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International Health Comparisons
A compendium of published information on healthcare systems,
the provision of healthcare and health achievement in 10 countries
International Health Comparisons
A compendium of published information on healthcare systems,
the provision of healthcare and health achievement in 10 countries
The National Audit Office team consisted of:
Ashley McDougall, Paul Duckett and Manjeet
Manku under the direction of James Robertson.
For further information about the National Audit Office
please contact:
National Audit Office
Press Office
157-197 Buckingham Palace Road
Victoria
London
SW1W 9SP
Tel: 020 7798 7400
Email: [email protected]
INTERNATIONAL HEALTH COMPARISONS
Contents
Part 1
Making comparisons
Appendices
1
Introduction
1
Scope and structure of the report
1
Basis of the compendium
1
Difficulties in interpreting the information
1
Part 2
Healthcare systems
3
Expenditure on health
3
Financing arrangements in different countries
4
Part 3
Providing healthcare
Health personnel
9
9
Medical infrastructure
14
Medicines and drugs
14
Medical procedures carried out
14
Preventative medical programmes
14
Part 4
Health achievements
17
Life expectancy
17
Infant and perinatal mortality
17
Main causes of death
19
Health outcomes
21
Performance of healthcare systems
21
1. Healthcare delivery systems
28
Australia
28
Canada
30
England
32
France
34
Germany
36
Italy
38
Japan
40
New Zealand
42
Sweden
44
United States
46
2. Death rates from the main cancers over time
48
INTERNATIONAL HEALTH COMPARISONS
Figure Guide
Figure 27: Main cancer killers with death rates
23
Figure 28: Deaths from lung cancer
23
Figure 29: Deaths from breast cancer
24
Figure 30: Deaths from main circulatory diseases
24
5
Figure 31: Deaths from ischaemic heart
disease, 1980 to 1999
25
Figure 4: Health expenditure per head
5
Figure 32: Five-year survival rates for lung cancer
25
Figure 5: Sources of health expenditure
6
Figure 33: Five-year survival rates for breast cancer
26
Figure 6: The methods of financing healthcare
7
26
Figure 7: Number of practising physicians
9
Figure 34: Five-year survival rates for cancer of
the colon
Figure 35: Five-year survival rates for prostate cancer
27
Figure 36: Average length of stay for acute care
27
Figure 1: Definitions of 'disability' used in
calculating disability adjusted life expectancy
2
Figure 2: National expenditure on health as a
percentage of Gross Domestic Product (GDP)
in recent years
3
Figure 3: Health expenditure as a percentage
of GDP, 1980 to 2001
Figure 8: Level of practising physicians,
1980 to 2000
10
Figure 9: Number of practising nurses
11
Appendix 1
Figure 10: Acute hospital admissions
11
Figure 1.1 Financing of healthcare in Australia, 1999
29
Figure 11: Practising nurses per 1,000 acute admissions 12
Figure 1.2: Financing of healthcare in Canada, 1999
31
Figure 12: Practising nurses per acute bed day
12
Figure 1.3: Financing of healthcare in England, 1999
33
Figure 13: Number of acute hospital beds
per 1,000 of population
13
Figure 1.4: Financing of healthcare in France, 1999
35
13
Figure 1.5: Financing of healthcare in Germany, 1995
(Values in Billion DM)
37
Figure 14: Bed occupancy for acute beds
Figure 15: Availability of Magnetic Resonance
Imaging units
14
Figure 1.6: Financing of healthcare in Italy, early 1990s 39
Figure 16: Public expenditure on pharmaceuticals
and other medical non-durables prescribed for
out-patients
15
Figure 17: Coronary bypass procedures per 100,000
of population
15
Figure 1.10: Financing of healthcare in the United States, 47
early 1990s
Figure 18: Percentage of children immunised
against measles
16
Appendix 2
Figure 19: Percentage of children immunised against
diphtheria, tetanus and pertussis (whooping cough)
16
Figure 20: Life expectancy at birth
18
Figure 21: Potential years of life lost
18
Figure 22: Perinatal mortality, 1980 to 2000
19
Figure 23: Infant mortality, 1980 to 2000
20
Figure 24: Main causes of death
21
Figure 25: Deaths from cancer, 1980 to 1999
22
Figure 26: Latest known mortality for all cancers
22
Figure 1.7: Financing of healthcare in Japan, early 2000 41
Figure 1.8: Financing of healthcare in New Zealand, 1998 43
Figure 1.9: Financing of healthcare in Sweden, 1999
45
Figure 2.1: Deaths from cervical cancer, 1980 to 1999
48
Figure 2.2: Deaths from breast cancer, 1980 to 1999
49
Figure 2.3: Deaths from prostate cancer, 1980 to 1999
50
Figure 2.4: Deaths from lung cancer, 1980 to 1999
50
INTERNATIONAL HEALTH COMPARISONS
Part 1
Introduction
1.1 Members of the Committee of Public Accounts have
expressed interest in comparative material on
healthcare in other countries. This compendium of
information has been compiled from published sources
by the National Audit Office and is provided for
background information. A copy has been placed in the
library of the House of Commons.
Scope and structure of the
compendium
1.2 This compendium sets out comparative data on
healthcare systems and health in 10 countries, selected
as broadly comparable industrialised nations
(specifically, the G7 countries1), or as those innovative
countries frequently included in comparisons (Australia,
New Zealand and Sweden).
Making comparisons
World Health Organization3, the two reports prepared for
the Chancellor of the Exchequer by Derek Wanless in
2001 and 20024, together with the supporting report
commissioned by HM Treasury from the European
Observatory5, work by The Commonwealth Fund6, and
the EUROCARE-2 and National Cancer Institute studies
on cancer survival rates7.
1.6 Analysis of the data has been confined to setting out the
comparisons in tabular and graphical form to show
relative positions at a certain date, and the direction of
travel, together with brief textual explanations and
highlighting of key differences. The compendium does
not examine the causes of differences between
countries or draw conclusions on policy issues such as
which methods of financing healthcare are best. The
Department of Health has seen the compendium, and
has noted that the inconsistencies and incompatibilities
between data sources in different countries mean that
valid comparisons cannot be made on the basis of these
figures alone.
1.3 The structure of the compendium is as follows:
Part 1: Making comparisons;
!
Part 2: Healthcare systems;
!
Part 3: Providing healthcare; and
!
Part 4: Health achievements.
1.4 In addition, two appendices set out more detail on
healthcare delivery systems (Appendix 1) and death
rates from the main cancers over time (Appendix 2).
Basis of the report
1.5 The report draws exclusively on published information,
principally the most recent data for 2002 from
the Organisation for Economic Co-operation and
Development (OECD)2. Other sources of data include the
1
2
3
4
5
6
7
Difficulties in interpreting
the information
Lack of comparability and completeness of
the data
1.7 The OECD data used extensively in this compendium are
collected by countries primarily for their own purposes
and methods, timing and definitions vary, see Figure 1 for
example. In addition, available information indicates that
validation procedures vary between countries. In some
countries, for example, data are based on surveys of selfreporting individuals. The report notes when a comparison
is likely to be particularly prone to such problems, but
inevitably a margin of uncertainty remains within the data
as presented.
Canada, France, Germany, Italy, Japan, the United Kingdom and the United States.
OECD Health Data 2002.
World Health Report 2000: Health systems: improving performance, World Health Organization, 2000.
Securing Our Future Health: Taking a Long-Term View, Interim report, November 2001, Final report, April 2002.
Health care systems in eight countries: trends and challenges, European Observatory on Health Care Systems, April 2002.
Multinational comparisons of health systems data, Anderson G.F. and Hussey P.S., The Commonwealth Fund, 2000.
Survival of cancer patients in Europe: the EUROCARE-2 Study, 1999, SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002.
part one
!
1
INTERNATIONAL HEALTH COMPARISONS
1
Definitions of 'disability' used in calculating disability
adjusted life expectancy
!
Australia takes disability to be one or more of 17
defined conditions.
!
Canada takes disability to be limitations in 19 specific
activities lasting at least six months - the last survey was
in 1991.
!
France includes as disabled all those in retirement homes
- the last survey was in 1991-92.
!
Germany extrapolates to disability days the results of a
survey asking about disability in the previous four weeks.
!
Japan takes disability to be confinement to bed.
!
New Zealand takes disability to be as self-reported in the
Household Disability Survey.
!
United Kingdom available data relate to Great Britain
households only, although an adjustment for communal
establishments was made from the 1991 census - disability
is self-reported as a long-standing limitation on activities in
any way.
for secondary (hospital) care. As a result there are fewer
in-patient admissions per 1,000 of the population than
in a country such as France, which has no such
gatekeeper function. A country where older people
make up a smaller proportion of the population than
average might be expected to have lower expenditure
per head on healthcare for example. The compendium
flags up such problems where applicable.
There are uncertain relationships between
cause and effect and the impact of policy
changes may not yet be apparent
1.10 Complex relationships between cause and effect mean
that it is not straightforward to identify which elements
should be changed to achieve desired outcomes. The
indicators may be misleading if used in an uncritical
way to suggest that healthcare could be improved, for
example, by a simple matching against the levels of
indicators in other countries.
Source: OECD Health Data 2002
1.8 A further difficulty is that published data are more
complete on some issues of interest than others. This
inevitably means that only a partial picture can be
drawn for some topics.
The nature of healthcare systems impacts on
measured indicators
part one
1.9 Differences between countries measured by any
particular indicator may reflect the way that healthcare
systems are organised or demographic factors. They do
not necessarily imply that healthcare received by
patients is better or worse. For example, general
practitioners in the United Kingdom act as gatekeepers
2
1.11 A further consideration in drawing conclusions is that
the comparisons make no allowance for policy and
resourcing changes already in train in this country or
elsewhere, aimed at producing improvements, but
which have not had time to work through. In particular,
the Government has allocated an additional £2.4 billion
in 2003-04 to improve the NHS in the United Kingdom,
with spending growing by 7.4 per cent a year after
inflation over the five years to 2007-08. Health spending
in England will rise by 7.5 per cent a year. Taking into
account these new resources, United Kingdom health
spending is expected to rise to 9.4 per cent of Gross
Domestic Product (GDP) in 2007-08. Current
comparisons may not therefore be a reliable guide to the
future or where intervention is needed to raise standards
of healthcare.
