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Organization and financing of social health insurance systems - current status and recent policy developments

Busse R, Saltman RB, Dubois H
In: Saltman RB, Busse R, Figueras J (eds.) Social health insurance systems in western Europe. Buckingham: Open University Press, S. 33-80




The concept of social health insurance (SHI) is deeply ingrained in the fabric of health care systems in western Europe. It provides the organizing principle and a preponderance of the funding in seven countries – Austria, Belgium, France, Germany, Luxembourg, the Netherlands and Switzerland. Since 1995, it has also become the legal basis for organizing health services in Israel. Previously, SHI models played an important role in a number of other countries that subsequently changed to predominantly tax-funded arrangements in the second half of the twentieth century – Denmark (1973), Italy (1978), Portugal (1979), Greece (1983) and Spain (1986). Moreover, there are segments of SHI-based health care funding arrangements still operating in predominantly tax-funded countries like Finland, Sweden and the United Kingdom, as well as in Greece and Portugal. In addition, a substantial number of central and eastern European (CEE) countries have introduced adapted SHI models since they regained control over national policy-making – among them Hungary (1989), Lithuania (1991), Czech Republic (1992), Estonia (1992), Latvia (1994), Slovakia (1994) and Poland (1999).

Despite this pivotal role in European health care, the organization and operation of SHI systems has received notably less attention from academics and researchers than have tax-funded systems. Neither the core system characteristics that define the SHI model, nor the performance of various SHI models in comparison with that of various tax-funded systems, have received the type of systematic assessment they deserve. This is the case not only in the English language literature. Those comparative studies available in Dutch, French or German language (the seven western European SHI countries) tend to be limited to neighbouring (border) countries, and often focus on narrow technical rather than broader conceptual issues. Wide structural and organizational differences between western European SHI countries (as well as with Israel) further complicate efforts to delineate common patterns and problems.

The availability of widely accessible, comparative knowledge about SHI systems could be helpful for health policy-making both outside and inside Western European SHI systems. Outside, policy-makers in central and eastern Europe (CEE), but also in other potentially interested areas such as south-east Asia, South America and the United States, would benefit from being able to obtain a clear picture of how western European SHI systems are organized and how well they perform. Among other advantages, this might reduce political tendencies within some former Soviet Bloc countries to focus on only the official form of SHI systems without considering the equally important societal characteristics necessary to make those systems work successfully. Inside SHI systems, a clearer comparative picture could assist policy-makers as they grapple with increasing challenges to the economic, political and social sustainability of the traditional SHI framework (see below).
One of the most striking observations about contemporary SHI systems is the contrast between this knowledge gap about what they are and how well they function, on the one hand, and the strength of the emotional attachment of the citizens within these countries to their particular SHI system, on the other hand. How can one account for such a powerful popular attachment to a health care arrangement that is so hard to describe and about the performance of which information is so limited? This observation suggests that, before detailing the dilemmas that contemporary SHI systems confront, it may be useful to consider how SHI systems look in the eyes of those who support them.

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