International Health Comparisons by clayr86

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									International Health Comparisons
A compendium of published information on healthcare systems,
the provision of healthcare and health achievement in 10 countries
  International Health Comparisons




   A compendium of published information on healthcare systems,
the provision of healthcare and health achievement in 10 countries
The National Audit Office team consisted of:
     Ashley McDougall, Paul Duckett and Manjeet
     Manku under the direction of James Robertson.




For further information about the National Audit Office
please contact:

National Audit Office
Press Office
157-197 Buckingham Palace Road
Victoria
London
SW1W 9SP

Tel: 020 7798 7400

Email: enquiries@nao.gsi.gov.uk
                                                                              INTERNATIONAL HEALTH COMPARISONS




Contents
Part 1                                                  Appendices
                                                          1. Healthcare delivery systems                   28
 Making comparisons                                1
                                                             Australia                                     28
   Introduction                                     1
                                                             Canada                                        30
   Scope and structure of the report                1
                                                             England                                       32
   Basis of the compendium                          1
                                                             France                                        34
   Difficulties in interpreting the information     1
                                                             Germany                                       36
                                                             Italy                                         38
Part 2
                                                             Japan                                         40
                                                             New Zealand                                   42
 Healthcare systems                                3
                                                             Sweden                                        44
   Expenditure on health                            3
                                                             United States                                 46
   Financing arrangements in different countries    4
                                                          2. Death rates from the main cancers over time   48

Part 3

 Providing healthcare                              9
   Health personnel                                 9
   Medical infrastructure                          14
   Medicines and drugs                             14
   Medical procedures carried out                  14
   Preventative medical programmes                 14


Part 4

 Health achievements                               17
   Life expectancy                                 17
   Infant and perinatal mortality                  17
   Main causes of death                            19
   Health outcomes                                 21
   Performance of healthcare systems               21
INTERNATIONAL HEALTH COMPARISONS




 Figure Guide
 Figure 1: Definitions of 'disability' used in             2   Figure 27: Main cancer killers with death rates           23
     calculating disability adjusted life expectancy
                                                               Figure 28: Deaths from lung cancer                        23
 Figure 2: National expenditure on health as a             3
                                                               Figure 29: Deaths from breast cancer                      24
     percentage of Gross Domestic Product (GDP)
     in recent years                                           Figure 30: Deaths from main circulatory diseases          24
 Figure 3: Health expenditure as a percentage              5   Figure 31: Deaths from ischaemic heart                    25
     of GDP, 1980 to 2001                                          disease, 1980 to 1999
 Figure 4: Health expenditure per head                     5   Figure 32: Five-year survival rates for lung cancer       25
 Figure 5: Sources of health expenditure                   6   Figure 33: Five-year survival rates for breast cancer     26
 Figure 6: The methods of financing healthcare             7   Figure 34: Five-year survival rates for cancer of         26
                                                                   the colon
 Figure 7: Number of practising physicians                 9
                                                               Figure 35: Five-year survival rates for prostate cancer   27
 Figure 8: Level of practising physicians,                10
     1980 to 2000                                              Figure 36: Average length of stay for acute care          27
 Figure 9: Number of practising nurses                    11   Appendix 1
 Figure 10: Acute hospital admissions                     11   Figure 1.1 Financing of healthcare in Australia, 1999     29
 Figure 11: Practising nurses per 1,000 acute admissions 12    Figure 1.2: Financing of healthcare in Canada, 1999       31
 Figure 12: Practising nurses per acute bed day           12   Figure 1.3: Financing of healthcare in England, 1999      33
 Figure 13: Number of acute hospital beds                 13   Figure 1.4: Financing of healthcare in France, 1999       35
     per 1,000 of population
                                                               Figure 1.5: Financing of healthcare in Germany, 1995      37
 Figure 14: Bed occupancy for acute beds                  13       (Values in Billion DM)
 Figure 15: Availability of Magnetic Resonance            14   Figure 1.6: Financing of healthcare in Italy, early 1990s 39
     Imaging units
                                                               Figure 1.7: Financing of healthcare in Japan, early 2000 41
 Figure 16: Public expenditure on pharmaceuticals         15
                                                               Figure 1.8: Financing of healthcare in New Zealand, 1998 43
     and other medical non-durables prescribed for
     out-patients                                              Figure 1.9: Financing of healthcare in Sweden, 1999       45
 Figure 17: Coronary bypass procedures per 100,000        15   Figure 1.10: Financing of healthcare in the United States, 47
     of population                                                 early 1990s
 Figure 18: Percentage of children immunised              16   Appendix 2
     against measles
                                                               Figure 2.1: Deaths from cervical cancer, 1980 to 1999     48
 Figure 19: Percentage of children immunised against      16
                                                               Figure 2.2: Deaths from breast cancer, 1980 to 1999       49
     diphtheria, tetanus and pertussis (whooping cough)
                                                               Figure 2.3: Deaths from prostate cancer, 1980 to 1999     50
 Figure 20: Life expectancy at birth                      18
                                                               Figure 2.4: Deaths from lung cancer, 1980 to 1999         50
 Figure 21: Potential years of life lost                  18
 Figure 22: Perinatal mortality, 1980 to 2000             19
 Figure 23: Infant mortality, 1980 to 2000                20
 Figure 24: Main causes of death                          21
 Figure 25: Deaths from cancer, 1980 to 1999              22
 Figure 26: Latest known mortality for all cancers        22
                                                                                                    INTERNATIONAL HEALTH COMPARISONS




Part 1                                                                           Making comparisons




Introduction                                                                            World Health Organization3, the two reports prepared for
                                                                                        the Chancellor of the Exchequer by Derek Wanless in
1.1 Members of the Committee of Public Accounts have                                    2001 and 20024, together with the supporting report
    expressed interest in comparative material on                                       commissioned by HM Treasury from the European
    healthcare in other countries. This compendium of                                   Observatory5, work by The Commonwealth Fund6, and
    information has been compiled from published sources                                the EUROCARE-2 and National Cancer Institute studies
    by the National Audit Office and is provided for                                    on cancer survival rates7.
    background information. A copy has been placed in the
    library of the House of Commons.                                             1.6 Analysis of the data has been confined to setting out the
                                                                                     comparisons in tabular and graphical form to show
                                                                                     relative positions at a certain date, and the direction of
Scope and structure of the                                                           travel, together with brief textual explanations and
compendium                                                                           highlighting of key differences. The compendium does
                                                                                     not examine the causes of differences between
1.2 This compendium sets out comparative data on                                     countries or draw conclusions on policy issues such as
    healthcare systems and health in 10 countries, selected                          which methods of financing healthcare are best. The
    as broadly comparable industrialised nations                                     Department of Health has seen the compendium, and
    (specifically, the G7 countries1), or as those innovative                        has noted that the inconsistencies and incompatibilities
    countries frequently included in comparisons (Australia,                         between data sources in different countries mean that
    New Zealand and Sweden).                                                         valid comparisons cannot be made on the basis of these
                                                                                     figures alone.
1.3 The structure of the compendium is as follows:

     !   Part 1: Making comparisons;
                                                                                 Difficulties in interpreting
     !   Part 2: Healthcare systems;
                                                                                 the information
     !   Part 3: Providing healthcare; and
     !   Part 4: Health achievements.                                            Lack of comparability and completeness of
                                                                                 the data
1.4 In addition, two appendices set out more detail on                           1.7 The OECD data used extensively in this compendium are
    healthcare delivery systems (Appendix 1) and death                               collected by countries primarily for their own purposes
    rates from the main cancers over time (Appendix 2).                              and methods, timing and definitions vary, see Figure 1 for
                                                                                     example. In addition, available information indicates that
Basis of the report                                                                  validation procedures vary between countries. In some
                                                                                     countries, for example, data are based on surveys of self-
1.5 The report draws exclusively on published information,                           reporting individuals. The report notes when a comparison
    principally the most recent data for 2002 from                                   is likely to be particularly prone to such problems, but
    the Organisation for Economic Co-operation and                                   inevitably a margin of uncertainty remains within the data
    Development (OECD)2. Other sources of data include the                           as presented.
                                                                                                                                                    part one




1    Canada, France, Germany, Italy, Japan, the United Kingdom and the United States.
2    OECD Health Data 2002.
3    World Health Report 2000: Health systems: improving performance, World Health Organization, 2000.
4    Securing Our Future Health: Taking a Long-Term View, Interim report, November 2001, Final report, April 2002.
5    Health care systems in eight countries: trends and challenges, European Observatory on Health Care Systems, April 2002.                        1
6    Multinational comparisons of health systems data, Anderson G.F. and Hussey P.S., The Commonwealth Fund, 2000.
7    Survival of cancer patients in Europe: the EUROCARE-2 Study, 1999, SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002.
             INTERNATIONAL HEALTH COMPARISONS




           1    Definitions of 'disability' used in calculating disability                 for secondary (hospital) care. As a result there are fewer
                adjusted life expectancy                                                   in-patient admissions per 1,000 of the population than
                                                                                           in a country such as France, which has no such
                !   Australia takes disability to be one or more of 17                     gatekeeper function. A country where older people
                    defined conditions.                                                    make up a smaller proportion of the population than
                !   Canada takes disability to be limitations in 19 specific               average might be expected to have lower expenditure
                    activities lasting at least six months - the last survey was           per head on healthcare for example. The compendium
                    in 1991.                                                               flags up such problems where applicable.
                !   France includes as disabled all those in retirement homes
                    - the last survey was in 1991-92.
                !   Germany extrapolates to disability days the results of a
                                                                                      There are uncertain relationships between
                    survey asking about disability in the previous four weeks.        cause and effect and the impact of policy
                !   Japan takes disability to be confinement to bed.                  changes may not yet be apparent
                !   New Zealand takes disability to be as self-reported in the        1.10 Complex relationships between cause and effect mean
                    Household Disability Survey.                                           that it is not straightforward to identify which elements
                !   United Kingdom available data relate to Great Britain                  should be changed to achieve desired outcomes. The
                    households only, although an adjustment for communal                   indicators may be misleading if used in an uncritical
                    establishments was made from the 1991 census - disability
                                                                                           way to suggest that healthcare could be improved, for
                    is self-reported as a long-standing limitation on activities in
                    any way.                                                               example, by a simple matching against the levels of
                                                                                           indicators in other countries.
               Source: OECD Health Data 2002