INTERNATIONAL HEALTH COMPARISONS
Part 2
Healthcare systems
2.1 There is a lack of systematic published material on the
details of how healthcare systems are organised across the
world, though Appendix 1 gives details of healthcare
systems in the 10 comparator countries. Better information
is available on healthcare expenditure and how this
expenditure is financed, which is set out in this Part.
2.3 For Australia, Canada, France, Germany, Japan, the
United Kingdom and the United States, reported data
closely follow the OECD guidelines for reporting health
expenditure according to a common international
standard. Thus the data are believed to be fairly
comparable. For New Zealand the definition of
healthcare is sufficiently different that its information is
of limited comparability. For Italy and Sweden, the
differences are such that the OECD believes they are not
well suited for international comparisons.
Expenditure on health
2.2 A widely used means of comparison is expenditure as a
proportion of GDP. The OECD data presented here for
expenditure include public and private expenditure, but
there are however definitional and timing differences
that may distort the statistics.
National expenditure on health as a percentage of Gross Domestic Product (GDP) in recent years
14
Expenditure as a percentage of GDP
12
10 country average of 8.9 per cent
10
7.2
2.5
2.3
8
2.5
2.6
1.3
2
1.8
6
6.2
6.6
Italy
(2001)
New
Zealand
(2000)
Sweden
(1998)
1.6
1.4
6
7.8
4
7.2
5.8
6.8
5.9
5.7
5.9
2
0
United
States
(2000)
Germany
(1998)
France
(2000)
Canada
(2001)
Australia
(1998)
The darker tinted bars represent private expenditure. The lighter tinted bars represent public expenditure.
Source: OECD Health Data 2002
Japan
(1999)
United
Kingdom
(2000)
part two
2
2.4 Figure 2 shows that total healthcare expenditure as a
proportion of GDP varied from 7.3 per cent to
13 per cent and was 8.9 per cent on average across the
10 countries. Total health spending in recent years as a
percentage of GDP was lower in the United Kingdom
3
INTERNATIONAL HEALTH COMPARISONS
than in other comparator countries except Japan. The
United Kingdom Government has subsequently
announced increased spending in the 2002 Budget. The
Government estimates that this will increase total spend
on healthcare to 9.4 per cent of GDP by 2007-08, up
from 7.3 per cent in 20008.
2.5 Spending in all countries has increased as a percentage of
GDP over the last 20 years or so, with the exception of
Sweden where it has fallen over a number of years. The
trends are shown in Figure 3. As a result of differing rates
of growth of spending, the spread in percentage GDP
spent across the 10 countries has increased from
3.5 per cent in 1980 to 5.7 per cent in 2000. The United
States and New Zealand both saw very rapid growth in
the late 1980s.
2.6 Health expenditure per head is an alternative way of
measuring the resources devoted to healthcare but is
subject to the additional uncertainty of relying on a
particular exchange rate to make the comparisons. The
caveats to the figures for healthcare as a proportion of
GDP figures apply equally: definitional differences as to
what is included in expenditure, timing differences, and
figures may be affected by demographic factors. Age
standardised spends per head are not available.
2.7 Figure 4 shows the OECD's 2002 estimates based on a
United States $ exchange rate9. There is a greater than
four fold variation between the highest and lowest figures
for health expenditure per head, which range from over
$4,600 per year per person in the United States to just
over $1,000 in New Zealand. Average expenditure per
head of population is $2,220. The United Kingdom figure
is some 86 per cent of the average of $2,028 for the five
European countries covered (Germany, Sweden, France,
the United Kingdom and Italy in descending order of
spend per head).
2.9 Figure 2 also shows that public spending dominates in
nine of the comparator countries. Sweden (with public
expenditure of 84 per cent of total expenditure) and the
United Kingdom (81 per cent) have the highest publicly
financed share of total health spending among the
comparator countries. Public spending is the lowest in
the United States (45 per cent), and private funding
therefore makes up more than half of total health
expenditure. It is the only country where this is the case
- excluding the United States, privately financed
healthcare accounts for 23 per cent of the total on
average across the other nine countries.
2.10 The methods of public and private financing vary
between countries, but are usually a combination of
general taxation, social insurance, out of pocket
payments and private insurance. Figure 5 gives a further
breakdown of the figures in Figure 2 for the comparator
countries. The United Kingdom is one of six comparator
countries (Australia, Canada, Italy, New Zealand,
Sweden) in which general taxes are the main source of
public funds. France, Germany and Japan finance the
majority of health spending through specific social
insurance contributions. Private insurance is third
lowest in the United Kingdom, just above Italy and
Japan, accounting for just 4 per cent of total funding and
highest in the United States, followed by France. United
Kingdom out of pocket payments are slightly higher than
in France but lower than in other comparator countries.
Out of pocket expenditure is highest in Italy, as a
proportion of total spend, followed by Australia and the
United States.
2.11 Further details of the funding arrangements are given in
Figure 6.
part two
Financing arrangements in
different countries
4
2.8 An important difference between healthcare systems is the
extent to which individuals have private insurance. In the
United States, private insurance is the only means of cover
for much of the population, whilst in other countries it is
held mainly by high income groups who opt out of social
insurance coverage. In Canada private insurers are
generally prevented from offering coverage that duplicates
that provided by the Government, while in the United
Kingdom private insurance is held in addition to cover
provided by the Government. In France and New Zealand,
private insurance is widely used to cover out of pocket
payments, such as some prescription costs.
8
9
Budget Report 2002, HM Treasury, Chapter 6.
The exchange rates have been calculated by the International Monetary Fund. They are par or market rates averaged over the year.
INTERNATIONAL HEALTH COMPARISONS
3
Health expenditure as a percentage of GDP, 1980 to 2001
Expenditure on healthcare as a percentage of GDP
14
13
12
United States
Germany
France
Canada
Australia
Italy
Sweden
New Zealand
Japan
United Kingdom
11
10
9
8
7
6
5
France
Sweden
9
19 7
98
19
99
20
00
20
01
96
19
95
19
94
19
93
19
92
19
91
19
90
Canada
New Zealand
19
89
19
88
19
87
19
86
19
85
Australia
Japan
19
84
19
83
19
82
19
81
19
19
19
80
4
Germany
United Kingdom
Italy
United States
Source: OECD Health Data 2002
Health expenditure per head
5,000
4,631
4,500
Expenditure per head (at US$ exchange rate)
4,000
3,500
10 country average of US$2,220
3,000
2,696
2,623
2,500
2,146
2,069
2,058
2,000
1,737
1,683
1,492
1,500
1,062
1,000
500
0
United
States
(2000)
Germany
(1998)
Source: OECD Health Data 2002
Japan
(1999)
Sweden
(1998)
France
(2000)
Canada
(2000)
United
Kingdom
(2000)
Australia
(1998)
Italy
(2000)
New
Zealand
(2000)
part two
4
5
INTERNATIONAL HEALTH COMPARISONS
5
Sources of health expenditure
14.0
Expenditure as a percentage of GDP
12.0
10.0
8.0
6.0
4.0
2.0
0.0
United
States
(2000)
Germany
(1998)
France
(2000)
Canada
(2001)
Australia
(1998)
New
Zealand
(2000)
Italy
(2001)
Taxation
Social insurance
Out of pocket patient costs
Other private payments
Japan
(1999)
United
Kingdom
(2000)
Private insurance
NOTE
No further recent breakdown of the source of funds is available for Sweden beyond that for public/private expenditure in Figure 2.
part two
Source: OECD Health Data 2002
6
INTERNATIONAL HEALTH COMPARISONS
The methods of financing healthcare
Australia
Public finances are raised from a general and compulsory health tax levy on income, through Medicare, the public health insurance
system. Medicare reimburses 75 per cent of the scheduled fee for private in-patient services and 85 per cent of ambulatory services,
including GP consultations.
Out of pocket payments (16 per cent of total health expenditure), are for pharmaceuticals not covered under the Pharmaceutical
Benefits Scheme, patient contributions for pharmaceuticals, dental treatment, the gap between the Medicare benefit and the schedule
fee charged by physicians, and payments for other services such as physiotherapy and ambulance services, not covered by Medicare.
Private insurance accounts for about 8 per cent of health care expenditure and about 45 per cent of the population have private
insurance (mostly supplementary). Mainly not-for-profit mutual insurers cover the gap between Medicare benefits and schedule fees for
in-patient services. Doctors may bill above the scheduled fee. Private insurers also offer private hospital treatment, choice of specialists
and avoidance of queues for elective surgery.
Canada
National health insurance plans (Medicare) are funded by general and dedicated taxation and cover all medically necessary physician
and hospital services.
The majority of the population has supplementary private insurance coverage through group plans, to include dental care, prescription
drugs, rehabilitation services, private care nursing and private rooms in hospitals.
France
Public health finances come from taxes and compulsory social health insurance contributions from employers and employees. The
Sickness Insurance Funds cover 99 per cent of the population. The population have no choice of insurer. They are automatically
affiliated to a health insurance scheme on the basis of their professional status and place of residence.
Mutual Insurance Funds provide supplementary, voluntary insurance to cover cost-sharing arrangements and extra billings. Salaried
workers purchase voluntary insurance from their employers, but this can be purchased on an individual basis. The mutual funds cover
80 per cent of the population, which means that for most of the population, 100 per cent of the cost of the majority of normal
medical procedures is reimbursed.
Private insurance is voluntary for those who do not contribute to the national health insurance system.
There are patient contributions for ambulatory care (around 30 per cent for GP and specialist visits), drugs (between 35 per cent and
65 per cent depending on the therapeutic value) and 40 per cent for laboratory tests. Out of pocket payments account for 10 per cent
of health care expenditure.
Germany
General taxation and compulsory Social Insurance Fund contributions account for the majority of healthcare funding. Employers and
employees make contributions equally. The unemployed, homeless, and immigrants are covered through a special sickness fund
financed through general tax revenues.
Private insurance, based on voluntary individual contributions, covers 8 per cent of the population (the affluent, self-employed and
civil servants).
Cost-sharing is mainly for drugs. Ambulatory care and preventative dental care do not require any patient contributions. User charges
apply to the first 14 days in hospital or rehabilitation each year, ambulance transportation, non-physician care and some dental
treatment, but some groups are exempt (e.g. low income and elderly).
Italy
Taxation is the main source of public finance. There are patient contributions for pharmaceuticals, diagnostic procedures and specialist
visits and direct payments by users for the purchase of private health care services and over the counter drugs.
