria, and typology/countries in each typology.

#### **3.1. Period 1985–2000**

In the period 1985–2000, there are four well-known typologies in the literature: three of them are constructed using the unique criterion of funding, and the fourth typology and oldest is based on the three criteria of classification: coverage, funding, and ownership. There is a fifth typology worth to be referred, for curiosity, which is based on geographical neighborhood.

(1) Let us start from the oldest typology from these 30 years. This typology was proposed by OECD [10], in 1987, in a work supervised of George J. Schieber. Using the three criteria reflecting health system functions, health systems are classified into three types: *Beveridge model*, *Bismarck model*, and private insurance. This last type of health system could not be found in Europe. This typology was very well received, and it has been referred ever since. *Beveridge model* is defined by universal coverage, taxed funded, and public ownership of provision. The *Bismarck model*, on his turn, is defined by universal coverage, social contributions funded, and provision is done by public or private or both sectors. Despite the importance of this typology, it did not classify all European countries, and it placed some dominance in the criterion of financing.

(2) In another work proposed by the WHO under the direction of Saltmann and Figueras [11] and inspired by the OECD typology, three-group typology is proposed. Based on one criterion of funding, three groups are identified: the *Beveridge model, the Bismarck model*, and the *Mixed model*. The first two groups are identical to those identified before: the *Beveridge model* is mainly financed by taxes, and the *Bismarck model* is based on social insurance. The *Mixed model* gathers health systems which are in transition or in transformation. Systems in transition mean those who have strong features of the *Bismarck model* but are in transition to something


**Table 1.** Six types of OECD health-care systems Böhm et al. [22].

else; the systems in transformation account for countries moving from an insurance-based system to a taxed-based system and those moving from a *Semashko system*<sup>1</sup> to an insuredbased one (ex-communist countries).

(3) Finally, under the direction of Jakubowski et al., the European Parliament in 1998 [13] has also proposed a typology for classifying national health systems. The criteria of funding continue to be the differentiating factor between groups of countries. But now, the authors have introduced a second layer of funding, the supplementary health system funding. This latter funding accounts for both the direct payments and the private voluntary health insurance payment for supplementary health care. This typology is applied to 15 EU countries, and it reflects the variety of health systems across the European countries.

The typology considers four groups of countries, and their names describe the main features of the health systems in each group: (i) *public taxation/private voluntary health insurance and direct payments*; (ii) *public taxation/direct payments but no private voluntary health insurance*; (iii) *social contributions insurance*/*private voluntary health insurance, direct payments, and public taxation*; and (iv) *mixed compulsory social insurance and private voluntary health insurance*/*public taxation, direct payments*.

(4) The last typology presented for this period is proposed by Figueras et al. [14] in 1994 who have used a simple criterion: spatial neighborhood criterion. These authors clustered the national health systems in four groups: *Northern macro-region*, *Center Western macro-region*, *Center Eastern macro-region*, and *Southern macro-region*. This typology is clear and simple to apply. Nevertheless, it does not convey information about the type of health systems.

#### **3.2. Period 2000–2015**

or analytical. The non-analytical is based on descriptive and/or qualitative analysis, while the analytical is sustained in statistical methods, such as principal component analysis and cluster

The diversity of proposals is relevant and provides value added on the general and analytical perspective about each health system. In **Table 1** of the Appendix, a synthesis of the set of typologies referred here is presented for a clear perspective of the 30 years of European health system classification. This table lists the author (year), type of analysis/methods, classifying

In the period 1985–2000, there are four well-known typologies in the literature: three of them are constructed using the unique criterion of funding, and the fourth typology and oldest is based on the three criteria of classification: coverage, funding, and ownership. There is a fifth typology worth to be referred, for curiosity, which is based on geographical neighborhood.

