Addressing health inequity during the COVID-19 pandemic through primary health care and public health collaboration: a multiple case study analysis in eight high-income countries.

BACKGROUND: The COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions. METHODS: We analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021. RESULTS: Four themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries. CONCLUSIONS: This study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach.

BACKGROUND: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. METHODS: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. RESULTS: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. CONCLUSIONS: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆.

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Physical accessibility of primary care facilities for people with disabilities: a cross-sectional survey in 31 countries.

BACKGROUND: Primary care is the first point of care, also for people with disabilities. The accessibility of primary care facilities is therefore very important. In this study we analysed comparative data on physical accessibility of general practices (GP practices) in 31 (mainly) European countries. METHODS: We used data from the QUALICOPC study, conducted in 2011 among GPs in 34 (mainly European) countries and constructed a physical accessibility scale. We applied multilevel analysis to assess the differences between and within countries and to test hypotheses, related to characteristics of the practices and of the countries. RESULTS: We found large differences between countries and a strong clustering of physical accessibility within countries. Physical accessibility was negatively related to the age of the GPs, and was less in single-handed and in inner city practices. Of the country variables only the length of the period of social democratic government participation during the previous decades was positively related to physical accessibility. CONCLUSION: A large share of the variation in physical accessibility of GP practices was on the level of countries. This means that national policies can be used to increase physical accessibility of GP practices.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries.

INTRODUCTION: Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions). OBJECTIVES: This cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae. METHODS: Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries. RESULTS: 11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations. DISCUSSION AND CONCLUSIONS: A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Community participation in primary care: willingness to participate, a web survey in the Netherlands.

AimThe aim of the study is to explore to what extent members of the community are willing to participate in the way their primary care practice is organized and which characteristics of people and community are associated with this willingness. BACKGROUND: Community participation in primary care refers to involvement of community members in the organization, governance and policy making of primary care facilities. Due to demographic changes and changes in the role of patients and the community concerning health care, it becomes important to include the social environment of patients into healthcare. Community participation may help GPs to improving their practice and providing care according to the needs of the population. Interpreted this way, it may be an important contributor to quality of care. METHODS: In 2016, a web questionnaire was send to 800 members of the Dutch Health Care Consumer Panel. The response rate was 34%. Willingness to participate was divided into perceived readiness, ability and time to participate. The data were analysed using frequency tables and linear regression analysis.FindingsHalf of the participants were ready to give their opinion on primary care and one-third reported willingness to participate in decision making. Participants were less optimistic about their ability to participate and the time they have available for participation. Readiness and perceived ability were mainly determined by the importance that the respondents attributed to participation. Participants with previous experience in volunteering appeared more willing to spend time on participation. CONCLUSIONS: This study showed that half of the respondents are willing to participate, but they are less sure about their ability to do so and that finding time to participate is seen as problematic. Future research should focus on which characteristics influence willingness. This knowledge might help primary care facilities to recruit people more easily and successfully.

Paying hospital specialists: Experiences and lessons from eight high-income countries.

Payment systems for specialists in hospitals can have far reaching consequences for the efficiency and quality of care. This article presents a comparative analysis of payment systems for specialists in hospitals of eight high-income countries (Canada, England, France, Germany, Sweden, Switzerland, the Netherlands, and the USA/Medicare system). A theoretical framework highlighting the incentives of different payment systems is used to identify potentially interesting reform approaches. In five countries,most specialists work as employees - but in Canada, the Netherlands and the USA, a majority of specialists are self-employed. The main findings of our review include: (1) many countries are increasingly shifting towards blended payment systems; (2) bundled payments introduced in the Netherlands and Switzerland as well as systematic bonus schemes for salaried employees (most countries) contribute to broadening the scope of payment; (3) payment adequacy is being improved through regular revisions of fee levels on the basis of more objective data sources (e.g. in the USA) and through individual payment negotiations (e.g. in Sweden and the USA); and (4) specialist payment has so far been adjusted for quality of care only in hospital specific bonus programs. Policy-makers across countries struggle with similar challenges, when aiming to reform payment systems for specialists in hospitals. Examples from our reviewed countries may provide lessons and inspiration for the improvement of payment systems internationally.

Netherlands: Health System Review.