Mutual fund contributions and private insurance (corporate and non-corporate) account for 9 per cent of health expenditure.
part two
6
7
INTERNATIONAL HEALTH COMPARISONS
6
The methods of financing healthcare (continued)
Japan
Japan's health care system is predominately publicly funded. The majority of public finances comes from the Employees’ Health
Insurance System (Government and non-governmental bodies) and National Health Insurance (self-employed, pensioners, trade
associations and others not covered by workplace based insurance). Most employees and their dependents obtain health insurance
through their employers, financed largely through mandatory payroll contributions from both employers and employees.
New Zealand
Public hospital out-patient and in-patient services are free, but most people meet some costs of primary health care (although some
groups are exempt or have health concession cards) and make a payment for pharmaceuticals. Income-related patient contributions
are required for GP services and non-hospital drugs.
Private insurance is mainly not-for-profit covering private medical care and complementary, used to cover cost-sharing requirements,
elective surgery in private hospitals and specialist out-patient consultations. It does not offer comprehensive health cover. It covers
about a third of the population.
Sweden
The majority of funding comes from taxes and is supplemented by grants from the national Government. There are direct patient fees
for most medical services (flat rate payments), for example, consultation with public physicians in the primary sector, specialists in a
hospital, in-patient stay and consultations with private ambulatory doctors. There is a national ceiling on out of pocket amounts
payable by individuals in any one year. After the ceiling is reached the patient pays no further charges.
The voluntary health insurance market is very small.
United Kingdom
The United Kingdom's healthcare system is predominately public sector with the majority of the funds coming from general taxation
and some from national insurance contributions. About 11.5 per cent of the population have supplementary private medical insurance,
usually for reasons of faster access.
National Health Service care is free at the point of delivery, but charges are levied on prescription drugs, ophthalmic services and
dental services. There are exemptions, for example, for children, elderly, and the unemployed and 85 per cent of prescriptions are
exempt from the charge.
United States
The United States' healthcare system is predominately privately funded, with 55 per cent of the revenue from private sources.
Individuals can purchase private health insurance or it can be funded by voluntary premium contributions shared by employers and
employees on a negotiable basis. It covers 58 per cent of the population.
Public funds (payroll taxes, federal revenues and premiums) fund Medicare, a social insurance programme for the elderly, the disabled,
and end stage renal patients. It covers 13 per cent of the population and accounts for 20 per cent of total health expenditure.
Medicaid, a joint federal-state health insurance programme covers certain groups of the poor. It covers 17 per cent of the population
and accounts for 20 per cent of total health expenditure.
part two
Sources: Securing Our Future Health: Taking a Long-Term View, Wanless, Interim report, November 2001, Final report April 2002; Health care systems in
eight countries: trends and challenges European Observatory on Health Care Systems,2002; Multinational comparisons of health systems data, Anderson
G.F. and Hussey P.S., The Commonwealth Fund, 2000
8
INTERNATIONAL HEALTH COMPARISONS
Part 3
Providing healthcare
premature mortality of almost four per cent for women
and about three per cent for men10.
3.1 This Part of the compendium sets out comparative
figures on how healthcare is provided in terms of
healthcare personnel, medical technology, drugs, the
number of medical procedures carried out and
preventative medical programmes.
3.3 Figure 7 provides information about the number of
practising physicians per 1,000 people in the
population. The statistics need very careful
interpretation because there are significant definitional
differences. For the United Kingdom, the figures shown
update those in the Wanless Review of the future needs
of the NHS11 which also used OECD data. The figures
are based on doctors working in the NHS and exclude
private sector doctors, locums and clinical academics.
In Italy, retired physicians continue to be classified as
'practising', and this leads to anomalies. Italy has one of
the lowest expenditures per head on healthcare
(see Figure 4), but it has the highest recorded ratio of
doctors to the population.
Health personnel
Doctors and nurses
3.2 Recent OECD research has concluded that the number
of doctors is the second most important variable (after
occupation) in terms of explaining variations in
premature mortality (deaths under the age of 70)
across countries and over time. They also found that a
10 per cent increase in the number of doctors, holding
all other factors constant, would result in a reduction in
7
Number of practising physicians
7
Number per 1,000 of population
6
6
5
4
3.6
3
3
2.9
2.8
2.5
2.2
2.1
2
1.9
1.8
Japan
(2000)
United
Kingdom
(2000)
0
Italy
(2000)
Germany
(2000)
France
(1998)
Sweden
(1999)
United
States
(1999)
Australia
(1998)
New
Zealand
(2000)
Canada
(2000)
part three
1
Source: OECD Health Data 2002
10
11
Exploring the effects of health care on mortality across OECD countries, OECD Labour market and social policy - Occasional Papers No. 46, January 2001,
paragraph 45.
Securing our Future Health: Taking a Long-Term View, Interim report, November 2001.
9
INTERNATIONAL HEALTH COMPARISONS
classifications as to what constitutes a nurse and that
while the UK uses full time equivalents, other countries
use headcounts. Germany, which has a high number of
doctors, also has a high number of nurses in relation to
the population. These ratios cannot, however, be taken as
direct measures of the adequacy of provision as the
figures take no account of the pattern of healthcare
provision in different countries. Factors such as the rate
of day case procedures or length of stay can have a major
impact on the need for in-patient admissions and
throughput. Length of stay in the United Kingdom is one
of the lowest among the 10 comparator countries.
3.4 The OECD data show the United Kingdom as having the
lowest number of practising physicians at 1.8 per 1000
persons, considerably below the mean of 2.5 (excluding
Italy). Taking into account data provided by the general
Medical Council on the number of practising physicians,
the Department of Health estimated in 1996 that there
were 2.6 doctors per 1,000 of population, compared
with the OECD reported figure for the United Kingdom
of 1.7. For 1996, Germany reported 3.4 and France 3.0
practising physicians per 1,000 of population.
3.5 The number of physicians in the United Kingdom has
increased steadily over the last 20 years - by 40 per cent
over this period, Figure 8. But reported provision in
other countries has generally increased at a faster rate.
The result is that the countries have moved further apart
and, discounting Italy for definitional reasons, the
spread of provision has increased from 1.0 per 1,000 to
1.8 per 1,000.
3.7 Acute admission rates are shown in Figure 10, which
puts the United Kingdom in the centre of the 10 country
range. These figures can be used in conjunction with
those for numbers of nurses to standardise for the rate of
admissions and length of stay as in Figures 11 and 12.
3.8 In terms of nurses per acute admission, the United
Kingdom comes at the low end of the range, but both
France and Italy have lower provision, Figure 11. In
terms of nurses per acute day, the United Kingdom is
above the other European countries in its provision,
Figure 12.
3.6 As well as having the lowest reported number of doctors
per head, the United Kingdom also has the second
lowest reported number of practising nurses in relation to
the population, Figure 9, although the UK nurse numbers
are for the NHS only. The Department of Health told us
that UK qualified private sector nurses account for about
a quarter of all qualified nurses. The Department also
noted that different countries still use different
8
Level of practising physicians, 1980 to 2000
Physician density per 1,000 of population
7
6
Italy
Germany
France
United States
Canada
Japan
United Kingdom
5
4
3
2
1
part three
NOTE
Data are not available for all years for Japan
10
Source: OECD Health Data 2002
Italy
00
99
United Kingdom
20
98
19
97
19
96
19
95
19
94
J apan
19
92
93
19
19
90
91
19
19
89
Ger many
19
88
19
87
86
Fr ance
19
19
85
19
84
Canada
19
83
19
82
19
81
19
19
19
80
0
United States
INTERNATIONAL HEALTH COMPARISONS
9
Number of practising nurses
Practising nurses per 1,000 of population
12
10
9.7
9.3
8.4
8.3
8
8.1
7.8
7.6
6
6
5.3
4.5
4
2
0
New
Zealand
(2000)
Germany
(1998)
Sweden
(1999)
United
States
(1999)
Australia
(1997)
Japan
(1998)
Canada
(2000)
France
(1997)
United
Kingdom
(2000)
Italy
(1999)
Source: OECD Health Data 2002
10 Acute hospital admissions
205.2
204
200
175.7
159
156
150
147
117.6
99.4
100
50
0
Germany
(2000)
NOTE
France
(1999)
Italy
(1998)
Sweden
(1996)
Australia
(1999)
United
Kingdom
(2000)
United
States
(2000)
Canada
(1999)
Acute care is one in which the principal intent is one or more of the following:
! to manage labour (obstetrics)
! to cure illness or to provide definitive treatment of injury
! to perform surgery
! to relieve symptoms of illness or injury (excluding palliative care)
! to reduce severity of an illness or injury
! to protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function
! to perform diagnostic or therapeutic procedures
part three
Acute admissions per 1,000 of population
250
11
Source: OECD Health Data 2002
INTERNATIONAL HEALTH COMPARISONS
11 Practising nurses per 1,000 acute admissions
Practising nurses per 1,000 acute admissions
80
75
70
70
60
51
50
45
40
36
29
30
26
20
10
0
Canada
(1999)
United
States
(1999)
Australia
(1997)
Germany
(2000)
United
Kingdom
(2000)
France
(1997)
Italy
(1998)
Source: OECD Health Data 2002
12 Practising nurses per acute bed day
Nursing staff per acute bed day (Full Time Equivalent)
1.6
1.4
part three
1.31
1.2
1
1
0.8
0.8
0.6
0.6
0.47
0.4
0.2
0
12
1.4
Australia
(1999)
Source: OECD Health Data 2002
United
States
(2000)
United
Kingdom
(1997)
Italy
(1998)
Germany
(2000)
France
(1999)
INTERNATIONAL HEALTH COMPARISONS
13 Number of acute hospital beds per 1,000 of population
7
6.4
Acute beds per 1,000 of population
6
5
4.5
4.2
4
3.8
3.3
3.3
3
3
2.4
2
1
0
Germany
(2000)
Italy
(1999)
France
(2000)
Australia
(1999)
Canada
(1999)
United
Kingdom
(2000)
United
States
(2000)
Sweden
(2000)
Source: OECD Health Data 2002
14 Bed occupancy for acute beds
90
83
81.1
80
77.5
77.4
Percentage of available acute beds
73.3
70
70
63.9
60
50
40
30
20
10
United
Kingdom
(2000)
Source: OECD Health Data 2002
Germany
(2000)
Sweden
(1996)
France
(1999)
Italy
(1998)
Australia
(1999)
United
States
(2000)
part three
0
13
INTERNATIONAL HEALTH COMPARISONS
Medical infrastructure
of prescribing generic drugs which are considerably
cheaper than branded ones and expenditure may not be
a good measure of volume. The effects of different price
regulation systems is another factor, as is the availability
of over the counter drugs in some countries that would
be prescription only in others.
