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Are health problems systemic? Politics of access and choice under Beveridge and Bismarck systems

  • Zeynep Or (a1), Chantal Cases (a2), Melanie Lisac (a3), Karsten Vrangbæk (a4), Ulrika Winblad (a5) and Gwyn Bevan (a6)
  • DOI:
  • Published online: 01 July 2010

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless, the nature and intensity of the reforms required are largely determined by each country’s basic social security model. Most reforms in Beveridge-type systems have sought to increase choice and reduce waiting times while those in major Bismarck-type systems have focused on cost control by constraining the choice of providers. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of healthcare system, which underlie these differences? Have recent reforms been effective?

Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms. Thus, while countries may share similar problems in terms of improving healthcare performance, adopting a ‘copy-and-paste’ approach to healthcare reform is likely to be ineffective.

Corresponding author
Correspondence to: Zeynep Or, Institute for Research and Information in Health Economics, 10 rue Vauvenargues, 75018, Paris, France. Email:
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G. Bevan (2008), ‘Is choice working for patients in the English NHS?’, British Medical Journal, 337: a935.

G. Bevan (2009), ‘Have targets done more harm than good in the English NHS?’, British Medical Journal, 338: a3129.

G. Bevan C. Hood (2006), ‘What’s measured is what matters: targets and gaming in the English public health care system’, Public Administration, 84(3): 517538.

G. Bevan R. Robinson (2005), ‘The interplay between economic and political logics: path dependency in health care in England’, Journal of Health Politics Policy and Law, 30: 5378.

M. Fredriksson U. Winblad (2008), ‘Consequences of a decentralised healthcare governance model: measuring regional authority support for patient choice in Sweden’, Social Science and Medicine, 67: 271279.

M. Hanning U. Winblad Spångberg (2000), ‘Maximum waiting time – a treat to clinical freedom? Implementation of a policy to reduce waiting times’, Health Policy, 52: 1532.

C. Propper , M. Sutton , C. Whitnall F. Windmeijer (2008), ‘Did ‘targets and terror’ reduce waiting times in England for hospital care?’, The B.E. Journal of Economic Analysis & Policy, 8(2, Article 5.

P. C. Smith (2002), ‘Measuring health system performance’, European Journal of Health Economics, 3: 145148.

A. Dixon , R. Robertson , R. Bal (2010), ‘The experience of implementing choice at point of referral: a comparison of the Netherlands and England’, Health Economics, Policy and Law, 5: 295317.

C.M. Flood , A. Haugan (2010), ‘Lessons for Canada from regulatory approaches to the public/private divide in Sweden, the UK, the Netherlands, Germany and France’, Health Economics, Policy and Law, 5: 319341.

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Health Economics, Policy and Law
  • ISSN: 1744-1331
  • EISSN: 1744-134X
  • URL: /core/journals/health-economics-policy-and-law
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