Published on Investing in Health

What does a “developed” health system look like?

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SDM-TR-052 World Bank

It’s hard to say with much precision. Or at least that’s one of the main impressions you get when scanning a 2010 report on OECD health system institutional characteristics. The results are from a survey of 29 mostly high-income countries, based on responses to 81 questions about their health systems, including various aspects of financing, coverage, service delivery organization and governance. It is proving to be a useful reference point as we undertake a stock-taking of reforms across Europe and Central Asia.

The fact that there are many varieties of advanced health systems is hardly surprising, of course, but it runs much deeper than the old Beveridge vs. Bismarck dichotomy. How countries approach issues like coverage rules, facility ownership status and provider payment methods cannot be neatly divided into two groups. Once you look across a large number of characteristics and countries, similarities would seem to be the exception, not the rule.

They do appear to have some things in common, however, such as the use of health technology assessment, similar regulations for human resources, and measures to protect patient rights. (Although if we were to dig deeper than the questions asked in the survey, more variation would surely be uncovered here too).

Interestingly, only about half of Organisation for Economic Co-operation and Development (OECD) systems have embarked on what we might think of as ‘innovative’ reform agendas such as performance-related payment systems, publishing information on the quality of care or the widespread use of IT for exchanging information among providers.

What do the OECD’s heterogeneous approaches mean for our work to strengthen health systems in low- and middle-income countries (LMICs)? I am sure people have lots of ideas about drawing the right lessons. A few thoughts come to mind.

First, it is good to be open-minded about what kind of system is most appropriate for any particular LMIC. There is no obvious “best practice” health system to which all LMICs should converge. This is all the more true since if we were to look for rigorous empirical evidence about “what works” in terms of various institutional characteristics, we would probably be hard-pressed to come up with many clear verdicts.

On the other hand, presumably there has also been some learning going on in the OECD, and thus LMICs may be able to avoid approaches that are rarely found in advanced systems (e.g., line-item budgeting for hospitals), and at the same time they can get a head-start on more recent trends (e.g., the use of IT).

Finally, it is worth noting that there are fewer differences across the OECD when it comes to the big-picture outcomes that we really care about. Life expectancy is quite similar, and financial protection is usually very good. All the more reason to make sure that any reform agenda is linked to achieving objectives.


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