3.9 A basic measure of healthcare capacity is the number of
beds per head, though it suffers from the same problems
as the statistics for medical staff in being affected by
patterns of health care. The ratios shown in Figure 13
range from 6.4 beds per 1,000 of population in
Germany, to 2.4 in Sweden with the United Kingdom at
the lower end of this range.
3.13 Figure 16 shows expenditure on what countries classify
as public funding for drugs and other medical nondurables prescribed for hospital out-patients. There is a
wide range of spending across countries, with the
highest spending per head in France and Japan at almost
three times that in Australia and the United States.
3.10 Taking account of the use made of acute hospital
beds, the United Kingdom has the highest occupancy
of such beds of the countries for which information is
available, Figure 14.
Medical procedures carried out
3.11 Magnetic Resonance Imaging units stand as a proxy for
investment in new technology and how up to date
medical facilities are. In relation to the size of the
population, the figure for England of 3.9 per million
people is a little over half of the 10 country average of
6.9 per million people. However, Figure 15 shows that
the average is influenced by very high provision in Japan.
Canada has the lowest provision with about two-thirds
the numbers in England. Since 2000 there has been an
increase in the provision of MRI units in the United
Kingdom, partly through support from the New
Opportunities Fund.
3.14 Comparable information on individual procedures across
different countries is limited but is available for coronary
bypass procedures in eight comparator countries. The
United States carries out almost five times as many of
these operations as in the United Kingdom per head of
population, Figure 17. If the United States is excluded as
an outlier, the average rate for the other countries is just
over 60 procedures per 100,000 of population.
Preventative medical programmes
3.15 A measure of the extent of preventative health measures is
the extent of childhood immunisation. A range of caveats
applies including issues such as public perception of the
safety of immunisation and the authorities' policy on when
or whether this should be carried out.
Medicines and drugs
3.12 Medicines are an essential component of healthcare.
But as with other measures, comparisons can be very
misleading. The United Kingdom has pursued a policy
15 Availability of Magnetic Resonance Imaging units
25
23.2
Units per million of population
20
15
10
8.1
7.9
6.7
6.2
4.7
part three
5
14
0
Japan
(1999)
United
States
(1999)
Source: OECD Health Data 2002
Sweden
(1999)
Italy
(1999)
Germany
(1997)
Australia
(2000)
3.9
England
(2000)
2.8
2.6
2.5
France
(1999)
New
Zealand
(1998)
Canada
(2000)
INTERNATIONAL HEALTH COMPARISONS
16 Public expenditure on pharmaceuticals and other medical non-durables prescribed for out-patients
300
272
271
Expenditure per head (US$ exchange rate)
250
237
217
201
200
201
157
150
149
133
112
103
101
Australia
(1998)
United
States
(2000)
100
50
0
Japan
(1999)
France
(2000)
Germany
(1998)
Sweden
(1997)
United
Kingdom
(2000)
Italy
(2000)
New
Zealand
(1997)
Canada
(2000)
Source: OECD Health Data 2002
17 Coronary bypass procedures per 100,000 of population
Coronary bypasses per 100,000 of population
250
200
202.6
150
100
91.5
90.2
66.4
51.6
50
0
United
States
(1998)
Australia
(1999)
Germany
(1998)
Canada
(1999)
New
Zealand
(2000)
46.4
Italy
(1999)
41.2
United
Kingdom
(1996)
35
France
(1993)
part three
Source: OECD Health Data 2002
15
INTERNATIONAL HEALTH COMPARISONS
and the United Kingdom achieved a rate in excess of
91 per cent. Sweden achieved a rate of 99 per cent,
while the lowest rate was in the United States at
83 per cent, Figure 19.
3.16 Immunisation against measles is reported as close to
universal in Japan, Canada and Sweden, though it falls
below 90 per cent in Australia, France, Germany and
Italy, Figure 18. Immunisation against diphtheria,
tetanus and whooping cough is generally higher
18 Percentage of children immunised against measles
100
96.5
96.2
95.2
92
Prorportion of eligible population (per cent)
90
91
84.5
83
80
75
75
Germany
(1997)
Italy
(1999)
70
60
50
40
30
20
10
0
Japan
(1999)
Canada
(1998)
Sweden
(2000)
United
States
(1999)
United
Kingdom
(2001-2002)
Australia
(2000)
France
(1998)
Source: OECD Health Data 2002 and Department of Health. Figure for United Kingdom is for Measles, Mumps and Rubella coverage at 24 months
19 Percentage of children immunised for diphtheria, tetanus and pertussis (whooping cough)
100
99.1
98
95
91.8
part three
Proportion of eligible population (per cent)
90
16
89.8
88.4
85
84.2
83
Germany
(1997)
Canada
(1998)
United
States
(1999)
80
70
60
50
40
30
20
10
0
Sweden
(2000)
France
(1998)
Italy
(1999)
United
Kingdom
(2000)
Australia
(2000)
New
Zealand
(1999)
Source: OECD Health Data 2002 and Department of Health. The United Kingdom figure relates to diptheria, tetanus and polio rather than pertussis but the
OECD has calculated that this figure is only marginally different to those given for other countries
INTERNATIONAL HEALTH COMPARISONS
4.1 This Part presents comparative information relevant to how
well healthcare systems perform. A first measure is the state
of health in countries, though this is determined by many
factors other than the healthcare system. A second
measure is the extent to which healthcare systems improve
health. Limited comparative information is available on
this, though data are available about survival rates after
cancer treatment.
Life expectancy
4.2 A fundamental measure of health in a particular country
is life expectancy though while healthcare systems have
an influence on life expectancy, it depends equally if not
more on a wide range of other factors such as personal
income, lifestyle, education, nutritional standards, and
housing quality. One way of measuring life expectancy
is the number of years that individuals born 'now' can
on average expect to live if current patterns of mortality
and disability continue to apply. The measure has the
limitation of applying only to the current birth cohort.
Life expectancy has generally risen over time, so life
expectancy for the population as a whole will be lower
than indicated by the most recent statistics.
4.3 Figure 20 shows that life expectancy at birth (in recent
years) ranges between about 79 and 85 years for women
across the 10 comparator countries, and between 74 and
78 years for men. This amounts to an 8 per cent range for
women and 5 per cent for men. Japan has the longest
expected life span, followed closely within European
countries by France and Sweden and then Italy and
Germany. The United Kingdom comes towards the lower
end of the fairly small range for both men and women.
The United Kingdom has, however, one of the smallest
differences in life expectancy between women and men
at 4.8 years, with France at 7.5 years being the largest.
4.4 An alternative way of assessing life expectancy is based
on the calculation of 'Potential years of life lost'. This
measure assumes that all those who die before the age
12
13
of 70 die prematurely. This figure needs to be seen in the
context of the currently expected life spans at birth of
around 80 years for women and 75 years for men.
4.5 The United States loses more potential life years than the
other countries in the comparator group, Figure 21. There
is a considerable variation across countries, and in
contrast to the data on life expectancy at birth, where the
United Kingdom is among the lowest, on the years lost
measure, the United Kingdom ranks fourth lowest behind
Sweden, Japan and Italy. This illustrates the dangers of
relying on single indicators to draw conclusions.
4.6 For both sexes, the highest number of years lost
(per 100,000 population) is some 80 per cent above the
lowest one. There are also marked differences in the
number of years of life lost by men and women. In the
United Kingdom, potential years of life lost for males are
64 per cent higher than for females.
Infant and perinatal mortality
4.7 An important reason for increased life expectancy at
birth has been a decline in infant mortality. Among the
explanations for this are better ante and post-natal care
and widespread immunisation against childhood
diseases - influences within the control of health policy
makers. Recent research suggests that the number of
doctors per capita appears to be the second most
important variable (behind occupation) in explaining
both perinatal and infant mortality. The results indicate,
all else equal, that a 10 per cent increase in the number
of doctors would result in almost a 6 per cent decrease
in perinatal mortality and a 6½ per cent decrease in
infant mortality12. The research found that the overall
level of public financing also appears to be a significant
factor in reducing both infant and perinatal mortality13.
The OECD hypothesis is that this may reflect the
likelihood that publicly funded systems provide more
equitable health service provision.
Exploring the effects of health care on mortality across OECD countries, OECD Labour market and social policy - Occasional Papers No. 46, January 2001,
paragraph 55.
ibid paragraph 56.
part four
Part 4
Health achievements
17
INTERNATIONAL HEALTH COMPARISONS
20 Life expectancy at birth
86
84.6
84
82.5
82
82
82
81.7
81.6
80.8
80.7
79.8
Years
80
78
77.6
77.4
76.6
76
79.4
76.3
75.3
75
75.7
74.7
75
73.9
74
72
70
68
Japan
(2000)
France
(1999)
Australia
(2000)
Sweden
(2000)
Canada
(1999)
Italy
(1997)
New
Zealand
(1999)
Germany
(1999)
United
Kingdom
(1999)
United
States
(1999)
The lighter tinted bar represents female patients. The darker tinted bar represents male patients.
NOTE
The life expectancy is calculated on the assumption that age-specific mortality levels remain constant.
Source: OECD Health Data 2002
21 Potential years of life lost
Potential years lost below age 70 per 100,000 people
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
part four
0
18
United
States
(1998)
France
(1998)
New
Zealand
(1998)
Germany
(1999)
Canada
(1997)
Australia
(1999)
United
Kingdom
(1999)
Italy
(1998)
Japan
(1999)
The lighter tinted bar represents male patients. The darker tinted bar represents female patients.
Source: OECD Health Data 2002, based on World Health Organization data
Sweden
(1998)
INTERNATIONAL HEALTH COMPARISONS
Deaths from cancer
4.8 Figures 22 and 23 show the strong decline in perinatal
and infant mortality over the 1980s and the continued
but less marked decrease across most comparator
countries since then. All these countries have made
steady progress over the last 20 years, with those having
the highest rates in 1980 reducing rates a little faster. The
result has been that the spread between the countries for
perinatal mortality has reduced from 9.1 deaths per
1,000 total births in 1980 to 4.5 per 1,000 in 2000.
From 1993, the United Kingdom started to count
mortality after 24 weeks gestation, rather than the
28 weeks used by other countries.