This analysis of the Dutch health system reviews recent developments in organization and governance, health financing, healthcare provision, health reforms and health system performance. Without doubt, two major reforms implemented since the mid-2000s are among the main issues today. The newly implemented long-term care reform will have to realize a transition from publicly provided care to more self-reliance on the part of the citizens and a larger role for municipalities in its organization. A particular point of attention is how the new governance arrangements and responsibilities in long-term care will work together. The 2006 reform replaced the division between public and private insurance by one universal social health insurance and introduced managed competition as a driving mechanism in the healthcare system. Although the reform was initiated almost a decade ago, its stepwise implementation continues to bring changes in the healthcare system in general and in the role of actors in particular. In terms of performance, essential healthcare services are within easy reach and waiting times have been decreasing. The basic health insurance package and compensations for lower incomes protect citizens against catastrophic spending. Out-of-pocket payments are low from an international perspective. Moreover, the Dutch rate the quality of the health system and their health as good. International comparisons show that the Netherlands has low antibiotic use, a low number of avoidable hospitalizations and a relatively low avoidable mortality. National studies show that healthcare has made major contributions to the health of the Dutch population as reflected in increasing life expectancy. Furthermore, some indicators such as the prescription of generics and length of stay reveal improvements in efficiency over the past years. Nevertheless, the Netherlands still has one of the highest per capita health expenditures in Europe, although growth has slowed considerably after reverting to more traditional sector agreements on spending.

Netherlands: health system review

This analysis of the Dutch health system reviews recent developmentsin organization and governance, health financing, health care provision,health reforms and health system performance. Without doubt, two majorreforms implemented since the mid-2000s are among the main issues today.The newly implemented long-term care reform will have to realize a transitionfrom publicly provided care to more self-reliance on the part of the citizens anda larger role for municipalities in its organization. A particular point of attentionis how the new governance arrangements and responsibilities in long-term carewill work together.The 2006 reform replaced the division between public and private insuranceby one universal social health insurance and introduced managed competitionas a driving mechanism in the health care system. Although the reform wasinitiated almost a decade ago, its stepwise implementation continues to bringchanges in the health care system in general and in the role of actors in particular.In terms of performance, essential health care services are within easy reachand waiting times have been decreasing. The basic health insurance packageand compensations for lower incomes protect citizens against catastrophicspending. Out-of-pocket payments are low from an international perspective.Moreover, the Dutch rate the quality of the health system and their health asgood. International comparisons show that the Netherlands has low antibioticuse, a low number of avoidable hospitalizations and a relatively low avoidablemortality. National studies show that health care has made major contributionsto the health of the Dutch population as reflected in increasing life expectancy.Furthermore, some indicators such as the prescription of generics and lengthof stay reveal improvements in efficiency over the past years. Nevertheless, theNetherlands still has one of the highest per capita health expenditures in Europe,although growth has slowed considerably after reverting to more traditionalsector agreements on spending.

Pharmaceutical regulation in 15 European countries: review

In the context of pharmaceutical care, policy-makers repeatedly facethe challenge of balancing patient access to effective medicines withaffordability and rising costs. With the aim of guiding the health policydiscourse towards questions that are important to actual and potential patients,this study investigates a broad range of regulatory measures, spanningmarketing authorization to generic substitution and resulting price levels in asample of 16 European health systems (Austria, Belgium, Denmark, England,Finland, France, Germany, Greece, Ireland, Italy, the Netherlands, Poland,Portugal, Scotland, Spain and Sweden).All countries employ a mix of regulatory mechanisms to containpharmaceutical expenditure and ensure quality and efficiency in pharmaceuticalcare, albeit with varying configurations and rigour. This variation alsoinfluences the extent of publicly financed pharmaceutical costs. Overall,observed differences in pharmaceutical expenditure should be interpreted inconjunction with the differing volume and composition of consumption andprice levels, as well as dispensation practices and their impact on measurementof pharmaceutical costs.No definitive evidence has yet been produced on the effects of differentcost-containment measures on patient outcomes. Depending on the foremostpolicy concerns in each country, different levers will have to be used to enablethe delivery of appropriate care at affordable prices.

The basic benefit package: composition and exceptions to the rules. A case study.

With the introduction of the Health Insurance Act in 2006 in the Netherlands, the basic package of the former sickness funds became valid for all citizens. The basic benefit package has been subject to change, responding to increasing health care expenditures, medical innovations and the economic crisis. In this paper we address the decision criteria used to assess the package annually since 2006 and describe some developments that do not follow the criteria, leading to a yo-yo effect. We discuss the formation of the decision for in- or exclusion and why some treatments seem to follow an, at first sight, arbitrary in- and exclusion pathway. We first describe the official way of establishing the basic benefit package and than will describe why some treatments follow a deviated path. We conclude that political pressure and pressure from interest groups may lead to inclusion or postponement of exclusion. Reform of the organization of certain forms of health care (in our example mental care) may lead to seemingly inconsequent changes. The yo-yo effect of some treatments or pharmaceuticals may have negative effects on health care providers, insurers and patients. The seemingly well defined criteria available for defining the basic package appear to be broadly interpretable and other influences may determine the final decision of inclusion or exclusion.