(1) Let us start from the oldest typology from these 30 years. This typology was proposed by OECD [10], in 1987, in a work supervised of George J. Schieber. Using the three criteria reflecting health system functions, health systems are classified into three types: *Beveridge model*, *Bismarck model*, and private insurance. This last type of health system could not be found in Europe. This typology was very well received, and it has been referred ever since. *Beveridge model* is defined by universal coverage, taxed funded, and public ownership of provision. The *Bismarck model*, on his turn, is defined by universal coverage, social contributions funded, and provision is done by public or private or both sectors. Despite the importance of this typology, it did not classify all European countries, and it placed some dominance in the criterion

(2) In another work proposed by the WHO under the direction of Saltmann and Figueras [11] and inspired by the OECD typology, three-group typology is proposed. Based on one criterion of funding, three groups are identified: the *Beveridge model, the Bismarck model*, and the *Mixed model*. The first two groups are identical to those identified before: the *Beveridge model* is mainly financed by taxes, and the *Bismarck model* is based on social insurance. The *Mixed model* gathers health systems which are in transition or in transformation. Systems in transition mean those who have strong features of the *Bismarck model* but are in transition to something

National health service State State State National health insurance State State Private Social-based mixed system Societal Societal State Social health insurance Societal Societal Private Private health-care system Private Private Private Etatist social health insurance State Societal Private

**Regulation Financing Provision**

analysis.

**3.1. Period 1985–2000**

60 Advances in Health Management

of financing.

criteria, and typology/countries in each typology.

**Table 1.** Six types of OECD health-care systems Böhm et al. [22].

The period 2000–2015 has brought several new proposals on how to classify health systems due to the increasing interest to compare health system on the international level. The set of typologies presented here is distinguished between the analytical and the non-analytical or descriptive. The latter set of typologies is more descriptive and does not use any statistical analysis to find groups of health systems, while the first set of typologies tends to be more sophisticated in their analysis to determine homogeneous groups.

#### *3.2.1. Non-analytical typologies*

(1) The use of the single criterion of funding is still a strategy used to derive groups of national health systems, as it can be found, for instance, in the works by Busse et al. [15] in 2007 and by Thompson et al. [16]. Their proposals are quite similar and countries are grouped identically. Both classify the national health systems in *tax-financed system*, *social insurance system*, and *mixed model* mainly privately financed. The difference is that Busse et al. differentiate the health systems with high of public share of financing from those with high private share.

<sup>1</sup> The Semashko system [12] was born in the former URSS and implemented in the most former socialist countries. Health-care services are basically a total public health-care system, health facilities were owned by the State, and health professionals were paid by the State. The Semashko system provided a universal access to health care, and therefore no one was excluded. But after the collapse of the socialist regimes, the shortage of financial resources led to a higher contribution of patients who are now obliged to pay direct fees to providers.

(2) Blanchette and Tolley [17], in 2001, combine the private or public nature of involvement in financing and delivery functions, resulting in four types of health systems. The authors could only find two groups of health systems in Europe, in particular, the *publicly financed health systems* with *public or private delivery*. But they have analyzed a small set of European countries and left out the more mixed health systems.

(3) The criterion governing production/technology is introduced by Moran [18] in 2000. This criterion captures the way system of innovation is governed within a health system. Medical technology is largely produced by private actors, who also maintain their property rights, but the validation and safeguard of those property rights may be under the public responsibility. The author uses the term "state" as a notion that captures the institutions related with the governance of consumption, provision, and production. The four suggested clusters of health systems are *supply health-care state*, *entrenched command and state control*, *corporatist health-care state*, and *insecure command and control state,* which are next summarized.

(i) *Supply health-care state*: funding is done through private insurance, so access is limited; the public control of costs is limited; private hospitals and doctors remain relatively unchecked; and there are no real constraints to medical innovation adoption. This type of health system cannot be found in Europe. (ii) *Entrenched command and state control*: the governance of consumption is mainly public, and access is based on citizenship; there is strong control of resource allocation by the state; the governance of provision of public owned hospitals and of doctors is subject to extensive public control; and there is a moderate constraint to medical innovation. (iii) *Corporatist health-care state*: funding is made through social insurance contributions; the state has a limited control over health-care costs; the same is true for the governance of provision, where private hospitals are prominent and where there are only some constraints on the private interest of doctors; and there are only some constraints on medical innovation. (iv) *Insecure command and control state*: those are systems similar to the entrenched command and state control health-care systems, but there is nearly no control or influence relative to the private interests; and there is a state governance over provision and doctors, but there coexist a strong private sector, where state influence is very limited.