4.10 Analysis of cancer mortality statistics is a difficult area
and variations across countries need careful
interpretation. The chances of dying from cancer depend
on how quickly patients recognise and act on symptoms,
the impact of measures affecting lifestyle (such as
smoking habits) and the existence of screening
programmes. There are also marked differences in cancer
mortality rates between socio-economic groups, (which
correlate with some of the other factors mentioned).
However, the quality of medical intervention is also an
important factor, recognised for example for the United
Kingdom in the NHS Cancer Plan14.
Main causes of death
4.11 Cancer is an illness in the United Kingdom subject to
active measures to improve performance and this needs
to be borne in mind when considering the statistics. As
part of the performance improvements expected as a
result of the increased funding announced in the 2002
Budget, the Government requires the NHS to reduce
mortality rates from cancer by at least 20 per cent in
people under 75 by 2010.
4.9 The main causes of death for the comparator countries
are shown at Figure 24. The most significant causes of
death from disease in developed countries are cancer
(malignant neoplasms) and cardio-vascular illness, and
patterns are similar in all countries.
22 Perinatal mortality, 1980 to 2000
20
18
16
Deaths per 1,000 total births
14
12
United Kingdom
United States
France
Italy
Australia
Germany
Canada
Sweden
New Zealand
Japan
10
8
6
4
2
France
Sweden
00
99
20
98
Germany
United Kingdom
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
Canada
New Zealand
19
88
19
87
19
86
19
85
19
84
Australia
Japan
19
83
19
82
19
81
19
19
19
80
0
Italy
United States
NOTE
14
Source: OECD Health Data 2002
part four
Perinatal mortality is the number of deaths within seven days of birth plus foetal deaths of 28 weeks of gestation or more
per 1,000 total births (live and stillbirths). The UK includes deaths from 24-28 weeks of gestation while other countries do not.
The NHS Cancer Plan, Department of Health, September 2000.
19
INTERNATIONAL HEALTH COMPARISONS
23 Infant mortality, 1980 to 2000
16
14
Deaths per 1,000 live births
12
10
United States
United Kingdom
New Zealand
Canada
8
6
Italy
France
Germany
Sweden
Japan
4
2
Australia
Japan
Canada
New Zealand
00
99
20
98
19
97
19
96
Germany
United Kingdom
19
95
19
94
19
93
19
92
19
91
France
Sweden
19
90
19
89
19
88
19
87
19
86
19
85
19
84
19
83
19
82
19
81
19
19
19
80
0
Italy
United States
NOTE
Infant mortality is the number of deaths of babies aged under one year that occurred during a year per 1,000 live births
during the same year, expressed as a rate.
Source: OECD Health Data 2002
4.12 Figure 25 shows the trend in cancer deaths for the
10 comparator countries over the last two decades. For
the last year of complete comparisons, the United
Kingdom and New Zealand jointly had the highest
death rates, although the rates in both countries are on
a downward trend.
part four
4.13 Recent data for death rates from all cancers (against a
standardised age profile to take account of different
demographics in countries) are shown in Figure 26.
New Zealand and the United Kingdom report
comparatively high death rates. The rate (per 100,000
population) in France and Germany is about 2½ and
5 per cent lower than in the United Kingdom respectively.
The rate in Sweden, the country with the lowest cancer
death rate among the 10 countries, is about 18 per cent
below that of the United Kingdom.
4.14 Figure 27 shows the mortality rates for the four main
cancer killers in the comparator countries. Overall, the
United Kingdom is in the top group for overall deaths
although it has the highest rate only for breast cancer.
15
20
4.15 Further comparative information on death rates from the
main cancers over time is given in Appendix 2.
Figures 28 and 29 show death rates from lung and
breast cancer.
4.16 United Kingdom mortality comes towards the middle of
the range for lung cancer, but is above all of these
comparator countries for breast cancer.
Deaths from circulatory diseases
4.17 Cardio-vascular diseases include ischaemic heart
disease, myocardial infarction and cerebro-vascular
diseases15. As part of the performance improvements
expected as a result of the increased funding announced
in the 2002 Budget, the Government requires the NHS
to reduce substantially mortality rates from heart disease
by at least 40 per cent in people under 75 by 2010.
'Ischaemia' means an inadequate supply of blood and is usually the consequence of the gradual narrowing of the arteries supplying blood and oxygen. If a
narrowed coronary artery blocks off suddenly - as it may if a blood clot forms in it - the part of the heart muscle supplied by that artery may die and cause
severe chest pain. This is a 'heart attack', also known as a myocardial infarction ('myocardium' referring to the heart muscle and 'infarction' referring to the
death of a part of it). There are two main forms of cerebro-vascular disease leading to stroke - resulting from either ischaemic disease affecting the blood
circulation system of the brain, or from haemorrhage of surface blood vessels.
INTERNATIONAL HEALTH COMPARISONS
24 Main causes of death
Deaths per 100,000 of population (standardised)
700
600
500
400
300
200
100
0
United
Kingdom
(1999)
United
States
(1998)
Germany
(1999)
Diseases of circulatory system
Endocrine and metabolic diseases
New
Zealand
(1998)
Italy
(1998)
Malignant neoplasms
Canada
(1997)
Sweden
(1998)
Australia
(1999)
Diseases of respiratory system
Diseases of digestive system
France
(1998)
Japan
(1999)
Non-medical causes
Diseases of nervous system
NOTE
Age-standardised death rates take into account the differences in age structure of the populations
Source: OECD Health Data 2002
4.19 Trends in most countries for ischaemic heart disease
have been downward, most markedly in countries with
highest death rates at the start of the period from 1980
shown in Figure 31.
Health outcomes
4.20 Information about the value added by healthcare
systems in general or in relation to specific interventions
is very limited. The most comprehensive international
data relate to cancer survival rates. The standard
measure is the percentage of cancer patients alive five
years after treatment. This measure has potential
drawbacks, as increases in five-year survival rates may
be the result of better and earlier diagnosis, rather than
represent a real postponement of death.
4.21 Figures 32 to 35 show the five-year survival rates for the
four main cancer killers. The performance of England is
consistently at or near the bottom for the comparator
countries, alternating bottom position with Scotland.
These are based on historical data for patients diagnosed
between 1985 and 1989. The implementation of the
Calman/Hine report (1995) and the NHS Cancer Plan
(2000) is not, therefore, reflected in these figures, but is
expected to affect incidence, survival and mortality rates.
Performance of healthcare systems
4.22 Healthcare systems are complex and making
judgements about their performance overall is very
difficult. Average length of stay is often used as an
indicator of the efficiency with which a system treats
patients, alongside the assumption that all medically
appropriate treatment is delivered to clinically
acceptable standards and discharges are medically
approved. On this basis, a lower length of stay indicates
better efficiency in the use of acute beds. Germany has
the longest length of acute (hospital) stay at 9.6 days,
while the United Kingdom is in the middle of the range
of countries at 6.2 days, Figure 36.
part four
4.18 United Kingdom death rates are highest, second highest
and third highest respectively across the group of
countries for the three circulatory conditions included in
Figure 30. The overall death rate is two and a half times
that of France, with that for ischaemic heart disease
being four times the rate reported from Japan.
21
INTERNATIONAL HEALTH COMPARISONS
25 Deaths from cancer, 1980 to 1999
Deaths per 100,000 of population (standardised)
220
210
200
New Zealand
United Kingdom
France
Canada
Germany
United States
Italy
Australia
Japan
Sweden
190
180
170
160
150
France
Sweden
Germany
United Kingdom
99
98
19
97
19
96
19
94
95
19
19
93
19
92
19
91
19
90
19
89
Canada
New Zealand
19
87
88
19
19
86
19
85
19
84
Australia
Japan
19
83
19
82
19
81
19
19
19
80
140
Italy
United States
Source: OECD Health Data 2002
26 Latest known mortality for all cancers
200
189.1
184.7
part four
Deaths per 100,000 of population (standardised)
180
22
180
177.1
175.3
174.9
174.8
164.5
160
154.6
152.3
Japan
(1999)
Sweden
(1998)
140
120
100
80
60
40
20
0
New
Zealand
(1998)
United
Kingdom
(1999)
Source: OECD Health Data 2002
France
(1998)
Canada
(1997)
Germany
(1999)
United
States
(1998)
Italy
(1998)
Australia
(1999)
INTERNATIONAL HEALTH COMPARISONS
27 Main cancer killers with death rates
Deaths per 100,000 of population (standardised)
140
120
30.9
26.2
100
26.7
23.8
25.4
80
26.7
28.8
28.9
26.9
27.2
24.1
19.2
38.1
25.9
24.8
23.4
22
9.3
60
9.5
21.9
35.7
42.7
47.9
40
52.1
32.6
33.7
32.8
37.2
22.9
20
28
0
New
Zealand
(1998)
18.1
19.6
17.6
Canada
(1997)
United
Kingdom
(1999)
United
States
(1998)
Colon
27.6
23.5
19
21.4
17.1
18.5
18.7
Germany
(1999)
France
(1998)
Australia
(1999)
Sweden
(1998)
Italy
(1998)
Japan
(1999)
Lung
Breast
Prostate
Source: OECD Health Data 2002
28 Deaths from lung cancer
80
71.4
68.9
63.9
61.3
60
59.4
49.9
50
40
32.2
31
29.1
25.3
18.9
20
0
48.9
37.6
30
10
49.7
11.2
Italy
(1998)
16.7
14
12.7
9.7
United
States
(1998)
Canada
(1997)
France
(1998)
United
Kingdom
(1999)
Germany
(1999)
Australia
(1999)
New
Zealand
(1998)
Japan
(1999)
The lighter tinted bar represents male deaths. The darker tinted bar represents female deaths.
Source: OECD Health Data 2002
Sweden
(1998)
part four
Deaths per 100,000 of population (standardised)
71.9
70
23
INTERNATIONAL HEALTH COMPARISONS
29 Deaths from breast cancer
Deaths per 100,000 females (standardised)
30
28.9
28.8
26.7
25.9
25
24.8
24.1
23.4
22
21.9
20
15
9.5
10
5
9
United
Kingdom
(1999)
New
Zealand
(1998)
Canada
(1997)
Germany
(1999)
France
(1998)
United
States
(1998)
Italy
(1998)
Australia
(1999)
Sweden
(1998)
Germany
(1999)
Canada
(1997)
Australia
(1999)
Italy
(1998)
France
(1998)
0
Japan
(1999)
Source: OECD Health Data 2002
30 Deaths from main circulatory diseases
Deaths per 100,000 of population (standardised)
160
140
120
100
80
60
40
20
part four
0
24
United
Kingdom
(1999)
New
Zealand
(1998)
Sweden
(1998)
United
States
(1998)
The lightest tinted bar represents ischaemic heart disease.