                                                                                      1.11 A further consideration in drawing conclusions is that
                                                                                           the comparisons make no allowance for policy and
           1.8 A further difficulty is that published data are more
                                                                                           resourcing changes already in train in this country or
               complete on some issues of interest than others. This
                                                                                           elsewhere, aimed at producing improvements, but
               inevitably means that only a partial picture can be
                                                                                           which have not had time to work through. In particular,
               drawn for some topics.
                                                                                           the Government has allocated an additional £2.4 billion
                                                                                           in 2003-04 to improve the NHS in the United Kingdom,
           The nature of healthcare systems impacts on                                     with spending growing by 7.4 per cent a year after
                                                                                           inflation over the five years to 2007-08. Health spending
           measured indicators
                                                                                           in England will rise by 7.5 per cent a year. Taking into
           1.9 Differences between countries measured by any                               account these new resources, United Kingdom health
               particular indicator may reflect the way that healthcare                    spending is expected to rise to 9.4 per cent of Gross
               systems are organised or demographic factors. They do                       Domestic Product (GDP) in 2007-08. Current
               not necessarily imply that healthcare received by                           comparisons may not therefore be a reliable guide to the
               patients is better or worse. For example, general                           future or where intervention is needed to raise standards
               practitioners in the United Kingdom act as gatekeepers                      of healthcare.
part one




   2
                                                                                                                              INTERNATIONAL HEALTH COMPARISONS




Part 2                                                                                                       Healthcare systems




2.1 There is a lack of systematic published material on the                                                  2.3 For Australia, Canada, France, Germany, Japan, the
    details of how healthcare systems are organised across the                                                   United Kingdom and the United States, reported data
    world, though Appendix 1 gives details of healthcare                                                         closely follow the OECD guidelines for reporting health
    systems in the 10 comparator countries. Better information                                                   expenditure according to a common international
    is available on healthcare expenditure and how this                                                          standard. Thus the data are believed to be fairly
    expenditure is financed, which is set out in this Part.                                                      comparable. For New Zealand the definition of
                                                                                                                 healthcare is sufficiently different that its information is
                                                                                                                 of limited comparability. For Italy and Sweden, the
Expenditure on health                                                                                            differences are such that the OECD believes they are not
                                                                                                                 well suited for international comparisons.
2.2 A widely used means of comparison is expenditure as a
    proportion of GDP. The OECD data presented here for
                                                                                                             2.4 Figure 2 shows that total healthcare expenditure as a
    expenditure include public and private expenditure, but
                                                                                                                 proportion of GDP varied from 7.3 per cent to
    there are however definitional and timing differences
                                                                                                                 13 per cent and was 8.9 per cent on average across the
    that may distort the statistics.
                                                                                                                 10 countries. Total health spending in recent years as a
                                                                                                                 percentage of GDP was lower in the United Kingdom

 2   National expenditure on health as a percentage of Gross Domestic Product (GDP) in recent years


                                          14


                                          12
     Expenditure as a percentage of GDP




                                                                                                                              10 country average of 8.9 per cent

                                          10
                                                   7.2          2.5
                                                                             2.3
                                                                                          2.5
                                           8
                                                                                                       2.6           2           1.8          1.3
                                                                                                                                                              1.6       1.4
                                           6


                                           4                    7.8
                                                                             7.2                                                              6.6
                                                                                          6.8                                    6.2                                    5.9
                                                   5.8                                                               6                                        5.7
                                                                                                       5.9
                                           2


                                           0
                                                 United      Germany        France      Canada      Australia       Italy        New        Sweden            Japan    United
                                                  States      (1998)        (2000)      (2001)       (1998)        (2001)      Zealand       (1998)          (1999)   Kingdom
                                                                                                                                                                                part two




                                                 (2000)                                                                         (2000)                                 (2000)

                                               The darker tinted bars represent private expenditure. The lighter tinted bars represent public expenditure.


     Source: OECD Health Data 2002                                                                                                                                              3
               INTERNATIONAL HEALTH COMPARISONS




                 than in other comparator countries except Japan. The                         2.9 Figure 2 also shows that public spending dominates in
                 United Kingdom Government has subsequently                                       nine of the comparator countries. Sweden (with public
                 announced increased spending in the 2002 Budget. The                             expenditure of 84 per cent of total expenditure) and the
                 Government estimates that this will increase total spend                         United Kingdom (81 per cent) have the highest publicly
                 on healthcare to 9.4 per cent of GDP by 2007-08, up                              financed share of total health spending among the
                 from 7.3 per cent in 20008.                                                      comparator countries. Public spending is the lowest in
                                                                                                  the United States (45 per cent), and private funding
           2.5 Spending in all countries has increased as a percentage of                         therefore makes up more than half of total health
               GDP over the last 20 years or so, with the exception of                            expenditure. It is the only country where this is the case
               Sweden where it has fallen over a number of years. The                             - excluding the United States, privately financed
               trends are shown in Figure 3. As a result of differing rates                       healthcare accounts for 23 per cent of the total on
               of growth of spending, the spread in percentage GDP                                average across the other nine countries.
               spent across the 10 countries has increased from
               3.5 per cent in 1980 to 5.7 per cent in 2000. The United                       2.10 The methods of public and private financing vary
               States and New Zealand both saw very rapid growth in                                between countries, but are usually a combination of
               the late 1980s.                                                                     general taxation, social insurance, out of pocket
                                                                                                   payments and private insurance. Figure 5 gives a further
           2.6 Health expenditure per head is an alternative way of                                breakdown of the figures in Figure 2 for the comparator
               measuring the resources devoted to healthcare but is                                countries. The United Kingdom is one of six comparator
               subject to the additional uncertainty of relying on a                               countries (Australia, Canada, Italy, New Zealand,
               particular exchange rate to make the comparisons. The                               Sweden) in which general taxes are the main source of
               caveats to the figures for healthcare as a proportion of                            public funds. France, Germany and Japan finance the
               GDP figures apply equally: definitional differences as to                           majority of health spending through specific social
               what is included in expenditure, timing differences, and                            insurance contributions. Private insurance is third
               figures may be affected by demographic factors. Age                                 lowest in the United Kingdom, just above Italy and
               standardised spends per head are not available.                                     Japan, accounting for just 4 per cent of total funding and
                                                                                                   highest in the United States, followed by France. United
           2.7 Figure 4 shows the OECD's 2002 estimates based on a                                 Kingdom out of pocket payments are slightly higher than
               United States $ exchange rate9. There is a greater than                             in France but lower than in other comparator countries.
               four fold variation between the highest and lowest figures                          Out of pocket expenditure is highest in Italy, as a
               for health expenditure per head, which range from over                              proportion of total spend, followed by Australia and the
               $4,600 per year per person in the United States to just                             United States.
               over $1,000 in New Zealand. Average expenditure per
               head of population is $2,220. The United Kingdom figure                        2.11 Further details of the funding arrangements are given in
               is some 86 per cent of the average of $2,028 for the five                           Figure 6.
               European countries covered (Germany, Sweden, France,
               the United Kingdom and Italy in descending order of
               spend per head).


           Financing arrangements in
           different countries
           2.8 An important difference between healthcare systems is the
               extent to which individuals have private insurance. In the
               United States, private insurance is the only means of cover
               for much of the population, whilst in other countries it is
               held mainly by high income groups who opt out of social
               insurance coverage. In Canada private insurers are
               generally prevented from offering coverage that duplicates
               that provided by the Government, while in the United
               Kingdom private insurance is held in addition to cover
               provided by the Government. In France and New Zealand,
               private insurance is widely used to cover out of pocket
part two




               payments, such as some prescription costs.



           8     Budget Report 2002, HM Treasury, Chapter 6.
   4       9     The exchange rates have been calculated by the International Monetary Fund. They are par or market rates averaged over the year.
                                                                                                                                                              INTERNATIONAL HEALTH COMPARISONS




3   Health expenditure as a percentage of GDP, 1980 to 2001

                                                        14

                                                        13
    Expenditure on healthcare as a percentage of GDP




                                                        12

                                                                                                                                                                                   United States
                                                        11
                                                                                                                                                                                   Germany
                                                                                                                                                                                   France
                                                        10
                                                                                                                                                                                   Canada
                                                         9                                                                                                                         Australia
                                                                                                                                                                                   Italy
                                                         8                                                                                                                         Sweden
                                                                                                                                                                                   New Zealand
                                                         7                                                                                                                         Japan
                                                                                                                                                                                   United Kingdom
                                                         6

                                                         5

                                                         4
                                                             80

                                                                   81
                                                                        82

                                                                              83

                                                                                   84

                                                                                         85
                                                                                              86

                                                                                                   87

                                                                                                        88

                                                                                                              89

                                                                                                                     90

                                                                                                                          91
                                                                                                                               92

                                                                                                                                    93
                                                                                                                                         94

                                                                                                                                              95

                                                                                                                                                    96


                                                                                                                                                         19 7
                                                                                                                                                            98

                                                                                                                                                            99

                                                                                                                                                            00

                                                                                                                                                            01
                                                                                                                                                            9
                                                         19

                                                                  19
                                                                       19

                                                                            19

                                                                                 19

                                                                                        19
                                                                                             19

                                                                                                  19

                                                                                                       19

                                                                                                            19

                                                                                                                 19

                                                                                                                      19
                                                                                                                            19

                                                                                                                                   19
                                                                                                                                        19

                                                                                                                                             19

                                                                                                                                                  19

                                                                                                                                                       19


                                                                                                                                                         19

                                                                                                                                                         20

                                                                                                                                                         20
                                                                            Australia             Canada                  France              Germany                   Italy
                                                                            Japan                 New Zealand             Sweden              United Kingdom            United States



    Source: OECD Health Data 2002




4   Health expenditure per head

                                                       5,000
                                                                   4,631
                                                       4,500
    Expenditure per head (at US$ exchange rate)




                                                       4,000

                                                       3,500
                                                                                                                                                 10 country average of US$2,220
                                                       3,000
                                                                                 2,696        2,623
                                                       2,500
                                                                                                             2,146        2,069          2,058
                                                       2,000
                                                                                                                                                     1,737      1,683
                                                                                                                                                                             1,492
                                                       1,500
                                                                                                                                                                                        1,062
                                                       1,000

                                                        500

                                                          0
                                                                  United       Germany         Japan        Sweden        France        Canada       United    Australia      Italy       New
                                                                   States       (1998)        (1999)         (1998)       (2000)        (2000)      Kingdom     (1998)       (2000)     Zealand
                                                                                                                                                                                                    part two




                                                                  (2000)                                                                             (2000)                              (2000)


    Source: OECD Health Data 2002


                                                                                                                                                                                                    5
           INTERNATIONAL HEALTH COMPARISONS




           5   Sources of health expenditure



                                                    14.0


                                                    12.0
               Expenditure as a percentage of GDP




                                                    10.0


                                                    8.0


                                                    6.0


                                                    4.0


                                                    2.0


                                                    0.0
                                                           United    Germany    France       Canada    Australia     New         Italy       Japan       United
                                                            States    (1998)    (2000)       (2001)     (1998)     Zealand      (2001)      (1999)      Kingdom
                                                           (2000)                                                   (2000)                               (2000)

                                                                         Taxation                           Social insurance             Private insurance

                                                                         Out of pocket patient costs        Other private payments

               NOTE

               No further recent breakdown of the source of funds is available for Sweden beyond that for public/private expenditure in Figure 2.