International developments in revenues and incomes of general practitioners from 2000 to 2010.

BACKGROUND: The remuneration system of General Practitioners (GPs) has changed in several countries in the past decade. The aim of our study was: to establish the effect of these changes on the revenues and income of GPs in the first decade of the 21st century. METHODS: Annual GP revenue and practice costs were collected from national institutes in the eight countries included in our study (Belgium, Denmark, Finland, France, Germany, The Netherlands, Sweden, The United Kingdom (UK)) from 2000-2010. The data were corrected for inflation and purchasing power. Data on the remuneration systems and changes herein were collected from the European Observatory Health Systems Reviews and country experts. RESULTS: Comprehensive changes in the remuneration system of GPs were associated with considerable changes in GP income. Incremental changes mainly coincided with a gradual increase in income after correction for inflation. Average GP income was higher in countries with a strong primary care structure. CONCLUSIONS: The gap between the countries where GPs have a lower income (Belgium, Sweden, France and Finland) and the countries where GPs have a higher income (Netherlands, Germany and the UK) continues to exist over time and appeared to be related to dimensions of primary care, such as governance and access. New payment forms, such as integrated care payment systems, and new health care professionals that are working for GPs, increasingly blur the line between practice costs and income, making it more and more important to clearly define expenditures on GPs, to remain sight on the actual income of GPs.

Explaining governmental involvement in home care across Europe: an international comparative study.

The involvement of governments in the home care sector strongly varies across Europe. This study aims to explain the differences through the conditions for the involvement of informal care and governments in society; wealth and the demographic structure. As this study could combine qualitative data and quantitative data analyses, it could consider larger patterns than previous studies which were often based on ideographic historical accounts. Extensive data were gathered in 30 European countries, between 2008 and 2010. In each country, policy documents were analysed and experts were interviewed. International variation in regulation and governmental funding of personal care and domestic aid are associated with differences in prevailing values on family care, tax burden and wealth in a country. Hence, this study provides evidence for the obstacles - i.e. country differences - for transferring home care policies between countries. However, longitudinal research is needed to establish whether this is indeed the causal relationship we expect.

Home care across Europe: current structure and future challenges

For every person over the age of 65 in today’s European Union, there are four people of working age but, by 2050, there will only be two. Demand for long-term care, of which home care forms a significant part, will inevitably increase in the decades to come. Despite the importance of the issue, however, up-to-date and comparative information on home care in Europe is lacking. This book attempts to fill some of that gap by examining current European policy on home care services and strategies. Home care across Europe probes a wide range of topics including the links between social services and health-care systems, the prevailing funding mechanisms, how service providers are paid, the impact of governmental regulation, and the complex roles played by informal caregivers. Drawing on a set of Europe-wide case studies (available in a second, online volume), the study provides comparable descriptive information on many aspects of the organization, financing and provision of home care across the continent. It is a text that will help frame the coming debate about how best to serve elderly citizens as European populations age.

The Netherlands: health system review.