The darkest tinted bar represents acute myocardial infarction.
The medium tinted bar represents cerebro-vascular disease.
Source: OECD Health Data 2002
Japan
(1999)
INTERNATIONAL HEALTH COMPARISONS
31 Deaths from ischaemic heart disease, 1980 to 1999
Deaths per 100,000 of population (standardised)
350
300
250
200
United Kingdom
New Zealand
Germany
Sweden
United States
Canada
Australia
Italy
France
Japan
150
100
50
France
Sweden
99
98
Germany
United Kingdom
19
97
19
96
19
19
94
95
19
93
19
92
19
90
91
19
19
89
Canada
New Zealand
19
19
88
87
19
86
19
85
Australia
Japan
19
84
19
83
19
82
19
19
81
19
19
80
0
Italy
United States
Source: OECD Health Data 2002
32 Five-year survival rates for lung cancer
18
16
15.9
15.4
13.8
Five-year survival rate (per cent)
14
12
11.5
12
11.7
10.8
10.1
10
8.7
8.6
9.9
8.9
9.6
8.8
8
7.1 7
6.3 6.1
6
4
2
0
France
United States
Germany
Netherlands
Italy
Europe
Sweden
England
Scotland
Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989
part four
The lighter tinted bar represents female deaths. The darker tinted bar represents male deaths.
25
INTERNATIONAL HEALTH COMPARISONS
33 Five-year survival rates for breast cancer
90
82.8
Five-year survival rates (per cent)
80
80.6
80.3
76.7
74.4
72.5
71.7
70
66.7
65
England
Scotland
60
50
40
30
20
10
0
United States
Sweden
France
Italy
Netherlands
Europe
Germany
Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989
34 Five-year survival rates for cancer of the colon
70
Five-year survival rates (per cent)
60
61.6 60.2
58.7
55.7
51.8
54
55.5
51.8
50
49.6 49.9
46.9 47
46.8 46.7
41.1
41 41.3
Scotland
England
40
30
20
10
0
United States Netherlands
France
Sweden
Germany
Italy
Europe
part four
The lighter tinted bar represents male patients. The darker tinted bar represents female patients.
26
Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989
INTERNATIONAL HEALTH COMPARISONS
35 Five-year survival rates for prostate cancer
90
81.1
Five-year survival rates (per cent)
80
67.6
70
64.7
61.7
60
55.7
55.3
50
47.4
47.2
44.3
40
30
20
10
0
United States
Germany
Sweden
France
Europe
Netherlands
Italy
Scotland
England
Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989
36 Average length of stay for acute care
12
10
9.6
8
7.2
7.1
Days
6.2
6.2
6
5.9
5.5
5
4.9
Sweden
(2000)
New
Zealand
(1998)
4
2
Germany
(2000)
Italy
(1998)
Canada
(1999)
Australia
(1999)
United
Kingdom
(2000)
United
States
(1999)
France
(1999)
Average length of stay is computed by dividing the number of days stayed (from the date of admission in an in-patient institution)
by the number of separations (discharges and deaths) during the year.
Source: OECD Health Data 2002
part four
0
27
INTERNATIONAL HEALTH COMPARISONS
Appendix 1
1.1 This appendix sets out the health care delivery systems in
the ten comparator countries. The main sources used to
compile it were: Health Care Systems In Eight Countries:
Trends and Challenges, European Observatory on Health
Care Systems, 2002; Multinational Comparisons of
Health Systems Data, Anderson G.F. and Hussey P.S., The
Commonwealth Fund, 2000; and, Securing Our Future
Health, Wanless D., Interim Report, November 2001. We
also used material from the European Observatory
web-site and from web-sites of Government health
departments of the countries.
Primary care
Australia
In-patient/secondary care
1.2 Australia offers universal access to health care to all
residents through Medicare. Individuals eligible for
Medicare receive free ambulatory medical care and free
accommodation and medical, nursing and other care as
public patients in state funded hospitals. Alternatively
they may choose treatment as private patients in public
or private hospitals, with some assistance from
Medicare. Figure 1.1 shows the health care delivery
system and flows of finance in Australia. Australia has
complex health care system with many types of services
and providers and a range of funding and regulatory
mechanisms. There is a large and vigorous private sector
in health services.
Role of the Government
appendix one
1.3 The federal Government has control over hospital
benefits, pharmaceuticals, and medical services. The
States are primarily responsible for funding and
administering public hospitals and mental and
community health services, and pay for public hospitals
with federal Government assistance.
28
Healthcare delivery systems
1.4 Private practitioners provide most community-based
medical and dental treatment and there is a large private
hospital sector. The bulk of primary medical care is
provided by GPs. They are mostly self-employed and run
their practices as businesses. They are reimbursed by a
fee-for-service system. Patients have a choice of GP with
no restrictions and may consult more than one GP since
there is no requirement to enrol with a practice. GPs act
as gatekeepers to in-patient and out-patient services.
1.5 In-patient care is provided by public hospitals (70 per
cent of stock of acute care beds). Patients with private
health insurance may chose to be admitted to either
public or private hospitals and may also choose their
specialist. Medicare subsidises medical costs but not
accommodation costs. Physicians in public out-patient
hospitals are either salaried (but may have private
practices and fee-for-service income) or paid on a per
session basis.
INTERNATIONAL HEALTH COMPARISONS
1.1 Financing of healthcare in Australia, 1999
Financial flows
Service flows
OOP - Out of pocket payments
OTC - Over the counter drugs
FFS - Fee-for-service
Private Health
Insurers
Voluntary contributions
30% rebate on private health
insurance premiums
Commonwealth
Government
Compulsory
health
insurance
levy
Taxes
General and specific purpose payments
Some states have
regional health
authorities
State & territory
Governments
Taxes
Budget and salaries
Public health
Population
Mostly free, may be
nominal charges
Mostly free, (80%),
some OOP & 15%
copayments
Small % are free, most
pay 15% copayments &
OOP
Community
health services
General
practitioners
Specialist
medical
practitioners
Budgets
Budgets
Some contracting
FFS or sessional
FFS
Reimbursement
against
schedule
Pharmacist
Free to health care card
holder, but copayments,
OOP & OTC charged to
others
Mostly FFS
with small
sessional &
capitation
payments
Case -mix and other
Public hospitals
Patients
Some contracting
Private hospitals
Reimbursement of hotel charges & 15% gap
between Government rebate & schedule of fees
Source: OECD Secretariat
Source: OECD Health Data 2002
appendix one
Hotel charges and
significant OOP costs
29
INTERNATIONAL HEALTH COMPARISONS
Canada
Primary care
1.6 Although predominately publicly funded, healthcare is
largely delivered by private providers, particularly in the
primary care sector, Figure 1.2.
1.8 Most primary physicians are in private practice and are
remunerated on a fee-for-service basis. Provincial
medical associations negotiate the fee schedules for
insured services with provincial health ministries.
Physicians must opt out of the public system of payment
to have the right to charge their own rates.
Role of the Government
appendix one
1.7 The federal Government requires that provincial health
insurance plans cover all medically necessary physician
and hospital services. The provincial governments have
the authority to regulate health providers. However,
they delegate control over physicians and other
providers to professional "colleges" whose duty is to
license providers and set standards for practice.
30
In-patient/secondary care
1.9 In-patient care takes place in public and private nonprofit hospitals that operate under global budgets or
regional budgets with some fee-for-service payment. Less
than 5 per cent of Canadian hospitals are privately
owned and are mainly long-term care facilities.
INTERNATIONAL HEALTH COMPARISONS
1.2 Financing of healthcare in Canada, 2000
OOP - Out of pocket payments
RHA - Regional Health Authority
Primary financier
Financial flows
Service flows
Private
Insurers
Voluntary contributions
premiums
Federal
Government
Healthcare services for natives living on
reserves, RCMP, inmates in federal
prisons, veterans & military personnel
Transfers
Taxes
Provincial
Governments
Global
budgets
RHAs (except NS
& Ont) funding for
service varies by
province
Transfers
Taxes
Municpal
Governments
Taxes
Workers
Compensation
Board
Employer
contribution
Community
health services
Population and Enterprises
OOP
Other
institutions
OOP
Dental & Vision
Care, Other
Practitioners
Limited coverage
Hospitals
OOP
Physicians
(about 80%
Fee-for-service)
OOP
Pharmaceuticals
(incl over the
counter drugs
Limited coverage
Patients
Source: OECD Secretariat
appendix one
Public Health
Source: OECD Health Data 2002
31
reimbursements
INTERNATIONAL HEALTH COMPARISONS
England
1.10 OECD system information is only available for England.
Other constituent parts of the United Kingdom have
their own structures for delivering a largely publically
funded health service, free at the point of use.
1.11 Primary care services are mainly provided by GPs and
multi-professional teams in health centres (under a
capitated budget), Figure 1.3. Hospitals are mainly
publicly owned with independent trust status. Private
hospitals mainly provide services to privately insured
patients or those who are willing to pay directly.
Role of the Government
1.12 The Government is responsible for health legislation and
general policy matters and is a purchaser and provider
of health care.
Primary care
appendix one
1.13 GPs act as gatekeepers and are brought together in
Primary Care Groups/Trusts with budgets for all care of
enrolled populations. Most ambulatory care is provided
by GPs in group practices. Private general practice is
very small. Physicians are paid directly by the
Government through a combination of methods: salary,
capitation, and fee-for-service.
32
1.14 Ambulatory care is also provided in 36 walk-in clinics
and there is a 24-hour telephone helpline service
(NHS Direct) as a first point of contact.
In-patient/secondary care
1.15 Access to emergency care is through personal
attendance at Accident and Emergency departments in
acute hospitals. Patients may walk in to such
departments or use the free ambulance service in cases
of extreme urgency. Patients may also be advised to
attend Accident and Emergency departments by their
GP or NHS Direct.
1.16 Access to in-patient care is through GP referral. Most
referrals are made to local hospitals and follow
contractual arrangements between health authorities,
Primary Care Trusts and the hospital. Secondary care is
provided in general acute NHS trusts, small-scale
community hospitals and highly specialised tertiary
level hospitals. Hospitals are semi-autonomous selfgoverning public trusts that contract with groups of
purchasers. Consultants are salaried.