               Source: OECD Health Data 2002
part two




   6
                                                                                                       INTERNATIONAL HEALTH COMPARISONS




6   The methods of financing healthcare

    Australia
    Public finances are raised from a general and compulsory health tax levy on income, through Medicare, the public health insurance
    system. Medicare reimburses 75 per cent of the scheduled fee for private in-patient services and 85 per cent of ambulatory services,
    including GP consultations.
    Out of pocket payments (16 per cent of total health expenditure), are for pharmaceuticals not covered under the Pharmaceutical
    Benefits Scheme, patient contributions for pharmaceuticals, dental treatment, the gap between the Medicare benefit and the schedule
    fee charged by physicians, and payments for other services such as physiotherapy and ambulance services, not covered by Medicare.
    Private insurance accounts for about 8 per cent of health care expenditure and about 45 per cent of the population have private
    insurance (mostly supplementary). Mainly not-for-profit mutual insurers cover the gap between Medicare benefits and schedule fees for
    in-patient services. Doctors may bill above the scheduled fee. Private insurers also offer private hospital treatment, choice of specialists
    and avoidance of queues for elective surgery.




    Canada
    National health insurance plans (Medicare) are funded by general and dedicated taxation and cover all medically necessary physician
    and hospital services.
    The majority of the population has supplementary private insurance coverage through group plans, to include dental care, prescription
    drugs, rehabilitation services, private care nursing and private rooms in hospitals.




    France
    Public health finances come from taxes and compulsory social health insurance contributions from employers and employees. The
    Sickness Insurance Funds cover 99 per cent of the population. The population have no choice of insurer. They are automatically
    affiliated to a health insurance scheme on the basis of their professional status and place of residence.
    Mutual Insurance Funds provide supplementary, voluntary insurance to cover cost-sharing arrangements and extra billings. Salaried
    workers purchase voluntary insurance from their employers, but this can be purchased on an individual basis. The mutual funds cover
    80 per cent of the population, which means that for most of the population, 100 per cent of the cost of the majority of normal
    medical procedures is reimbursed.
    Private insurance is voluntary for those who do not contribute to the national health insurance system.
    There are patient contributions for ambulatory care (around 30 per cent for GP and specialist visits), drugs (between 35 per cent and
    65 per cent depending on the therapeutic value) and 40 per cent for laboratory tests. Out of pocket payments account for 10 per cent
    of health care expenditure.




    Germany
    General taxation and compulsory Social Insurance Fund contributions account for the majority of healthcare funding. Employers and
    employees make contributions equally. The unemployed, homeless, and immigrants are covered through a special sickness fund
    financed through general tax revenues.
    Private insurance, based on voluntary individual contributions, covers 8 per cent of the population (the affluent, self-employed and
    civil servants).
    Cost-sharing is mainly for drugs. Ambulatory care and preventative dental care do not require any patient contributions. User charges
    apply to the first 14 days in hospital or rehabilitation each year, ambulance transportation, non-physician care and some dental
    treatment, but some groups are exempt (e.g. low income and elderly).




    Italy
    Taxation is the main source of public finance. There are patient contributions for pharmaceuticals, diagnostic procedures and specialist
    visits and direct payments by users for the purchase of private health care services and over the counter drugs.
    Mutual fund contributions and private insurance (corporate and non-corporate) account for 9 per cent of health expenditure.
                                                                                                                                                   part two




                                                                                                                                                   7
           INTERNATIONAL HEALTH COMPARISONS




           6   The methods of financing healthcare (continued)


               Japan
               Japan's health care system is predominately publicly funded. The majority of public finances comes from the Employees’ Health
               Insurance System (Government and non-governmental bodies) and National Health Insurance (self-employed, pensioners, trade
               associations and others not covered by workplace based insurance). Most employees and their dependents obtain health insurance
               through their employers, financed largely through mandatory payroll contributions from both employers and employees.




               New Zealand
               Public hospital out-patient and in-patient services are free, but most people meet some costs of primary health care (although some
               groups are exempt or have health concession cards) and make a payment for pharmaceuticals. Income-related patient contributions
               are required for GP services and non-hospital drugs.
               Private insurance is mainly not-for-profit covering private medical care and complementary, used to cover cost-sharing requirements,
               elective surgery in private hospitals and specialist out-patient consultations. It does not offer comprehensive health cover. It covers
               about a third of the population.




               Sweden
               The majority of funding comes from taxes and is supplemented by grants from the national Government. There are direct patient fees
               for most medical services (flat rate payments), for example, consultation with public physicians in the primary sector, specialists in a
               hospital, in-patient stay and consultations with private ambulatory doctors. There is a national ceiling on out of pocket amounts
               payable by individuals in any one year. After the ceiling is reached the patient pays no further charges.
               The voluntary health insurance market is very small.




               United Kingdom
               The United Kingdom's healthcare system is predominately public sector with the majority of the funds coming from general taxation
               and some from national insurance contributions. About 11.5 per cent of the population have supplementary private medical insurance,
               usually for reasons of faster access.
               National Health Service care is free at the point of delivery, but charges are levied on prescription drugs, ophthalmic services and
               dental services. There are exemptions, for example, for children, elderly, and the unemployed and 85 per cent of prescriptions are
               exempt from the charge.




               United States
               The United States' healthcare system is predominately privately funded, with 55 per cent of the revenue from private sources.
               Individuals can purchase private health insurance or it can be funded by voluntary premium contributions shared by employers and
               employees on a negotiable basis. It covers 58 per cent of the population.
               Public funds (payroll taxes, federal revenues and premiums) fund Medicare, a social insurance programme for the elderly, the disabled,
               and end stage renal patients. It covers 13 per cent of the population and accounts for 20 per cent of total health expenditure.
               Medicaid, a joint federal-state health insurance programme covers certain groups of the poor. It covers 17 per cent of the population
               and accounts for 20 per cent of total health expenditure.


               Sources: Securing Our Future Health: Taking a Long-Term View, Wanless, Interim report, November 2001, Final report April 2002; Health care systems in
               eight countries: trends and challenges European Observatory on Health Care Systems,2002; Multinational comparisons of health systems data, Anderson
               G.F. and Hussey P.S., The Commonwealth Fund, 2000
part two




   8
                                                                                                       INTERNATIONAL HEALTH COMPARISONS




Part 3                                                                                 Providing healthcare




3.1 This Part of the compendium sets out comparative                                        premature mortality of almost four per cent for women
    figures on how healthcare is provided in terms of                                       and about three per cent for men10.
    healthcare personnel, medical technology, drugs, the
    number of medical procedures carried out and                                       3.3 Figure 7 provides information about the number of
    preventative medical programmes.                                                       practising physicians per 1,000 people in the
                                                                                           population. The statistics need very careful
Health personnel                                                                           interpretation because there are significant definitional
                                                                                           differences. For the United Kingdom, the figures shown
Doctors and nurses                                                                         update those in the Wanless Review of the future needs
                                                                                           of the NHS11 which also used OECD data. The figures
3.2 Recent OECD research has concluded that the number                                     are based on doctors working in the NHS and exclude
    of doctors is the second most important variable (after                                private sector doctors, locums and clinical academics.
    occupation) in terms of explaining variations in                                       In Italy, retired physicians continue to be classified as
    premature mortality (deaths under the age of 70)                                       'practising', and this leads to anomalies. Italy has one of
    across countries and over time. They also found that a                                 the lowest expenditures per head on healthcare
    10 per cent increase in the number of doctors, holding                                 (see Figure 4), but it has the highest recorded ratio of
    all other factors constant, would result in a reduction in                             doctors to the population.

 7   Number of practising physicians

                                      7


                                            6
                                      6
     Number per 1,000 of population




                                      5


                                      4
                                                     3.6

                                                               3        2.9
                                      3                                          2.8
                                                                                              2.5
                                                                                                          2.2         2.1
                                      2                                                                                              1.9          1.8


                                      1


                                      0
                                           Italy   Germany   France   Sweden    United     Australia     New        Canada          Japan       United
                                          (2000)    (2000)   (1998)    (1999)    States     (1998)     Zealand      (2000)         (2000)      Kingdom
                                                                                                                                                               part three




                                                                                (1999)                  (2000)                                  (2000)


     Source: OECD Health Data 2002

                                                                                                                                                               9
10   Exploring the effects of health care on mortality across OECD countries, OECD Labour market and social policy - Occasional Papers No. 46, January 2001,
     paragraph 45.
11   Securing our Future Health: Taking a Long-Term View, Interim report, November 2001.
               INTERNATIONAL HEALTH COMPARISONS




