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Patterns and performance in social health insurance systems

Figueras J, Saltman RB, Busse R, Dubois H
In: Saltman RB, Busse R, Figueras J (eds.) Social health insurance systems in western Europe. Buckingham: Open University Press, S. 81-140



The complex, often divergent organizational arrangements within social health insurance (SHI) systems make them difficult to assess and evaluate. While this dilemma affects other health care systems as well, precisely the core characteristics that define SHI systems – e.g. pluralist, corporatist, self-regulatory – tend in practice to further complicate the assessment process. This chapter collects and reviews available quantitative data about SHI systems, looking for patterns of activity that make it possible to assess the performance of these systems along four key parameters: health status, satisfaction/responsiveness, equity and efficiency. As noted in Chapter 1 above, this conceptual framework is better tailored to examining key elements of the eight studied SHI systems than is the more globally focused tri-partite framework put forward by WHO in the World Health Report 2000 (WHO 2000). The parameters used here were selected as measures generally agreed by experts to be important to the functioning of a good health system, as well as for their political importance to national decision-makers in the formulation of health policy. The logic of their presentation is designed to look first at three parameters of outcomes achieved (health status, satisfaction/responsiveness, equity), and then to consider data regarding expenditures made to achieve these reported outcomes (efficiency). The objective of the chapter is to examine the degree to which it is possible to measure the performance of SHI systems along these four parameters, and the extent to which the available data allows us to draw useful observations about SHI systems generally.

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