National Health Systems
NATIONAL HEALTH SYSTEMS
In every country there is a "national health system," the characteristics of which are determined by historical departments, the country's economic level, and the policies of its government. To some extent in all countries, there is a free market in which private health services to individuals are bought and sold. At the same time, governments intervene in this market to attempt to assure appropriate health services to part or all of the population.
The structure of a national health system has five principle components: resource production, organization of programs, economic support, management, and delivery of services. Within each of these components, there are various activities and functions. These are indicated in Figure 1.
The extent to which governments intervene in the free market of private health services permits a national health system to be classified along a scale that varies from low to high intervention. If we pose four steps in the scaling, they range from national health systems that are (1) very entrepreneurial to (2) welfare-oriented to (3) universal and comprehensive to (4) socialist. This scaling may apply to health systems in countries of different economic levels. If we scale economic levels in three steps, there results a matrix of 12 cells. This is shown, with illustrative countries indicated in each cell in Table 1.
In the twentieth century there was a tendency of national health systems throughout the world to evolve from column 1 to column 2 and from column 2 to column 3. Column 3 (universal and comprehensive health systems) is the most enduring, and systems in column 4 (socialist systems)
tend to move in the other direction toward column 3. These trends mean that national health systems are achieving increasing equity for the populations they serve, without involving the complete control by government, implicit in the socialist health systems. The trends are also associated with an improvement in health status in virtually every country, as reflected by an extension of life expectancy at birth.
Trends in life expectancy at birth have shown improvement throughout the world. Considering the 30-year period from the mid-1950s to the mid-1980s, the trends in major world regions are shown in Table 2. Perhaps the most interesting feature of these data is that the improvement in all industrialized countries (from 65.7 to 72.3 years) was by 10.5 percent, while the improvement in all developing countries (from 41.0 to 57.6 years) was by 40.4 percent. In spite of the greater relative progress in the developing countries, of course, the advantages of life in the industrialized countries are still considerable.
These trends are due to actions in both the private and public sectors of national economies. Over recent decades the share of gross national product (GNP) devoted to the health system has increased in all countries. In the United States, for example, it rose from 5.3 percent of GNP in 1960 to 11.2 percent in 1987. In Honduras the share of GNP devoted to the health system rose from 5.1 percent in 1970 to 6.0 in 1976.
The proportion of health expenditures derived from governmental sources has also been increasing over the years. In the United States, for
|National Health Systems: Types Classified by Country's Economic Level and System's Health Policies, around 1986|
|Economic Level of Countries||Health System Policies (Market Intervention)|
|(GNP per capita)||Entrepreneurial||Welfare-Oriented||Comprehensive-Universal||Socialist|
|SOURCE: M. I. Roemer (1991). National Health Systems of the World, Vol. 1: The Countries. New York: Oxford University Press, p. 97.|
example, this share rose from 24.5 percent in 1960 to 41.1 percent in 1987. In Japan, governmental sources of health system expenditures were 60.0 percent in 1960, rising to 73.5 percent in 1987. Among developing countries the equivalent trend cannot be reported due to lack of data. A somewhat comparable trend can be noted in the proportion of central government budgets derived from public (compared with private) sources. In Uruguay, for example, this increased from 1.6 percent in 1972 to 4.8 percent in 1986, while in Bolivia over the same span of years it declined from 6.3 to 1.4 percent. Percentages, of course, can be deceptive; actual health spending for health in Bolivia continued at about the same level while the denominator of total government expenditure was rising.
The long-term meaning of these various trends suggests an improvement in health service equity throughout the world. Health care has been of rising importance in national economies, which is reflected by increasing shares of such expenditures being derived from governmental sources. This has led to gradual improvement of the health status of populations worldwide.
MILTON I. ROEMER
|Life Expectancy at Birth in Major World Regions, 1950–1985|
|Life Expectancy in Years|
|SOURCE: United Nations, Department of International Economic and Social Affairs (1989). World Population Prospects 1988 (Population Studies No. 106). New York: U.N., pp. 166–189.|
|All Developing Countries||41.0||57.6|
|All Industrialized Countries||65.7||72.3|
Roemer, M. I. (1991). National Health Systems of the World, Vol. 1: The Countries. New York: Oxford University Press.
—— (1993). National Health Systems of the World, Vol. 2: The Issues. New York: Oxford University Press.
United Nations, Department of International Economic and Social Affairs (1989). World Population Prospects 1988 (Population Studies No. 106). New York: U.N.
U.S. Public Health Service, Office of Disease Prevention and Health Promotion (1988). Disease Prevention/Health Promotion: The Facts. Palo Alto, CA: USPHS.