INTERNATIONAL HEALTH COMPARISONS
1.3 Financing of healthcare in England, 1999
Financial flows
Service flows
Referral flows
Private Health
Insurance
Risk related, voluntary premiums
Department of
Health
General taxation and
National Insurance contributions
NHS Executive
Global budgets for HCHS* and
prescribing set by weighted capitation
Regional
Offices
Retail
Pharmacists
Prescripton
charges
GP remuneration
and expenses
Prescribing
Prescribed
drugs
Population
Primary Care
Groups (can
evolve into
Primary Care
Trusts)
GP and practice
nursing services
Referrals
Patients
Hospital and
community
health services
GP remuneration
and expenses
Global budgets
for HCHS* and
prescribing
Strategic
Health
Authorities
Commissioning
of most HCHS*
Hospital and
Community
HealthTrusts
Commissioning of highly
specialised HCHS*
Direct
payments
Private
Hospitals
Direct payments
NOTE
*
HCHS: Hospital and Community Health Services
appendix one
Reimbursement
Source: Department of Health, England
Source: OECD Health Data 2002
33
INTERNATIONAL HEALTH COMPARISONS
France
In-patient/secondary care
1.17 All legal residents are covered by public health
insurance. They have no choice to opt out. Most have
additional private insurance to cover areas that are not
eligible for reimbursement by the public health
insurance system and many make out of pocket
payments to see a doctor. Health care is purchased and
paid for by health insurance schemes and the
Government and provided by private (self-employed)
practitioners and public and private (for-profit and notfor-profit) hospitals, Figure 1.4.
1.20 In-patient care is provided in public and private hospitals
(not-for-profit and for-profit). Doctors in public hospitals
are salaried whilst those in private hospitals are paid on
a fee-for-service basis. Some public hospital doctors are
allowed to treat private patients in the hospital, within
limits. A percentage of the private fee is payable to
the hospital.
Role of the Government
1.18 The French Government regulates contribution rates
paid to sickness funds, sets global budgets and salaries
for public hospitals, and supervises national fee
schedule negotiations.
1.21 Most out-patient care is delivered by doctors, dentists
and medical auxiliaries working in their own practices
(62 per cent are in sole practice, the remainder are
in groups). Out-patient care is also provided to a lesser
extent in hospitals and marginally in health centres (run
by local authorities or mutual associations).
Primary care
1.19 French patients have free choice of provider. They can
visit any GP or specialist practising privately or working
in hospital out-patient, without referral or any limit on
the number of consultations. Ambulatory care is mainly
provided by professionals practising privately. Most GPs
and specialists are paid on a fee-for-service basis
according to agreed fee schedules. Patients pay
physicians' bills and are reimbursed by sickness funds
(public reimbursement model). GPs have no formal
gatekeeper function. The Government introduced a nonobligatory gatekeeping mechanism in 1987 but only
1 per cent of the patients and 10 per cent of GPs signed
up to this.
appendix one
NOTES FOR FIGURE 1.4 (OPPOSITE)
Fully private health insurance concerns only a minority of extraterritorial workers, or cross border workers.
(1) ACOSS = Central Social Security Account
(2) CANAM = Health Insurance Fund for self-employed
(3) MSA = Health Insurance Fund for farmers
(4) URSSAFF = Body collecting social contributions
34
Source: OECD Secretariat
INTERNATIONAL HEALTH COMPARISONS
1.4 Financing of healthcare in France, 1999
"Mutuelles" &
private health
insurance
premiums
Private health
insurance
Reimbursement
of patients
Reimbursement
of patients
"Mutuelles", Social
Security, Mandatory
Sickness Funds
State financial
funds,
Refinancing of
deficits
Main health
insurance funds
(CNAMts)
ACOSS (1)
Fee-for-service
Private clinics
CANAM (2)
Payment of
global budgets
to hospitals
MSA (3)
Control
Ministry of Finance
and Industry,
controls balancing
accounts
Obligatory
employer/employee
social contributions
(CSG)
URSSAFF (4)
Ministry of Social
Affairs, Secretary of
State for Health and
other public bodies
Population and Enterprises
Regional hospital
supervisory
agencies
National target
for health
spending
Target for
medical spending
(ONDAM)
Tax services
Regulation of
supply,
hospitals, drugs
Public hospitals
and equivalent
hospitals
Allocation of
global budgets
Private
clinics
Local
government
Community
health centres
Agreement with
retail pharmacists
RE: generic &
substitution drugs
Doctors:
Generalists,
Specialists
Patients
Retail pharmacies
and drugs
Pharmaceutical
industry
Source: OECD Health Data 2002
Economic Regulatory
Agency for health
products
(Drug Agency)
Contracts
appendix one
Copayments and
other patient
direct payments
Prescribed auxiliary
and ambulatory
services
35
INTERNATIONAL HEALTH COMPARISONS
Germany
Primary care
1.22 92 per cent of the population is covered by statutory
health insurance, and just under 8 per cent by private
health insurance but 0.2 per cent is not covered at all.
Ambulatory care and hospital care have traditionally
been distinct domains with almost no out-patient care
delivered in hospitals, Figure 1.5. Ambulatory care is
delivered by private office-based physicians
(generalists and specialists). Hospital in-patient care is
provided by a mix of public and private providers,
although only a small proportion of total beds is in
for-profit hospitals.
1.24 All ambulatory care, including both primary care and
out-patient secondary care has been organised almost
exclusively on the basis of office-based physicians.
Their premises, equipment and personnel are
financed by the physicians' associations. Ambulatory
physicians offer almost all specialties with all
technical equipment up to MRI scanners. Besides
GPs, the most frequented specialists are internists,
gynaecologists and paediatricians. They are paid on a
fee-for-service basis. All treat public and private
patients. There is no formal gatekeeping system as
patients are free to choose their doctor.
Role of the Government
appendix one
1.23 The Government regulates the sickness funds. However,
it has increasingly tended to reduce its interventions in
favour of a self-regulating system.
36
In-patient/secondary care
1.25 Except in emergency conditions, access to in-patient
care requires a referral from an ambulatory physician.
Hospitals are public and private (for-profit and not-forprofit). They are staffed with salaried junior doctors and
fee-for-service senior doctors.
INTERNATIONAL HEALTH COMPARISONS
1.5 Financing of healthcare in Germany, 1995 (Values in Billion DM)
General
Government
98
6
57
Public and
private
employers
198
35
16
■
■
■
■
■
172
121
Mandatory Health Insurance
Mandatory long-term care insurance
Pension Fund
Mandatory Accident Insurance
Private Health Insurance
247
■
■
■
■
61
Private
households
211
39
237
10
39
16
26
26
In-patient Care
Ambulatory Care
Medical Goods (including denture)
Other benefits
Expenditure on
administration
123
87
82
67
55
Benefits-in-cash
(income transfers)
Benefits-in-kind
Private households
Source: Adapted from Federal Office of Statistics, 1998
NOTE
The benefits-in-cash which are not included in most of the diagrams are included here.
appendix one
Source: OECD Health Data 2002
37
INTERNATIONAL HEALTH COMPARISONS
Italy
In-patient/secondary care
1.26 The main providers are local health units (consisting of
health districts, hospitals and health promotion
divisions), public hospital trusts and private accredited
hospitals, Figure 1.6. Local health units are responsible
for maintaining the balance between the funding
provided by the regions and expenditure for service.
1.29 Access to secondary care is through a GP referral.
Referred patients are free to choose their provider
among those accredited by the health service.
Specialised ambulatory services are provided either by
local health units or by accredited public and private
facilities with which local health units have agreements
and contracts.
Role of the Government
1.30 In-patient care is provided by hospitals. The major
hospitals are given the status of independent trusts. The
rest of the public hospitals are kept under the direct
management of local health units. Hospital physicians
delivering secondary care earn a monthly salary.
1.27 Regional government, through regional health
departments, is responsible for ensure the delivery of a
benefit package through a network of local health units
and public and private accredited hospitals.
Primary care
appendix one
1.28 Primary care is provided by general practitioners,
paediatricians and self-employed and independent
physicians working alone under a Government contract
who are paid a capitation fee based on the numbers on
their list.
38
INTERNATIONAL HEALTH COMPARISONS
1.6 Financing of healthcare in Italy, early 1990s
Compulsory
social
contributions
Tax subsidies
Ministry
of Health
Treasury
Regional health
authorities
Local Health
Offices (LHO)
Payments to
Private insurance
premiums
Private insurance
companies
Reimbursements
to patients
Supplemental
health funds
Reimbursements
to patients
Health funds
Private structures
Preventative
care
Public
hospital Private
service Service
Reimbursements
of private
sector to patients
Budgets
Clinics
Direct
payment
of which:
the main Other
services care*
Population and
Enterprises
Reimbursement of patients
Pay beds and intramural professional activity
Patients
Prescription charges
Prescription
charges
Pharmacists
Salary
Specialists
operating within
the NHS
'convenzionati'
Per diem
Hospitals
under contract to NHS
and nursing homes
'convenzionati'
Capitation
General
practitioners
Source: Salvini, R. (1991), Il sistema sanitario italiano, ISPE, not published and Hoffmeyer et al, Financing Health Care, Romel, NERA 1994.
NOTE
*
Out-patient care, household advisory bureau, therapeutic appliances and thermal services, care for poor people, for Italians who
live abroad and for foreigners who live in Italy.
Source: OECD Health Data 2002
appendix one
List
prices
39
INTERNATIONAL HEALTH COMPARISONS
Japan
Primary care
1.31 Japan's healthcare system offers universal coverage and
stresses preventative care. Provision is mainly private,
with 80 per cent of Japan's hospitals and 94 per cent of
its physician run clinics being privately owned,
Figure 1.7. Investor-owned for-profit hospitals are
prohibited. Patients are free to select care providers.
1.33 Physicians have no formal gatekeeper function. Most are
in private practice and are paid through a uniform fee
schedule. Medical and pharmaceutical practices are
often combined, and a large proportion of physicians'
incomes is derived from prescriptions.
In-patient/secondary care
Role of the Government
appendix one
1.32 The Japanese Government acts as regulator and insurer.
It determines a fee schedule in consultation with
providers and consumers. All doctors receive the same
salary regardless of experience. It also subsidises health
care spending for the elderly, small business employees,
and the self-employed.
40
1.34 Hospitals are mainly private, although there are some
public ones. Hospitals combine acute and long-term
care functions and are paid according to a uniform fee
schedule. Hospital based physicians are salaried.