             3.4 The OECD data show the United Kingdom as having the                                                                         classifications as to what constitutes a nurse and that
                 lowest number of practising physicians at 1.8 per 1000                                                                      while the UK uses full time equivalents, other countries
                 persons, considerably below the mean of 2.5 (excluding                                                                      use headcounts. Germany, which has a high number of
                 Italy). Taking into account data provided by the general                                                                    doctors, also has a high number of nurses in relation to
                 Medical Council on the number of practising physicians,                                                                     the population. These ratios cannot, however, be taken as
                 the Department of Health estimated in 1996 that there                                                                       direct measures of the adequacy of provision as the
                 were 2.6 doctors per 1,000 of population, compared                                                                          figures take no account of the pattern of healthcare
                 with the OECD reported figure for the United Kingdom                                                                        provision in different countries. Factors such as the rate
                 of 1.7. For 1996, Germany reported 3.4 and France 3.0                                                                       of day case procedures or length of stay can have a major
                 practising physicians per 1,000 of population.                                                                              impact on the need for in-patient admissions and
                                                                                                                                             throughput. Length of stay in the United Kingdom is one
             3.5 The number of physicians in the United Kingdom has                                                                          of the lowest among the 10 comparator countries.
                 increased steadily over the last 20 years - by 40 per cent
                 over this period, Figure 8. But reported provision in                                                             3.7 Acute admission rates are shown in Figure 10, which
                 other countries has generally increased at a faster rate.                                                             puts the United Kingdom in the centre of the 10 country
                 The result is that the countries have moved further apart                                                             range. These figures can be used in conjunction with
                 and, discounting Italy for definitional reasons, the                                                                  those for numbers of nurses to standardise for the rate of
                 spread of provision has increased from 1.0 per 1,000 to                                                               admissions and length of stay as in Figures 11 and 12.
                 1.8 per 1,000.
                                                                                                                                   3.8 In terms of nurses per acute admission, the United
             3.6 As well as having the lowest reported number of doctors                                                               Kingdom comes at the low end of the range, but both
                 per head, the United Kingdom also has the second                                                                      France and Italy have lower provision, Figure 11. In
                 lowest reported number of practising nurses in relation to                                                            terms of nurses per acute day, the United Kingdom is
                 the population, Figure 9, although the UK nurse numbers                                                               above the other European countries in its provision,
                 are for the NHS only. The Department of Health told us                                                                Figure 12.
                 that UK qualified private sector nurses account for about
                 a quarter of all qualified nurses. The Department also
                 noted that different countries still use different


              8   Level of practising physicians, 1980 to 2000

                                                              7
                  Physician density per 1,000 of population




                                                              6


                                                                                                                                                                                     Italy
                                                              5
                                                                                                                                                                                     Germany
                                                                                                                                                                                     France
                                                              4                                                                                                                      United States
                                                                                                                                                                                     Canada
                                                                                                                                                                                     Japan
                                                              3                                                                                                                      United Kingdom


                                                              2


                                                              1


                                                              0
                                                                   80

                                                                        81

                                                                             82
                                                                                  83

                                                                                       84

                                                                                            85

                                                                                                 86

                                                                                                       87

                                                                                                            88

                                                                                                                 89

                                                                                                                      90

                                                                                                                            91

                                                                                                                                   92

                                                                                                                                         93

                                                                                                                                                94
                                                                                                                                                     95

                                                                                                                                                          96

                                                                                                                                                               97

                                                                                                                                                                    98

                                                                                                                                                                         99

                                                                                                                                                                              00
                                                                  19

                                                                       19

                                                                            19
                                                                                 19

                                                                                      19

                                                                                           19

                                                                                                19

                                                                                                      19

                                                                                                           19

                                                                                                                19

                                                                                                                     19

                                                                                                                           19

                                                                                                                                19

                                                                                                                                        19

                                                                                                                                              19
                                                                                                                                                   19

                                                                                                                                                        19

                                                                                                                                                             19

                                                                                                                                                                  19

                                                                                                                                                                       19

                                                                                                                                                                            20
part three




                                                                        Canada         Fr ance         Ger many            Italy         J apan           United Kingdom           United States

                  NOTE

                  Data are not available for all years for Japan

 10
                  Source: OECD Health Data 2002
                                                                                                                                       INTERNATIONAL HEALTH COMPARISONS




9   Number of practising nurses

                                                12



                                                10      9.7
    Practising nurses per 1,000 of population




                                                                  9.3

                                                                               8.4           8.3         8.1
                                                  8                                                                7.8         7.6


                                                                                                                                             6
                                                  6
                                                                                                                                                            5.3
                                                                                                                                                                    4.5
                                                  4



                                                  2



                                                  0
                                                        New     Germany       Sweden        United    Australia    Japan      Canada       France       United      Italy
                                                      Zealand    (1998)        (1999)        States    (1997)     (1998)      (2000)       (1997)      Kingdom     (1999)
                                                       (2000)                               (1999)                                                      (2000)


    Source: OECD Health Data 2002


10 Acute hospital admissions


                                                250



                                                        205.2           204
    Acute admissions per 1,000 of population




                                                200
                                                                                        175.7
                                                                                                       159          156
                                                150                                                                                  147


                                                                                                                                                    117.6

                                                                                                                                                                   99.4
                                                100




                                                 50




                                                  0
                                                      Germany       France               Italy        Sweden      Australia       United            United        Canada
                                                       (2000)       (1999)              (1998)         (1996)      (1999)        Kingdom             States       (1999)
                                                                                                                                  (2000)            (2000)
    NOTE

    Acute care is one in which the principal intent is one or more of the following:
    ! to manage labour (obstetrics)
                                                                                                                                                                            part three




    ! to cure illness or to provide definitive treatment of injury
    ! to perform surgery
    ! to relieve symptoms of illness or injury (excluding palliative care)
    ! to reduce severity of an illness or injury
    ! to protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function
    ! to perform diagnostic or therapeutic procedures
                                                                                                                                                                            11
    Source: OECD Health Data 2002
              INTERNATIONAL HEALTH COMPARISONS




             11 Practising nurses per 1,000 acute admissions


                                                                          80
                                                                                  75
                                                                                              70
                                                                          70
                 Practising nurses per 1,000 acute admissions




                                                                          60

                                                                                                            51
                                                                          50
                                                                                                                             45

                                                                          40
                                                                                                                                              36

                                                                                                                                                              29
                                                                          30
                                                                                                                                                                     26

                                                                          20


                                                                          10


                                                                           0
                                                                                Canada      United        Australia        Germany           United       France     Italy
                                                                                (1999)       States        (1997)           (2000)          Kingdom       (1997)    (1998)
                                                                                            (1999)                                           (2000)

                 Source: OECD Health Data 2002




             12 Practising nurses per acute bed day


                                                                          1.6

                                                                                  1.4
                 Nursing staff per acute bed day (Full Time Equivalent)




                                                                          1.4
                                                                                                   1.31

                                                                          1.2

                                                                                                                      1
                                                                           1

                                                                                                                                      0.8
                                                                          0.8

                                                                                                                                                        0.6
                                                                          0.6
                                                                                                                                                                   0.47
                                                                          0.4


                                                                          0.2


                                                                           0
                                                                                Australia       United            United              Italy           Germany      France
                                                                                 (1999)          States          Kingdom             (1998)            (2000)      (1999)
                                                                                                (2000)            (1997)

                 Source: OECD Health Data 2002
part three




 12
                                                                                                                             INTERNATIONAL HEALTH COMPARISONS




13 Number of acute hospital beds per 1,000 of population


                                          7
                                                6.4

                                          6



                                          5
    Acute beds per 1,000 of population




                                                         4.5
                                                                     4.2
                                          4                                            3.8

                                                                                                           3.3              3.3
                                                                                                                                           3
                                          3
                                                                                                                                                     2.4

                                          2


                                          1


                                          0
                                              Germany    Italy      France           Australia            Canada       United          United      Sweden
                                               (2000)   (1999)      (2000)            (1999)              (1999)      Kingdom           States      (2000)
                                                                                                                       (2000)          (2000)

    Source: OECD Health Data 2002




14 Bed occupancy for acute beds


                                         90
                                                 83
                                                            81.1
                                         80                                  77.5                77.4
                                                                                                                   73.3
                                                                                                                                      70
                                         70
    Percentage of available acute beds




                                                                                                                                                    63.9
                                         60


                                         50


                                         40


                                         30

                                         20


                                         10


                                          0
                                               United     Germany          Sweden                France             Italy          Australia       United
                                              Kingdom      (2000)           (1996)               (1999)            (1998)           (1999)          States
                                               (2000)                                                                                              (2000)

    Source: OECD Health Data 2002
                                                                                                                                                                part three




                                                                                                                                                                13
               INTERNATIONAL HEALTH COMPARISONS




             Medical infrastructure                                                                         of prescribing generic drugs which are considerably
                                                                                                            cheaper than branded ones and expenditure may not be
             3.9 A basic measure of healthcare capacity is the number of                                    a good measure of volume. The effects of different price
                 beds per head, though it suffers from the same problems                                    regulation systems is another factor, as is the availability
                 as the statistics for medical staff in being affected by                                   of over the counter drugs in some countries that would
                 patterns of health care. The ratios shown in Figure 13                                     be prescription only in others.
                 range from 6.4 beds per 1,000 of population in
                 Germany, to 2.4 in Sweden with the United Kingdom at                                  3.13 Figure 16 shows expenditure on what countries classify
                 the lower end of this range.                                                               as public funding for drugs and other medical non-
                                                                                                            durables prescribed for hospital out-patients. There is a
             3.10 Taking account of the use made of acute hospital                                          wide range of spending across countries, with the
                  beds, the United Kingdom has the highest occupancy                                        highest spending per head in France and Japan at almost
                  of such beds of the countries for which information is                                    three times that in Australia and the United States.
                  available, Figure 14.

             3.11 Magnetic Resonance Imaging units stand as a proxy for                                Medical procedures carried out
                  investment in new technology and how up to date
                                                                                                       3.14 Comparable information on individual procedures across
                  medical facilities are. In relation to the size of the
                                                                                                            different countries is limited but is available for coronary
                  population, the figure for England of 3.9 per million
                                                                                                            bypass procedures in eight comparator countries. The
                  people is a little over half of the 10 country average of
                                                                                                            United States carries out almost five times as many of
                  6.9 per million people. However, Figure 15 shows that
                                                                                                            these operations as in the United Kingdom per head of
                  the average is influenced by very high provision in Japan.
                                                                                                            population, Figure 17. If the United States is excluded as
                  Canada has the lowest provision with about two-thirds
                                                                                                            an outlier, the average rate for the other countries is just
                  the numbers in England. Since 2000 there has been an
                                                                                                            over 60 procedures per 100,000 of population.
                  increase in the provision of MRI units in the United
                  Kingdom, partly through support from the New
                  Opportunities Fund.
                                                                                                       Preventative medical programmes
                                                                                                       3.15 A measure of the extent of preventative health measures is
             Medicines and drugs                                                                            the extent of childhood immunisation. A range of caveats
                                                                                                            applies including issues such as public perception of the
             3.12 Medicines are an essential component of healthcare.
                                                                                                            safety of immunisation and the authorities' policy on when
                  But as with other measures, comparisons can be very
                                                                                                            or whether this should be carried out.
                  misleading. The United Kingdom has pursued a policy

             15 Availability of Magnetic Resonance Imaging units


                                                    25
                                                          23.2



                                                    20
                  Units per million of population




                                                    15




                                                    10
                                                                    8.1       7.9
                                                                                       6.7
                                                                                                 6.2