Despite the introduction of a new perspective to classify health systems, the author applies his typology to only six European countries; it would have been interesting to have it extended to more countries.

(4) Based on descriptive analysis of the relations across providers, payers, and users, in particular, the degree to which health-care financing and delivery is publicly controlled or administered. Docteur and Oxley [19] propose three types of health-care systems, in 2003: *public-integrated model*, *public-contract model*, and *private insurance/provider model*.

The *public-integrated model* combines on-budget financing of health-care provision with hospital providers that are part of the government sector; doctors and other health-care professionals can be either public employees or private contractors to the health-care authority; and complete population coverage is done under a strict budget. In the *public-contract model*, public payers contract with private health-care providers; the payers can be either a state agency or social security funds; often private hospitals and clinics are run on a nonprofit basis. A *private insurance/provider model* uses private insurance combined with private (often for profit) providers; insurance can be mandatory or voluntary; and payment methods are usually activity based.

The typology proposed by these authors introduces an additional criterion of the control/ administration. It is this criterion that allows characterizing health systems according to the type of relations established between the different parties of the health system. However, the classification is only applied to some European countries, and it follows closely the grouping of countries based on the dominance of the financing criterion.

(5) The most recent proposal on types of European health systems has been suggested by the European Union—Committee of the Regions [20], and it accounts for 27 EU countries, missing out Croatia*.* The original contribution of this work comes from the criterion used. The authors have used the role of local and regional authorities within health management systems to propose a typology. This typology yields five groups of health systems: decentralized, partially decentralized, operatively decentralized, centralized but structured at territorial level, and centralized. The name of each group describes the level of (de)centralization of the health system. The three criteria used to obtain this classification are (i) health funding by the Local and Regional Authorities (LRA); (ii) power and responsibility by LRA with regard to health-related legislative, planning, and implementation functions; and (iii) ownership and management of health-care facilities by LRA.

(6) A team of three researchers, Wendt et al. [21], in 2009 pursued the idea of building a typology based on the three criteria, financing, provision/delivery, and regulation/governance, according to the responsible actor—state/public, non-governmental/societal, and market/private. The resulting theoretical classification generates 27 potential health-care systems, but only 10 of them are plausible to find in real world. The empirical analysis was undertaken by Böhm et al. [22], 4 years later, using cluster analysis on 30 OECD countries. The result of that analysis is a set of six types of health-care systems described in **Table 1**.

#### *3.2.2. Analytical typologies*

(2) Blanchette and Tolley [17], in 2001, combine the private or public nature of involvement in financing and delivery functions, resulting in four types of health systems. The authors could only find two groups of health systems in Europe, in particular, the *publicly financed health systems* with *public or private delivery*. But they have analyzed a small set of European countries

(3) The criterion governing production/technology is introduced by Moran [18] in 2000. This criterion captures the way system of innovation is governed within a health system. Medical technology is largely produced by private actors, who also maintain their property rights, but the validation and safeguard of those property rights may be under the public responsibility. The author uses the term "state" as a notion that captures the institutions related with the governance of consumption, provision, and production. The four suggested clusters of health systems are *supply health-care state*, *entrenched command and state control*, *corporatist health-care* 

(i) *Supply health-care state*: funding is done through private insurance, so access is limited; the public control of costs is limited; private hospitals and doctors remain relatively unchecked; and there are no real constraints to medical innovation adoption. This type of health system cannot be found in Europe. (ii) *Entrenched command and state control*: the governance of consumption is mainly public, and access is based on citizenship; there is strong control of resource allocation by the state; the governance of provision of public owned hospitals and of doctors is subject to extensive public control; and there is a moderate constraint to medical innovation. (iii) *Corporatist health-care state*: funding is made through social insurance contributions; the state has a limited control over health-care costs; the same is true for the governance of provision, where private hospitals are prominent and where there are only some constraints on the private interest of doctors; and there are only some constraints on medical innovation. (iv) *Insecure command and control state*: those are systems similar to the entrenched command and state control health-care systems, but there is nearly no control or influence relative to the private interests; and there is a state governance over provision and doctors, but

Despite the introduction of a new perspective to classify health systems, the author applies his typology to only six European countries; it would have been interesting to have it extended