INTERNATIONAL HEALTH COMPARISONS
1.7 Financing of healthcare in Japan, early 2000
Financial flows
Service flows
Insurers
for Employees
(Society-Managed HI &
Government-Managed HI)
Employer
Contributions
(41.7% of THE
or 52.9% of NME
in 1998)
Insurer
for Government
Employees etc.
transfers
Insurers
for Self-Employed
(National HI)
Government
Taxes
Subsidies
(25.4% of THE
or 32.2% of NME
in 1998)
Medical Aid
Programme etc.
Social Insurance
Medical Care
Fee
Payment Fund
Reviews &
Payments
(67.1% of THE
or 85.1% of NME
in 1998)
Subsidies
Public Health
Programmes
Health Centres
Population
Patient Copayment
(11.7% of THE
or 14.8% of NME
in 1998)
and non-covered
services
Patients
Source: OECD Health Data 2002
Health Service
Facilities for
Elderly etc.
mixed payment
(half the cost for
elderly care
except for copayment)
Pharmacy
fee-for-service
Doctor's Clinic
fee-for-service
Hospital
(Including
special function
hospitals,
geriatric
hospitals)
fee-for-service
appendix one
(Half the cost for
elderly care
except copayment)
41
INTERNATIONAL HEALTH COMPARISONS
New Zealand
In-patient/secondary care
1.35 New Zealand's healthcare system covers all residents.
All essential services, including hospital and out-patient,
are provided free through the public health system, with
the exception of dentistry and ophthamology. Public
hospitals account for just over half the total bed stock
including the large tertiary sector. The costs of primary
health care are met or subsidised for certain groups.
About 40 per cent of the population hold concession
cards (usually low-income patients, children and higher
users of the services). Health services are delivered by a
mix of public and private providers, Figure 1.8.
1.38 Patients access secondary care via a GP referral.
Specialist physicians and surgeons provide ambulatory
care in community-based public or private clinics or in
hospital out-patient departments. Hospital out-patient
departments play a larger role in the health system
than in other countries since treatment is free
while consultations with community based
practitioners are charged.
Role of the Government
1.36 New Zealand's Government is a purchaser and provider
of healthcare and has responsibility for legislation and
general policy matters.
Primary care
appendix one
1.37 General practitioners act as gatekeepers and are
predominately private practitioners with two-thirds
working in group practices. Patients have a choice of
GPs and are free to see more than one GP, although in
practice continuity of care is high. They provide most
primary medical services. They are self-employed and
are paid through a combination of payment methods:
fee-for-service, partial Government subsidy, and
negotiated contracts with Health Funding Authority
through Independent Practitioner Associations.
42
1.39 Publicly owned hospitals provide most secondary and
tertiary care, while the growing private sector specialises
mainly in elective surgery and long-term care. Public
hospitals are not permitted to treat private patients.
Hospitals are semi-autonomous Government owned
companies that contract with the Health Funding
Authority. Consultants are salaried.
INTERNATIONAL HEALTH COMPARISONS
1.8 Financing of healthcare in New Zealand, 1998
Financial flows
Service flows
Ministry
of Health
Central
Government
General Taxation
Levies/Premiums
Population and
Enterprises
Accident
compensation
corporation (ACC)
copayments
Fees
Independent
Practitioners
Associations
Patients
Fees
Non IPA GPs and
other independent
practitioners
Broad risk
related
premiums
Reimbursement
Fees
Private
Insurance
* and other providers such as laboratories and radiology clinics
** relating to contracts with the Health Funding Authority
Source: OECD Health Data 2002
contracts/
subsidies**
capitation
budgets and
fee for service
subsidies**
fee for service
subsidies/
budget-holding
capitation**
Health Funding
Authority
Hospitals and
Health Services
(HHSs)
contracts
Voluntary and
Private Providers
contracts
Community
Trusts
contracts
Private
Hospitals
contracts
appendix one
Pharmacists*
43
INTERNATIONAL HEALTH COMPARISONS
Sweden
Primary care
1.40 Ambulatory care is provided by a mix of public doctors,
private doctors and hospital out-patient departments.
Hospitals are publicly owned but have independent
status, with the extent of privatisation varying between
counties, Figure 1.9.
1.42 Patients can choose between primary care centres or
hospital out-patient departments as the first point of
contact. Higher fees are applicable for out-patient visits
compared to visits to primary care centres.
In-patient/secondary care
Role of the Government
appendix one
1.41 The county councils are responsible for the purchasing
of health services and either act as purchasers
themselves or devolve this responsibility to other
purchasing agents.
44
1.43 Patients can access secondary care directly through a
hospital out-patient department. In many counties
patients can also select which hospital to be treated at,
and in some cases, without referral. Most hospitals are
publicly owned.
INTERNATIONAL HEALTH COMPARISONS
1.9 Financing of healthcare in Sweden, 1999
Private Health
insurance
Around 2% of
health funds
Taxes &
employer
fees
National
Government
National pay roll tax
Social insurance
board
General tax
equalisation
& grants
Around 72% of
health funds local payroll rax
Grants (weighted capitation
less FFS payments)
21 County councils
Municipalities
Home health care
Public hospitals &
LT institutions
Public primary
physicians
Salaries
Public primary
health centres
Budgets
Private general
practitioners
FFS
Private medical
specialists
FFS
Pharmacies
Patients
Reimbursements
and payments
Cash benefits
Budgets
Some
central
purchasing
agencies
Mixed payment
systems
mainly FFS
Some
devolved
district health
authorities
Subsidised prices and
prescribed out-patient
medications
appendix one
Population and
Enterprises
Source: OECD Health Data 2002
45
INTERNATIONAL HEALTH COMPARISONS
United States
Primary care
1.44 Health care services are mainly provided by private
practitioners, Figure 1.10.
1.46 General practitioners have no formal gatekeeper function,
except within some managed care plans. The majority of
physicians are in private practice and are paid through a
combination of charges, discounted fees paid by private
health plans, capitation rate contracts with private plans,
public programmes, and direct patient fees.
Role of the Government
appendix one
1.45 The federal Government is the single largest health care
insurer and purchaser. There are two principal schemes in
which the Government is involved: Medicaid and
Medicare. Medicaid is a jointly-funded, Federal-State
health insurance programme for certain low-income and
needy people. It covers approximately 36 million
individuals including children, the aged, blind, and/or
disabled, and people who are eligible to receive federally
assisted income maintenance payments. Medicare is a
health insurance programme for people 65 years of age
and older, some disabled people under 65 years of age,
and people with End-Stage Renal Disease (permanent
kidney failure treated with dialysis or a transplant). It
currently covers some 39 million Americans.
46
In-patient/secondary care
1.47 In-patient care is provided in public and private hospitals
(for-profit and not-for-profit). Hospitals are paid through a
combination of charges, per admission, and capitation.
INTERNATIONAL HEALTH COMPARISONS
1.10 Financing of healthcare in the United States, early 1990s
Budget/Trust Fund
Federal
Government
Premiums
Medicare
Private Insurers
Traditional
Insurers
Managed Care
Entities
Budgets
RBRVS
FFS (Traditional)/
Various Contracts
(Managed)
State Medicaid
Programmes
FFS (Traditional)
Budgets
Discounted FFS
and CPC
Physicians
Negotiated
Prices
Various Contracts (Managed)
State
Governments
CPC
(DRGS)
Pharmacists
Copayments &
Out of pocket payments
Co-pay & Out-of-Pocket
Discounted FFS
and CPC
Hospitals
FFS/Formularies
Copayments &
Out of pocket
payments
General Taxation
Patients
Reimbursement for Out of pocket/
Copayments (e.g. Medigap) other
benefits (e.g. pharmaceuticals)
General Taxation/Payroll Taxes
Tax-payers
Consumers
(Mostly) Risk-Related Premia
Source: Financing Health Care, Volume II, Hoffmeyer et al., 1994
CPC: Cost-per-case
FFS: Fee-for-service
RBRVS: Resource-based relative value scale
appendix one
Source: OECD Health Data 2002
47
INTERNATIONAL HEALTH COMPARISONS
Appendix 2
Death rates from the main
cancers over time
2.1 Deaths from cervical cancer, 1980 to 1999
Deaths per 100,000 females (standardised)
8
7
6
5
New Zealand
Germany
United Kingdom
United States
Japan
Canada
Sweden
Australia
France
Italy
4
3
2
1
appendix two
Source: OECD Health Data 2002
48
98
97
99
19
19
96
95
94
Germany
United Kingdom
19
19
19
92
93
19
19
91
89
90
France
Sweden
19
19
19
88
87
85
86
Canada
New Zealand
19
19
19
19
84
Australia
Japan
19
82
81
83
19
19
19
19
19
80
0
Italy
United States
INTERNATIONAL HEALTH COMPARISONS
2.2 Deaths from breast cancer, 1980 to 1999
40
Deaths per 100,000 females (standardised)
35
30
United Kingdom
New Zealand
Germany
Canada
France
United States
Italy
Sweden
Australia
Japan
25
20
15
10
5
Australia
Japan
99
19
98
19
97
96
Germany
United Kingdom
19
94
95
19
19
92
93
19
19
91
89
90
France
Sweden
19
19
19
88
87
85
86
Canada
New Zealand
19
19
19
19
84
19
82
83
19
19
81
19
19
19
80
0
Italy
United States
appendix two
Source: OECD Heath Data 2002
49
INTERNATIONAL HEALTH COMPARISONS
2.3 Deaths from prostate cancer, 1980 to 1999
45
Deaths per 100,000 males (standardised)
40
35
Sweden
New Zealand
Australia
France
United Kingdom
Canada
Germany
United States
Italy
Japan
30
25
20
15
10
5
Australia
Japan
99
98
Germany
United Kingdom
19
97
19
19
96
95
19
19
94
93
France
Sweden
19
92
19
91
19
90
Canada
New Zealand
19
89
19
88
19
87
19
86
19
85
19
84
19
83
19
82
19
81
19
19
19
80
0
Italy
United States
Source: OECD Health Data 2002
2.4 Deaths from lung cancer, 1980 to 1999
60
United States
Canada
United Kingdom
Italy
New Zealand
Australia
France
Germany
Japan
Sweden
50
40
30
20
10
Australia
Japan
Source: OECD Health Data 2002
Canada
New Zealand
France
Sweden
Germany
United Kingdom
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
19
85
19
84
19
83
19
82
19
81
19
80
0
19
appendix two
Deaths per 100,000 of population (standardised)
50
Italy
United States