                                                     5                                                        4.7
                                                                                                                          3.9
                                                                                                                                      2.8         2.6         2.5
part three




                                                    0
                                                          Japan   United    Sweden     Italy   Germany     Australia    England      France       New       Canada
                                                         (1999)    States    (1999)   (1999)    (1997)      (2000)       (2000)      (1999)     Zealand     (2000)
                                                                  (1999)                                                                         (1998)
 14
                  Source: OECD Health Data 2002
                                                                                                                                   INTERNATIONAL HEALTH COMPARISONS




16 Public expenditure on pharmaceuticals and other medical non-durables prescribed for out-patients

                                                  300
                                                          272      271

                                                  250                            237
     Expenditure per head (US$ exchange rate)




                                                                                              217
                                                                                              201      201
                                                  200


                                                                                                       157
                                                                                                                149
                                                  150
                                                                                                                          133
                                                                                                                                        112
                                                                                                                                                     103        101
                                                  100



                                                   50



                                                    0
                                                         Japan    France       Germany    Sweden      United    Italy      New         Canada      Australia   United
                                                        (1999)    (2000)        (1998)     (1997)    Kingdom   (2000)    Zealand       (2000)       (1998)      States
                                                                                                      (2000)              (1997)                               (2000)


    Source: OECD Health Data 2002



17 Coronary bypass procedures per 100,000 of population

                                                  250



                                                        202.6
                                                  200
    Coronary bypasses per 100,000 of population




                                                  150




                                                  100                91.5              90.2

                                                                                                     66.4
                                                                                                                51.6
                                                   50                                                                           46.4
                                                                                                                                                 41.2
                                                                                                                                                                 35



                                                    0
                                                        United     Australia        Germany         Canada       New           Italy             United        France
                                                         States     (1999)           (1998)         (1999)     Zealand        (1999)            Kingdom        (1993)
                                                        (1998)                                                  (2000)                           (1996)


    Source: OECD Health Data 2002
                                                                                                                                                                         part three




                                                                                                                                                                         15
               INTERNATIONAL HEALTH COMPARISONS




             3.16 Immunisation against measles is reported as close to                                                   and the United Kingdom achieved a rate in excess of
                  universal in Japan, Canada and Sweden, though it falls                                                 91 per cent. Sweden achieved a rate of 99 per cent,
                  below 90 per cent in Australia, France, Germany and                                                    while the lowest rate was in the United States at
                  Italy, Figure 18. Immunisation against diphtheria,                                                     83 per cent, Figure 19.
                  tetanus and whooping cough is generally higher


             18 Percentage of children immunised against measles

                                                                   100    96.5      96.2     95.2
                                                                                                        92          91
                                                                    90
                                                                                                                                 84.5        83
                                                                    80
                   Prorportion of eligible population (per cent)




                                                                                                                                                        75          75

                                                                    70

                                                                    60

                                                                    50

                                                                    40

                                                                    30

                                                                    20

                                                                    10

                                                                     0
                                                                          Japan    Canada   Sweden    United       United      Australia    France    Germany      Italy
                                                                         (1999)    (1998)    (2000)    States     Kingdom       (2000)      (1998)     (1997)     (1999)
                                                                                                      (1999)    (2001-2002)


                 Source: OECD Health Data 2002 and Department of Health. Figure for United Kingdom is for Measles, Mumps and Rubella coverage at 24 months



             19 Percentage of children immunised for diphtheria, tetanus and pertussis (whooping cough)

                                                                   100    99.1      98
                                                                                              95
                                                                                                       91.8
                                                                                                                   89.8          88.4
                                                                    90
                                                                                                                                             85         84.2        83
                                                                    80
                  Proportion of eligible population (per cent)




                                                                    70

                                                                    60

                                                                    50

                                                                    40

                                                                    30

                                                                    20

                                                                    10
part three




                                                                     0
                                                                         Sweden    France    Italy     United    Australia       New       Germany    Canada      United
                                                                          (2000)   (1998)   (1999)    Kingdom     (2000)       Zealand      (1997)    (1998)       States
                                                                                                       (2000)                   (1999)                            (1999)

                 Source: OECD Health Data 2002 and Department of Health. The United Kingdom figure relates to diptheria, tetanus and polio rather than pertussis but the
 16
                 OECD has calculated that this figure is only marginally different to those given for other countries
                                                                                                     INTERNATIONAL HEALTH COMPARISONS




Part 4                                                                           Health achievements




4.1 This Part presents comparative information relevant to how                          of 70 die prematurely. This figure needs to be seen in the
    well healthcare systems perform. A first measure is the state                       context of the currently expected life spans at birth of
    of health in countries, though this is determined by many                           around 80 years for women and 75 years for men.
    factors other than the healthcare system. A second
    measure is the extent to which healthcare systems improve                    4.5 The United States loses more potential life years than the
    health. Limited comparative information is available on                          other countries in the comparator group, Figure 21. There
    this, though data are available about survival rates after                       is a considerable variation across countries, and in
    cancer treatment.                                                                contrast to the data on life expectancy at birth, where the
                                                                                     United Kingdom is among the lowest, on the years lost
                                                                                     measure, the United Kingdom ranks fourth lowest behind
Life expectancy                                                                      Sweden, Japan and Italy. This illustrates the dangers of
4.2 A fundamental measure of health in a particular country                          relying on single indicators to draw conclusions.
    is life expectancy though while healthcare systems have
    an influence on life expectancy, it depends equally if not                   4.6 For both sexes, the highest number of years lost
    more on a wide range of other factors such as personal                           (per 100,000 population) is some 80 per cent above the
    income, lifestyle, education, nutritional standards, and                         lowest one. There are also marked differences in the
    housing quality. One way of measuring life expectancy                            number of years of life lost by men and women. In the
    is the number of years that individuals born 'now' can                           United Kingdom, potential years of life lost for males are
    on average expect to live if current patterns of mortality                       64 per cent higher than for females.
    and disability continue to apply. The measure has the
    limitation of applying only to the current birth cohort.
    Life expectancy has generally risen over time, so life                       Infant and perinatal mortality
    expectancy for the population as a whole will be lower                       4.7 An important reason for increased life expectancy at
    than indicated by the most recent statistics.                                    birth has been a decline in infant mortality. Among the
                                                                                     explanations for this are better ante and post-natal care
4.3 Figure 20 shows that life expectancy at birth (in recent                         and widespread immunisation against childhood
    years) ranges between about 79 and 85 years for women                            diseases - influences within the control of health policy
    across the 10 comparator countries, and between 74 and                           makers. Recent research suggests that the number of
    78 years for men. This amounts to an 8 per cent range for                        doctors per capita appears to be the second most
    women and 5 per cent for men. Japan has the longest                              important variable (behind occupation) in explaining
    expected life span, followed closely within European                             both perinatal and infant mortality. The results indicate,
    countries by France and Sweden and then Italy and                                all else equal, that a 10 per cent increase in the number
    Germany. The United Kingdom comes towards the lower                              of doctors would result in almost a 6 per cent decrease
    end of the fairly small range for both men and women.                            in perinatal mortality and a 6½ per cent decrease in
    The United Kingdom has, however, one of the smallest                             infant mortality12. The research found that the overall
    differences in life expectancy between women and men                             level of public financing also appears to be a significant
    at 4.8 years, with France at 7.5 years being the largest.                        factor in reducing both infant and perinatal mortality13.
                                                                                     The OECD hypothesis is that this may reflect the
4.4 An alternative way of assessing life expectancy is based                         likelihood that publicly funded systems provide more
    on the calculation of 'Potential years of life lost'. This                       equitable health service provision.
                                                                                                                                                               part four




    measure assumes that all those who die before the age


12   Exploring the effects of health care on mortality across OECD countries, OECD Labour market and social policy - Occasional Papers No. 46, January 2001,
     paragraph 55.
                                                                                                                                                               17
13   ibid paragraph 56.
             INTERNATIONAL HEALTH COMPARISONS




            20 Life expectancy at birth


                                                                        86
                                                                                 84.6
                                                                        84
                                                                                            82.5
                                                                                                         82            82
                                                                        82                                                         81.7         81.6
                                                                                                                                                             80.8         80.7
                                                                        80                                                                                                             79.8
                                                                                                                                                                                                   79.4

                                                                        78          77.6                                    77.4
                 Years




                                                                                                              76.6
                                                                                                                                       76.3
                                                                        76                                                                                       75.7
                                                                                               75                                                   75.3                                   75
                                                                                                                                                                              74.7
                                                                                                                                                                                                      73.9
                                                                        74


                                                                        72

                                                                        70


                                                                        68
                                                                                  Japan     France     Australia     Sweden        Canada        Italy        New        Germany       United      United
                                                                                 (2000)     (1999)      (2000)        (2000)       (1999)       (1997)      Zealand       (1999)      Kingdom       States
                                                                                                                                                             (1999)                    (1999)      (1999)

                                                                                            The lighter tinted bar represents female patients. The darker tinted bar represents male patients.

                NOTE

                The life expectancy is calculated on the assumption that age-specific mortality levels remain constant.

                Source: OECD Health Data 2002



            21 Potential years of life lost

                                                                        8,000
                 Potential years lost below age 70 per 100,000 people




                                                                        7,000


                                                                        6,000


                                                                        5,000


                                                                        4,000


                                                                        3,000


                                                                        2,000


                                                                        1,000


                                                                             0
                                                                                  United     France        New       Germany       Canada      Australia     United        Italy        Japan     Sweden
                                                                                   States    (1998)      Zealand      (1999)       (1997)       (1999)      Kingdom       (1998)       (1999)      (1998)
part four




                                                                                  (1998)                  (1998)                                             (1999)

                                                                                             The lighter tinted bar represents male patients. The darker tinted bar represents female patients.


