**2. Why classify health systems?**

The WHO definition implicitly considers the goals of a (national) health system. These goals are both final and intermediate [7]. The final goals of a health system are responsiveness to people's expectations, social and financial risk and fair protection, and improved health; the intermediate goals on their turn are improving access, improving coverage, delivering high quality and safe health services, promoting healthy behavior, and improving efficiency.

These goals justify the functions of health systems themselves. The WHO [5] proposes four functions of a health system which are (i) health service provision, (ii) health generation of resources (investment and training), (iii) stewardship, and (iv) health financing (collecting, pooling, and purchasing). The functions of the health systems may be described as follows:

(i) The *provision* (*also referred as delivery*) of health-care services which requires the management of resources and the creation of human resources, delivery of medications, medical ser-

(ii) The *generation of resources* which implies not only their management, but also their creation. While some inputs may be gathered in short term after the investment, other resources

(iii) *Stewardship* or overall system oversight which sets the context and policy framework for the overall health system. This function is usually (but not always) a governmental responsibility, where the health priorities, the institutional framework, the activities that should be coordinated with other systems, and the information needed to support the decision-making

(iv) *Financing or funding* which includes collecting revenues, pooling financial risk, and allocating revenue. (a) The collection of revenue may be done in different ways, and it includes general taxation, donor financing, mandatory payroll contributions, mandatory or voluntary risk-rated contributions (premiums), direct household out-of-pocket expenditures, and other forms of personal savings. (b) Risk pooling refers to the management of financial resources in order to spread the risk from an individual to the pool of individuals, reducing in this way the overall risk for the system. (c) Strategic purchasing or financing of the supply side means the way providers and purchasers establish an interaction and develop service delivery models.

The functions of the health system have been used as dimensions or criteria of classification of health systems. Most traditional criteria used are proxies of financing and delivery functions. But other criteria have been used to capture features of resource generation and stewardship, such as health system actors, cost-sharing, medical technology, and decentralization. Several typologies have been proposed in the last 30 years; some are simple and based on a single

The aim of this work is to review the most influential typologies created in the last 30 years to classify the European health systems. The different typologies are summarized, and their most significant features are presented. The contribution of this article is mainly of twofold. On the one hand, it provides a synthesized historical review of how national health systems have been studied over time in Europe; on the other hand, it allows for the possibility to easily describe, criticize, and analyze the evolution of a single health system in the last 30 years.

criterion, and others are more complex and based on statistical analysis.

may take a long time to obtain and train as the human resources.

vices, and medical equipment.

58 Advances in Health Management

process are set.

The classification of national health systems in groups which share identical characteristics according to some predefine criteria has been of interest of researchers and policy makers. The purposes for the produced typologies are several. Firstly, classification is a step on the process of cognition and knowledge, and it also provides order in a world of infinite instances [8]. Secondly, it allows the international comparison of different national health systems, mainly in terms of their functions. Actually, the nature of classifying health systems is itself a reply to the conceptual need of labeling the different nature of health systems. Thirdly, clustering national health systems allows the assessment of their performance, across countries and time, measured by the attained goals. But also policy assessment and policy recommendation are possible uses from typologies by studying the best references or cases in each group [9]. Finally, a last potential contribution from the typologies of health systems is the historical and comparative analysis that may be developed.

The creation of typologies of health systems can result from a deductive or an inductive method of research [8]. In this work, typologies presented have a deductive nature because it covers more European countries. The inductive method is usually centered in few cases which are presented as examples.

The research to create typologies continues nowadays and so the debate about which dimensions and variables are to be considered, whether or not national health systems fall into defined groups, and which countries may best represent a particular type [8]. Despite this debate, researchers agree on one issue. There is no pure health system in Europe where health systems tend to be set of mixture characteristics. So, aggregating health systems to create a typology is usually based on the principle of the dominant characteristic(s) or on some proximity measure between different indicators.