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of health systems and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems. They also describe the institutional framework, process, content, and implementation of health and health care policies, highlighting challenges and areas that require more in-depth analysis. Undoubtedly the dominant issue in the Dutch health care system at present is the fundamental reform that came into effect in 2006. With the introduction of a single compulsory health insurance scheme, the dual system of public and private insurance for curative care became history. Managed competition for providers and insurers became a major driver in the health care system. This has meant fundamental changes in the roles of patients, insurers, providers and the government. Insurers now negotiate with providers on price and quality and patients choose the provider they prefer and join a health insurance policy which best fits their situation. To allow patients to make these choices, much effort has been made to make information on price and quality available to the public. The role of the national government has changed from directly steering the system to safeguarding the proper functioning of the health markets. With the introduction of market mechanisms in the health care sector and the privatization of former sickness funds, the Dutch system presents an innovative and unique variant of a social health insurance system. Since the stepwise realization of the blueprint of the system has not yet been completed, the health care system in The Netherlands should be characterized as being in transition. Many measures have been taken to move from the old to the new system as smoothly as possible. Financial measures intended to prevent sudden budgetary shocks and payment mechanisms have been (and are) continuously adjusted and optimized. Organizational measures aimed at creating room for all players to become accustomed to their new role in the regulated market. As the system is still a "work in progress", it is too early to evaluate the effects and the consequences of the new system in terms of accessibility, affordability, efficiency and quality. Dutch primary care, with gatekeeping GPs at its core, is a strong foundation of the health care system. Gatekeeping GPs are a relatively unusual element in social health insurance systems. The strong position of primary care is considered to prevent unnecessary use of more expensive secondary care, and promote consistency and coordination of individual care. It continues to be a policy priority in The Netherlands. The position of the patient in The Netherlands is strongly anchored in several laws concerning their rights, their relation to providers and insurers, access to information, and possibilities to complain in case of maltreatment. In terms of quality and efficiency of the health care system, The Netherlands is, with some notable exceptions (e.g. implementation of innovations such as day surgery and electronic patient records), an average performer when compared to other wealthy countries. It is too early to tell whether efficiency and quality gains will occur as a result of the 2006 reform.

The Netherlands: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

Income development of General Practitioners in eight European countries from 1975 to 2005.

BACKGROUND: This study aims to gain insight into the international development of GP incomes over time through a comparative approach. The study is an extension of an earlier work (1975-1990, conducted in five yearly intervals). The research questions to be addressed in this paper are: 1) How can the remuneration system of GPs in a country be characterized? 2) How has the annual GP income developed over time in selected European countries? 3) What are the differences in GP incomes when differences in workload are taken into account? And 4) to what extent do remuneration systems, supply of GPs and gate-keeping contribute to the income position of GPs? METHODS: Data were collected for Belgium, Denmark, Germany, Finland, France, the Netherlands, Sweden and the United Kingdom. Written sources, websites and country experts were consulted. The data for the years 1995 and 2000 were collected in 2004-2005. The data for 2005 were collected in 2006-2007. RESULTS: During the period 1975-1990, the income of GPs, corrected for inflation, declined in all the countries under review. During the period 1995-2005, the situation changed significantly: The income of UK GPs rose to the very top position. Besides this, the gap between the top end (UK) and bottom end (Belgium) widened considerably. Practice costs form about 50% of total revenues, regardless of the absolute level of revenues. Analysis based on income per patient leads to a different ranking of countries compared to the ranking based on annual income. In countries with a relatively large supply of GPs, income per hour is lower. The type of remuneration appeared to have no effect on the financial position of the GPs in the countries in this study. In countries with a gate-keeping system the average GP income was systematically higher compared to countries with a direct-access system. CONCLUSION: There are substantial differences in the income of GPs among the countries included in this study. The discrepancy between countries has increased over time. The income of British GPs showed a marked increase from 2000 to 2005, due to the introduction of a new contract between the NHS and GPs.

Bismarck or Beveridge: a beauty contest between dinosaurs.

BACKGROUND: Health systems delivery systems can be divided into two broad categories: National Health Services (NHS) on the one hand and Social Security (based) Health care systems (SSH) on the other hand. Existing literature is inconclusive about which system performs best. In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-systems versus SSH-system for health outcomes, expenditure and population satisfaction. METHODS: In this study we used time series data for 17 European countries, that were characterized as either NHS or SSH country. We used the following performance indicators: For health outcome: overall mortality rate, infant mortality rate and life expectancy at birth. For health care costs: health care expenditure per capita in pppUS$ and health expenditure as percentage of GDP. Time series dated from 1970 until 2003 or 2004, depending on availability. Sources were OECD health data base 2006 and WHO health for all database 2006. For satisfaction we used the Eurobarometer studies from 1996, 1998 and 1999. RESULTS: SSH systems perform slightly better on overall mortality rates and life expectancy (after 1980). For infant mortality the rates converged between the two types of systems and since 1980 no differences ceased to exist.SSH systems are more expensive and NHS systems have a better cost containment. Inhabitants of countries with SSH-systems are on average substantially more satisfied than those in NHS countries. CONCLUSION: We concluded that the question 'which type of system performs best' can be answered empirically as far as health outcomes, health care expenditures and patient satisfaction are concerned. Whether this selection of indicators covers all or even most relevant aspects of health system comparison remains to be seen. Perhaps further and more conclusive research into health system related differences in, for instance, equity should be completed before the leading question of this paper can be answered. We do think, however, that this study can form a base for a policy debate on the pros and cons of the existing health care systems in Europe.