 18             Source: OECD Health Data 2002, based on World Health Organization data
                                                                                                                                       INTERNATIONAL HEALTH COMPARISONS




4.8 Figures 22 and 23 show the strong decline in perinatal                                               Deaths from cancer
    and infant mortality over the 1980s and the continued
    but less marked decrease across most comparator                                                      4.10 Analysis of cancer mortality statistics is a difficult area
    countries since then. All these countries have made                                                       and variations across countries need careful
    steady progress over the last 20 years, with those having                                                 interpretation. The chances of dying from cancer depend
    the highest rates in 1980 reducing rates a little faster. The                                             on how quickly patients recognise and act on symptoms,
    result has been that the spread between the countries for                                                 the impact of measures affecting lifestyle (such as
    perinatal mortality has reduced from 9.1 deaths per                                                       smoking habits) and the existence of screening
    1,000 total births in 1980 to 4.5 per 1,000 in 2000.                                                      programmes. There are also marked differences in cancer
    From 1993, the United Kingdom started to count                                                            mortality rates between socio-economic groups, (which
    mortality after 24 weeks gestation, rather than the                                                       correlate with some of the other factors mentioned).
    28 weeks used by other countries.                                                                         However, the quality of medical intervention is also an
                                                                                                              important factor, recognised for example for the United
                                                                                                              Kingdom in the NHS Cancer Plan14.
Main causes of death
                                                                                                         4.11 Cancer is an illness in the United Kingdom subject to
4.9 The main causes of death for the comparator countries                                                     active measures to improve performance and this needs
    are shown at Figure 24. The most significant causes of                                                    to be borne in mind when considering the statistics. As
    death from disease in developed countries are cancer                                                      part of the performance improvements expected as a
    (malignant neoplasms) and cardio-vascular illness, and                                                    result of the increased funding announced in the 2002
    patterns are similar in all countries.                                                                    Budget, the Government requires the NHS to reduce
                                                                                                              mortality rates from cancer by at least 20 per cent in
                                                                                                              people under 75 by 2010.


22 Perinatal mortality, 1980 to 2000

                                     20

                                     18

                                     16

                                     14
     Deaths per 1,000 total births




                                     12

                                     10                                                                                                               United Kingdom
                                                                                                                                                      United States
                                      8                                                                                                               France
                                                                                                                                                      Italy
                                                                                                                                                      Australia
                                      6
                                                                                                                                                      Germany
                                                                                                                                                      Canada
                                      4                                                                                                               Sweden
                                                                                                                                                      New Zealand
                                      2                                                                                                               Japan

                                      0
                                          80

                                               81

                                                    82
                                                         83

                                                              84

                                                                   85

                                                                        86
                                                                             87

                                                                                  88

                                                                                       89

                                                                                            90
                                                                                                 91

                                                                                                      92

                                                                                                           93

                                                                                                                94
                                                                                                                     95
                                                                                                                          96
                                                                                                                               97
                                                                                                                                    98

                                                                                                                                         99

                                                                                                                                              00
                                      19

                                           19

                                                19
                                                     19

                                                          19

                                                                 19

                                                                      19
                                                                           19

                                                                                19

                                                                                     19

                                                                                          19
                                                                                               19

                                                                                                    19

                                                                                                         19

                                                                                                              19
                                                                                                                   19
                                                                                                                        19
                                                                                                                             19
                                                                                                                                  19

                                                                                                                                        19

                                                                                                                                             20




                                                     Australia             Canada                France              Germany                  Italy
                                                     Japan                 New Zealand           Sweden              United Kingdom           United States

     NOTE

     Perinatal mortality is the number of deaths within seven days of birth plus foetal deaths of 28 weeks of gestation or more
     per 1,000 total births (live and stillbirths). The UK includes deaths from 24-28 weeks of gestation while other countries do not.
                                                                                                                                                                            part four




     Source: OECD Health Data 2002



14   The NHS Cancer Plan, Department of Health, September 2000.                                                                                                             19
                 INTERNATIONAL HEALTH COMPARISONS




            23 Infant mortality, 1980 to 2000

                                                  16


                                                  14


                                                  12
                   Deaths per 1,000 live births




                                                  10

                                                                                                                                                                  United States
                                                  8                                                                                                               United Kingdom
                                                                                                                                                                  New Zealand
                                                  6                                                                                                               Canada

                                                                                                                                                                  Italy
                                                  4
                                                                                                                                                                  France
                                                                                                                                                                  Germany
                                                  2                                                                                                               Sweden
                                                                                                                                                                  Japan

                                                  0
                                                       80

                                                            81

                                                                 82

                                                                      83

                                                                           84

                                                                                85

                                                                                     86

                                                                                          87

                                                                                               88

                                                                                                    89

                                                                                                         90

                                                                                                              91

                                                                                                                    92

                                                                                                                         93

                                                                                                                              94

                                                                                                                                   95

                                                                                                                                        96

                                                                                                                                             97

                                                                                                                                                  98

                                                                                                                                                       99

                                                                                                                                                            00
                                                      19

                                                           19

                                                                19

                                                                     19

                                                                          19

                                                                               19

                                                                                    19

                                                                                         19

                                                                                              19

                                                                                                   19

                                                                                                        19

                                                                                                             19

                                                                                                                  19

                                                                                                                       19

                                                                                                                            19

                                                                                                                                 19

                                                                                                                                      19

                                                                                                                                           19

                                                                                                                                                19

                                                                                                                                                     19

                                                                                                                                                          20
                                                            Australia           Canada                  France           Germany                  Italy
                                                            Japan               New Zealand             Sweden           United Kingdom           United States

                   NOTE

                   Infant mortality is the number of deaths of babies aged under one year that occurred during a year per 1,000 live births
                   during the same year, expressed as a rate.


                   Source: OECD Health Data 2002


            4.12 Figure 25 shows the trend in cancer deaths for the                                                4.15 Further comparative information on death rates from the
                 10 comparator countries over the last two decades. For                                                 main cancers over time is given in Appendix 2.
                 the last year of complete comparisons, the United                                                      Figures 28 and 29 show death rates from lung and
                 Kingdom and New Zealand jointly had the highest                                                        breast cancer.
                 death rates, although the rates in both countries are on
                 a downward trend.                                                                                 4.16 United Kingdom mortality comes towards the middle of
                                                                                                                        the range for lung cancer, but is above all of these
            4.13 Recent data for death rates from all cancers (against a                                                comparator countries for breast cancer.
                 standardised age profile to take account of different
                 demographics in countries) are shown in Figure 26.
                 New Zealand and the United Kingdom report                                                         Deaths from circulatory diseases
                 comparatively high death rates. The rate (per 100,000                                             4.17 Cardio-vascular diseases include ischaemic heart
                 population) in France and Germany is about 2½ and                                                      disease, myocardial infarction and cerebro-vascular
                 5 per cent lower than in the United Kingdom respectively.                                              diseases15. As part of the performance improvements
                 The rate in Sweden, the country with the lowest cancer                                                 expected as a result of the increased funding announced
                 death rate among the 10 countries, is about 18 per cent                                                in the 2002 Budget, the Government requires the NHS
                 below that of the United Kingdom.                                                                      to reduce substantially mortality rates from heart disease
                                                                                                                        by at least 40 per cent in people under 75 by 2010.
            4.14 Figure 27 shows the mortality rates for the four main
                 cancer killers in the comparator countries. Overall, the
part four




                 United Kingdom is in the top group for overall deaths
                 although it has the highest rate only for breast cancer.

            15     'Ischaemia' means an inadequate supply of blood and is usually the consequence of the gradual narrowing of the arteries supplying blood and oxygen. If a
                   narrowed coronary artery blocks off suddenly - as it may if a blood clot forms in it - the part of the heart muscle supplied by that artery may die and cause
 20                severe chest pain. This is a 'heart attack', also known as a myocardial infarction ('myocardium' referring to the heart muscle and 'infarction' referring to the
                   death of a part of it). There are two main forms of cerebro-vascular disease leading to stroke - resulting from either ischaemic disease affecting the blood
                   circulation system of the brain, or from haemorrhage of surface blood vessels.
                                                                                                                                              INTERNATIONAL HEALTH COMPARISONS




24 Main causes of death

                                                       700
     Deaths per 100,000 of population (standardised)




                                                       600


                                                       500


                                                       400


                                                       300


                                                       200


                                                       100


                                                         0
                                                              United     United      Germany      New         Italy      Canada     Sweden        Australia     France      Japan
                                                             Kingdom      States      (1999)    Zealand      (1998)      (1997)      (1998)        (1999)       (1998)     (1999)
                                                              (1999)     (1998)                  (1998)




                                                             Diseases of circulatory system     Malignant neoplasms        Diseases of respiratory system       Non-medical causes

                                                             Endocrine and metabolic diseases     Diseases of digestive system     Diseases of nervous system

     NOTE

     Age-standardised death rates take into account the differences in age structure of the populations

     Source: OECD Health Data 2002


4.18 United Kingdom death rates are highest, second highest                                                        4.21 Figures 32 to 35 show the five-year survival rates for the
     and third highest respectively across the group of                                                                 four main cancer killers. The performance of England is
     countries for the three circulatory conditions included in                                                         consistently at or near the bottom for the comparator
     Figure 30. The overall death rate is two and a half times                                                          countries, alternating bottom position with Scotland.
     that of France, with that for ischaemic heart disease                                                              These are based on historical data for patients diagnosed
     being four times the rate reported from Japan.                                                                     between 1985 and 1989. The implementation of the
                                                                                                                        Calman/Hine report (1995) and the NHS Cancer Plan
4.19 Trends in most countries for ischaemic heart disease                                                               (2000) is not, therefore, reflected in these figures, but is
     have been downward, most markedly in countries with                                                                expected to affect incidence, survival and mortality rates.
     highest death rates at the start of the period from 1980
     shown in Figure 31.
                                                                                                                   Performance of healthcare systems
                                                                                                                   4.22 Healthcare systems are complex and making
Health outcomes                                                                                                         judgements about their performance overall is very
4.20 Information about the value added by healthcare                                                                    difficult. Average length of stay is often used as an
     systems in general or in relation to specific interventions                                                        indicator of the efficiency with which a system treats
     is very limited. The most comprehensive international                                                              patients, alongside the assumption that all medically
     data relate to cancer survival rates. The standard                                                                 appropriate treatment is delivered to clinically
                                                                                                                                                                                       part four




     measure is the percentage of cancer patients alive five                                                            acceptable standards and discharges are medically
     years after treatment. This measure has potential                                                                  approved. On this basis, a lower length of stay indicates
     drawbacks, as increases in five-year survival rates may                                                            better efficiency in the use of acute beds. Germany has
     be the result of better and earlier diagnosis, rather than                                                         the longest length of acute (hospital) stay at 9.6 days,
     represent a real postponement of death.                                                                            while the United Kingdom is in the middle of the range         21
                                                                                                                        of countries at 6.2 days, Figure 36.
             INTERNATIONAL HEALTH COMPARISONS