(4) Based on descriptive analysis of the relations across providers, payers, and users, in particular, the degree to which health-care financing and delivery is publicly controlled or administered. Docteur and Oxley [19] propose three types of health-care systems, in 2003:

The *public-integrated model* combines on-budget financing of health-care provision with hospital providers that are part of the government sector; doctors and other health-care professionals can be either public employees or private contractors to the health-care authority; and complete population coverage is done under a strict budget. In the *public-contract model*, public payers contract with private health-care providers; the payers can be either a state agency or social security funds; often private hospitals and clinics are run on a nonprofit basis. A *private insurance/provider model* uses private insurance combined with private (often

*state*, and *insecure command and control state,* which are next summarized.

there coexist a strong private sector, where state influence is very limited.

*public-integrated model*, *public-contract model*, and *private insurance/provider model*.

to more countries.

and left out the more mixed health systems.

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Three typologies next presented share the analytical methodology. In fact, all three use cluster analysis to find out how the different health systems could form homogeneous groups. This form of creating a typology may be less intuitive, but it allows the description on the health system based on common traits sustained by the similarity of statistical information.

(1) In 2009, Wendt [23] used cluster analysis applied to ten health indicators to capture the classifying criteria of financing, provision, institutional characteristics, and health expenditures. The result of this analysis is the three types of health systems: *health service provision oriented*, *universal coverage-controlled access*, and *low-budget restricted access*, next described.

(i) The *health service provision oriented* is described by high level of total health expenditure, high share of public funding, and moderate private out-of-pocket funding; moderate level of inpatient and high level of outpatient healthcare; also by high level of autonomy of selfemployed doctors; and high freedom of choice for patients.

(ii) Countries in the *universal coverage-controlled access* group have high share of public health funding, medium level of total health expenditure, moderate level of inpatient, and low level of outpatient healthcare; the access to doctors is highly regulated, and doctors face strict regulation regarding their income arrangement.

(iii) The *low-budget restricted access* health systems are characterized by low level of total health expenditure which is related to the weaker economic position of these countries, high private out-of-pocket payments, high control of patients' access to medical doctors, low level of inpatient, and moderate level of outpatient healthcare; GPs receive in general a fixed salary, and income is strongly regulated and controlled.

(2) In the following year, another analytical typology is proposed by Reibling [24] who introduced new criteria for grouping national health systems. In particular, this author considered gatekeeping, cost-sharing, provider density (GPs, specialists, and nurses), and medical technology (magnetic resonance imaging units/MRI and computed tomography scanners/CT) as dimensions of classification. This author has based his proposal in cluster analysis over eighteen indicators and ended up finding four clusters:

(i) *Financial incentives states* that regulate patients' access to medical doctors mainly by costsharing, and there is a high availability of GP, nurses, and medical technology; (ii) *strong gatekeeping and low supply states* with no cost-sharing but extensive gatekeeping arrangements for doctor's visits, low numbers of health-care providers, relatively little medical technology, and some regulatory emphasis on provider density and technology; (iii) *weakly regulated and high supply states* with weak gatekeeping and a high supply of health-care providers; (iv) *mixed regulation states* that combine gatekeeping and cost-sharing arrangements, so there is a strong access regulation; physician densities are moderate, and medical technology is highly available.

(3) Finally, Joumard et al. [25] use a set of 22 indicators on institutional features to create a typology of health-care systems. The variables used in this analysis are several, and they may be grouped in those capturing: (i) the reliance on market mechanisms and regulations to steer the demand and supply of health care, (ii) coverage principles to promote equity, and (iii) budget and management approaches to control public spending. The authors perform a cluster analysis and find six groups of health-care systems: Group 1—private provision and private insurance for basic coverage; Group 2—private provision, public insurance for basic coverage, private insurance beyond basic coverage, and some gatekeeping; Group 3—private provision, public insurance for basic coverage, little private insurance beyond basic coverage, and no gatekeeping; Group 4—public provision and public insurance, no gatekeeping, and ample choice of providers; Group 5—public provision and public insurance, gatekeeping, limited choice of providers, and soft budget constraint; Group 6—public provision and public insurance, gatekeeping, ample choice of providers, and strict budget constraint.