            25 Deaths from cancer, 1980 to 1999

                                                                         220
                Deaths per 100,000 of population (standardised)




                                                                         210


                                                                         200
                                                                                                                                                                                                              New Zealand
                                                                         190                                                                                                                                  United Kingdom
                                                                                                                                                                                                              France
                                                                                                                                                                                                              Canada
                                                                         180                                                                                                                                  Germany
                                                                                                                                                                                                              United States
                                                                                                                                                                                                              Italy
                                                                         170                                                                                                                                  Australia
                                                                                                                                                                                                              Japan
                                                                                                                                                                                                              Sweden
                                                                         160


                                                                         150


                                                                         140
                                                                                80
                                                                                      81

                                                                                            82

                                                                                                  83

                                                                                                        84

                                                                                                              85

                                                                                                                     86

                                                                                                                            87

                                                                                                                                  88

                                                                                                                                         89

                                                                                                                                              90

                                                                                                                                                   91

                                                                                                                                                          92

                                                                                                                                                                93

                                                                                                                                                                       94

                                                                                                                                                                             95

                                                                                                                                                                                    96

                                                                                                                                                                                          97

                                                                                                                                                                                                98

                                                                                                                                                                                                       99
                                                                               19
                                                                                    19

                                                                                         19

                                                                                                 19

                                                                                                       19

                                                                                                             19

                                                                                                                   19

                                                                                                                           19

                                                                                                                                 19

                                                                                                                                       19

                                                                                                                                            19

                                                                                                                                                  19

                                                                                                                                                         19

                                                                                                                                                              19

                                                                                                                                                                     19

                                                                                                                                                                            19

                                                                                                                                                                                  19

                                                                                                                                                                                         19

                                                                                                                                                                                               19

                                                                                                                                                                                                     19
                                                                                              Australia              Canada                    France                Germany                        Italy
                                                                                              Japan                  New Zealand               Sweden                United Kingdom                 United States


                Source: OECD Health Data 2002




            26 Latest known mortality for all cancers

                                                                         200
                                                                                    189.1
                                                                                                  184.7
                                                                                                                   180           177.1
                                                                         180                                                                     175.3         174.9             174.8
                                                                                                                                                                                               164.5
                       Deaths per 100,000 of population (standardised)




                                                                         160                                                                                                                                154.6      152.3

                                                                         140

                                                                         120

                                                                         100

                                                                          80

                                                                          60

                                                                          40

                                                                          20

                                                                           0
part four




                                                                                  New             United          France         Canada       Germany          United         Italy           Australia      Japan    Sweden
                                                                                Zealand          Kingdom          (1998)         (1997)        (1999)           States       (1998)            (1999)       (1999)     (1998)
                                                                                 (1998)           (1999)                                                       (1998)


 22             Source: OECD Health Data 2002
                                                                                                                                                                INTERNATIONAL HEALTH COMPARISONS




27 Main cancer killers with death rates

                                                      140
    Deaths per 100,000 of population (standardised)




                                                      120

                                                                  30.9                                      23.8
                                                                                 26.2           26.7
                                                      100
                                                                                                                             25.4
                                                                                                                                         26.9         27.2                     19.2
                                                       80         28.8           26.7                       24.1
                                                                                                28.9                                                                38.1
                                                                                                                             25.9                      22                      23.4
                                                                                                                                         24.8
                                                       60                                                                                                                                 9.3
                                                                                                                                                                    21.9                  9.5
                                                                  35.7                                      52.1
                                                       40                        47.9           42.7                         32.6
                                                                                                                                         33.7         32.8                     37.2
                                                                                                                                                                                         27.6
                                                                                                                                                                    22.9
                                                       20
                                                                   28
                                                                                 18.1           19.6                         23.5            19       21.4                     18.5      18.7
                                                                                                            17.6                                                    17.1
                                                        0
                                                                   New          Canada          United     United       Germany         France      Australia      Sweden      Italy      Japan
                                                                 Zealand        (1997)         Kingdom      States       (1999)         (1998)       (1999)         (1998)    (1998)     (1999)
                                                                  (1998)                        (1999)     (1998)




                                                                                                   Colon             Lung           Breast         Prostate


    Source: OECD Health Data 2002




28 Deaths from lung cancer

                                                            80

                                                                   71.9          71.4
                                                            70                                  68.9
    Deaths per 100,000 of population (standardised)




                                                                                                           63.9
                                                                                                                            61.3
                                                            60                                                                          59.4


                                                                                                                                                     49.9          49.7      48.9
                                                            50


                                                            40                          37.6
                                                                                                    32.2                                                                                31
                                                            30                                                                  29.1
                                                                                                                                                                      25.3

                                                            20                                                                                           18.9
                                                                                                                                                                                             16.7
                                                                                                                                              14                                12.7
                                                                         11.2                                   9.7
                                                            10


                                                             0
                                                                    Italy        United         Canada      France           United    Germany      Australia       New       Japan    Sweden
                                                                   (1998)         States        (1997)      (1998)          Kingdom     (1999)       (1999)       Zealand    (1999)     (1998)
                                                                                                                                                                                                    part four




                                                                                 (1998)                                      (1999)                                (1998)

                                                                                The lighter tinted bar represents male deaths. The darker tinted bar represents female deaths.


    Source: OECD Health Data 2002                                                                                                                                                                   23
             INTERNATIONAL HEALTH COMPARISONS




            29 Deaths from breast cancer


                                                                                30        28.9       28.8
                                                                                                                26.7
                                  Deaths per 100,000 females (standardised)




                                                                                                                            25.9
                                                                                                                                        24.8
                                                                                25                                                                   24.1
                                                                                                                                                                  23.4
                                                                                                                                                                                  22        21.9

                                                                                20



                                                                                15



                                                                                10                                                                                                                    9.5



                                                                                    5
                                                                                                                                                                                                        9
                                                                                                                                                                                                       0
                                                                                          United      New      Canada     Germany      France       United        Italy        Australia   Sweden     Japan
                                                                                         Kingdom    Zealand    (1997)      (1999)      (1998)        States      (1998)         (1999)      (1998)   (1999)
                                                                                          (1999)     (1998)                                         (1998)



                Source: OECD Health Data 2002




            30 Deaths from main circulatory diseases


                                                                              160


                                                                              140
                Deaths per 100,000 of population (standardised)




                                                                              120


                                                                              100


                                                                               80


                                                                               60


                                                                               40


                                                                               20


                                                                               0
                                                                                         United      New      Sweden     United       Germany      Canada       Australia        Italy      France    Japan
                                                                                        Kingdom    Zealand     (1998)     States       (1999)      (1997)        (1999)         (1998)      (1998)   (1999)
                                                                                         (1999)     (1998)               (1998)

                                                                                                               The lightest tinted bar represents ischaemic heart disease.
                                                                                                              The darkest tinted bar represents acute myocardial infarction.
part four




                                                                                                              The medium tinted bar represents cerebro-vascular disease.

                Source: OECD Health Data 2002


 24
                                                                                                                                                                    INTERNATIONAL HEALTH COMPARISONS




31 Deaths from ischaemic heart disease, 1980 to 1999

                                                      350
    Deaths per 100,000 of population (standardised)




                                                      300


                                                      250


                                                      200
                                                                                                                                                                                               United Kingdom
                                                                                                                                                                                               New Zealand
                                                      150                                                                                                                                      Germany
                                                                                                                                                                                               Sweden
                                                                                                                                                                                               United States
                                                      100
                                                                                                                                                                                               Canada
                                                                                                                                                                                               Australia
                                                       50                                                                                                                                      Italy
                                                                                                                                                                                               France
                                                                                                                                                                                               Japan
                                                        0
                                                             80

                                                                  81

                                                                         82

                                                                                83

                                                                                      84

                                                                                           85

                                                                                                 86

                                                                                                      87
                                                                                                            88

                                                                                                                  89

                                                                                                                          90

                                                                                                                                91

                                                                                                                                       92

                                                                                                                                              93

                                                                                                                                                    94

                                                                                                                                                          95

                                                                                                                                                                96

                                                                                                                                                                      97

                                                                                                                                                                                 98

                                                                                                                                                                                       99
                                                            19

                                                                 19

                                                                       19

                                                                              19

                                                                                     19

                                                                                          19

                                                                                                19

                                                                                                     19
                                                                                                          19

                                                                                                                 19

                                                                                                                        19

                                                                                                                               19

                                                                                                                                     19

                                                                                                                                             19

                                                                                                                                                   19

                                                                                                                                                         19

                                                                                                                                                               19

                                                                                                                                                                     19

                                                                                                                                                                            19

                                                                                                                                                                                      19
                                                                         Australia              Canada                    France                  Germany                        Italy
                                                                         Japan                  New Zealand               Sweden                  United Kingdom                 United States
    Source: OECD Health Data 2002




32 Five-year survival rates for lung cancer

                                                        18

                                                                  15.9
                                                        16                         15.4

                                                        14                                       13.8
          Five-year survival rate (per cent)




                                                                                      12                                11.7
                                                        12             11.5
                                                                                                                 10.8
                                                                                                                                    10.1             9.9
                                                        10                                                                                                           9.6
                                                                                                      8.7                               8.6             8.9                8.8
                                                            8
                                                                                                                                                                                       7.1 7
                                                                                                                                                                                                    6.3 6.1
                                                            6


                                                            4


                                                            2


                                                            0
                                                                  France       United States    Germany        Netherlands           Italy          Europe          Sweden             England     Scotland


                                                                              The lighter tinted bar represents female deaths. The darker tinted bar represents male deaths.
                                                                                                                                                                                                                part four




    Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
    1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989




                                                                                                                                                                                                                25
             INTERNATIONAL HEALTH COMPARISONS




            33 Five-year survival rates for breast cancer

                                                       90
                                                                  82.8
                                                                                 80.6           80.3
                                                       80                                                    76.7
                                                                                                                           74.4
                                                                                                                                         72.5           71.7
                                                       70                                                                                                             66.7            65
                 Five-year survival rates (per cent)




                                                       60

                                                       50

                                                       40


                                                       30

                                                       20


                                                       10

                                                        0
                                                             United States    Sweden           France        Italy     Netherlands      Europe       Germany        England        Scotland



                Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
                1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989




            34 Five-year survival rates for cancer of the colon

                                                            70

                                                                  61.6 60.2
                                                            60                   58.7
                                                                                        55.7                    55.5
                                                                                                       54
                                                                                                51.8        51.8
                 Five-year survival rates (per cent)




                                                                                                                          49.6 49.9
                                                            50                                                                           46.9 47      46.8 46.7

                                                                                                                                                                       41.1         41 41.3
                                                            40


                                                            30


                                                            20


                                                            10


                                                             0
                                                                 United States Netherlands       France       Sweden       Germany          Italy       Europe       Scotland      England



                                                                              The lighter tinted bar represents male patients. The darker tinted bar represents female patients.
part four




                Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
                1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989




 26
                                                                                                                      INTERNATIONAL HEALTH COMPARISONS




35 Five-year survival rates for prostate cancer

                                          90
                                                   81.1
                                          80
    Five-year survival rates (per cent)




                                          70                    67.6
                                                                          64.7
                                                                                   61.7
                                          60
                                                                                               55.7        55.3

                                          50                                                                          47.4        47.2
                                                                                                                                                44.3

                                          40


                                          30


                                          20


                                          10


                                           0
                                               United States   Germany   Sweden   France      Europe    Netherlands   Italy     Scotland      England


    Sources: United States figures from SEER Cancer Statistics Review 1973-1999, National Cancer Institute, 2002, cancer first diagnosed between 1986 and
    1988. All other countries from Survival of cancer patients in Europe: the EUROCARE-2 study, 1999, cancer first diagnosed between 1985 and 1989




36 Average length of stay for acute care

                                          12



                                          10       9.6



                                           8
                                                                 7.2      7.1

                                                                                    6.2         6.2
                                           6                                                                5.9
                                                                                                                        5.5
             Days




                                                                                                                                    5              4.9

                                           4



                                           2



                                           0
                                                Germany         Italy    Canada   Australia    United      United     France     Sweden           New
                                                 (2000)        (1998)    (1999)    (1999)     Kingdom       States    (1999)      (2000)        Zealand
                                                                                               (2000)      (1999)                                (1998)

    Average length of stay is computed by dividing the number of days stayed (from the date of admission in an in-patient institution)
                                                                                                                                                            part four




    by the number of separations (discharges and deaths) during the year.


    Source: OECD Health Data 2002



                                                                                                                                                            27
               INTERNATIONAL HEALTH COMPARISONS




               Appendix 1                                                       Healthcare delivery systems




               1.1 This appendix sets out the health care delivery systems in   Primary care
                   the ten comparator countries. The main sources used to
                   compile it were: Health Care Systems In Eight Countries:     1.4 Private practitioners provide most community-based
                   Trends and Challenges, European Observatory on Health            medical and dental treatment and there is a large private
                   Care Systems, 2002; Multinational Comparisons of                 hospital sector. The bulk of primary medical care is
                   Health Systems Data, Anderson G.F. and Hussey P.S., The          provided by GPs. They are mostly self-employed and run
                   Commonwealth Fund, 2000; and, Securing Our Future                their practices as businesses. They are reimbursed by a
                   Health, Wanless D., Interim Report, November 2001. We            fee-for-service system. Patients have a choice of GP with
                   also used material from the European Observatory                 no restrictions and may consult more than one GP since
                   web-site and from web-sites of Government health                 there is no requirement to enrol with a practice. GPs act
                   departments of the countries.                                    as gatekeepers to in-patient and out-patient services.


                                                                                In-patient/secondary care
               Australia
                                                                                1.5 In-patient care is provided by public hospitals (70 per
               1.2 Australia offers universal access to health care to all
                                                                                    cent of stock of acute care beds). Patients with private
                   residents through Medicare. Individuals eligible for
                                                                                    health insurance may chose to be admitted to either
                   Medicare receive free ambulatory medical care and free
                                                                                    public or private hospitals and may also choose their
                   accommodation and medical, nursing and other care as
                                                                                    specialist. Medicare subsidises medical costs but not
                   public patients in state funded hospitals. Alternatively
                                                                                    accommodation costs. Physicians in public out-patient
                   they may choose treatment as private patients in public
                                                                                    hospitals are either salaried (but may have private
                   or private hospitals, with some assistance from
                                                                                    practices and fee-for-service income) or paid on a per
                   Medicare. Figure 1.1 shows the health care delivery
                                                                                    session basis.
                   system and flows of finance in Australia. Australia has
                   complex health care system with many types of services
                   and providers and a range of funding and regulatory
                   mechanisms. There is a large and vigorous private sector
                   in health services.


               Role of the Government
               1.3 The federal Government has control over hospital
                   benefits, pharmaceuticals, and medical services. The
                   States are primarily responsible for funding and
                   administering public hospitals and mental and
                   community health services, and pay for public hospitals
                   with federal Government assistance.
appendix one




 28
                                                                                                        INTERNATIONAL HEALTH COMPARISONS




1.1 Financing of healthcare in Australia, 1999



       OOP - Out of pocket payments                                                                                   Financial flows
       OTC - Over the counter drugs                                                                                   Service flows
       FFS - Fee-for-service


                                                                  Private Health
                                                                     Insurers
            Voluntary contributions


                                                                          30% rebate on private health
                                                                          insurance premiums

                                                                 Commonwealth
                                                                  Government
         Compulsory
            health
          insurance                                                       General and specific purpose payments
             levy   Taxes                                                                           Some states have
                                                                 State & territory
                                                                                                     regional health
                                                                  Governments
                                                                                                       authorities
                            Taxes

                                                                                     Budget and salaries
                                                                  Public health                                 Budgets
      Population


                                                                                     Budgets
                                                                  Community
                                      Mostly free, may be        health services
                                      nominal charges

                                                                                      Some contracting          Mostly FFS
                                                                    General                                     with small
                                      Mostly free, (80%),         practitioners                                 sessional &
                                      some OOP & 15%                                                            capitation
                                      copayments                                                                payments
                                                                   Specialist        FFS or sessional
                                                                    medical
                                                                                                                FFS
                                      Small % are free, most      practitioners
                                      pay 15% copayments &
                                      OOP
                                                                                                                Reimburse-
                                                                                                                ment
                                                                   Pharmacist
                                                                                                                against
                                      Free to health care card
                                                                                                                schedule
                                      holder, but copayments,
                                      OOP & OTC charged to
                                      others                                         Case -mix and other
                                                                 Public hospitals

                      Patients
                                                                           Some contracting


                                                                 Private hospitals

                          Hotel charges and
                          significant OOP costs
                                                                                                                                           appendix one




                                               Reimbursement of hotel charges & 15% gap
                                               between Government rebate & schedule of fees
                    Source: OECD Secretariat

                                                                                                                                            29
    Source: OECD Health Data 2002
               INTERNATIONAL HEALTH COMPARISONS




               Canada                                                            Primary care
               1.6 Although predominately publicly funded, healthcare is         1.8 Most primary physicians are in private practice and are
                   largely delivered by private providers, particularly in the       remunerated on a fee-for-service basis. Provincial
                   primary care sector, Figure 1.2.                                  medical associations negotiate the fee schedules for
                                                                                     insured services with provincial health ministries.
                                                                                     Physicians must opt out of the public system of payment
               Role of the Government                                                to have the right to charge their own rates.
               1.7 The federal Government requires that provincial health
                   insurance plans cover all medically necessary physician       In-patient/secondary care
                   and hospital services. The provincial governments have
                   the authority to regulate health providers. However,          1.9 In-patient care takes place in public and private non-
                   they delegate control over physicians and other                   profit hospitals that operate under global budgets or
                   providers to professional "colleges" whose duty is to             regional budgets with some fee-for-service payment. Less
                   license providers and set standards for practice.                 than 5 per cent of Canadian hospitals are privately
                                                                                     owned and are mainly long-term care facilities.
appendix one




 30
                                                                                              INTERNATIONAL HEALTH COMPARISONS




1.2 Financing of healthcare in Canada, 2000



        OOP - Out of pocket payments                                                                        Primary financier
        RHA - Regional Health Authority                                                                     Financial flows
                                                                                                            Service flows


                                                               Private
                                                               Insurers
            Voluntary contributions




                                                                              Healthcare services for natives living on
                                                                              reserves, RCMP, inmates in federal
   premiums                                                    Federal        prisons, veterans & military personnel
                                                             Government

                                                         Transfers                          RHAs (except NS
                                                                                            & Ont) funding for
                                                                              Global         service varies by
              Taxes                                                           budgets
                                                             Provincial                          province
                                                            Governments

                                                         Transfers
                       Taxes
                                                             Municpal
                                                            Governments

                                          Employer                               Workers
                                          contribution                         Compensation
                               Taxes                                              Board


                                                             Community
     Population and Enterprises                             health services


                                              OOP                Other
                                                              institutions


                                                                                 Limited coverage
                                              OOP          Dental & Vision
                                                            Care, Other
                                                            Practitioners



                                                              Hospitals
                                              OOP


                                                              Physicians
                                                             (about 80%
                                                           Fee-for-service)


                                                           Pharmaceuticals       Limited coverage
                                                            (incl over the
                                              OOP
                                                            counter drugs

                               Patients

                                                            Public Health
                                                                                                                                 appendix one




                                                          reimbursements
    Source: OECD Secretariat


    Source: OECD Health Data 2002                                                                                                 31
               INTERNATIONAL HEALTH COMPARISONS




               England                                                         1.14 Ambulatory care is also provided in 36 walk-in clinics
                                                                                    and there is a 24-hour telephone helpline service
               1.10 OECD system information is only available for England.          (NHS Direct) as a first point of contact.
                    Other constituent parts of the United Kingdom have
                    their own structures for delivering a largely publically
                    funded health service, free at the point of use.           In-patient/secondary care
                                                                               1.15 Access to emergency care is through personal
               1.11 Primary care services are mainly provided by GPs and
                                                                                    attendance at Accident and Emergency departments in
                    multi-professional teams in health centres (under a
                                                                                    acute hospitals. Patients may walk in to such
                    capitated budget), Figure 1.3. Hospitals are mainly
                                                                                    departments or use the free ambulance service in cases
                    publicly owned with independent trust status. Private
                                                                                    of extreme urgency. Patients may also be advised to
                    hospitals mainly provide services to privately insured
                                                                                    attend Accident and Emergency departments by their
                    patients or those who are willing to pay directly.
                                                                                    GP or NHS Direct.

                                                                               1.16 Access to in-patient care is through GP referral. Most
               Role of the Government
                                                                                    referrals are made to local hospitals and follow
               1.12 The Government is responsible for health legislation and        contractual arrangements between health authorities,
                    general policy matters and is a purchaser and provider          Primary Care Trusts and the hospital. Secondary care is
                    of health care.                                                 provided in general acute NHS trusts, small-scale
                                                                                    community hospitals and highly specialised tertiary
                                                                                    level hospitals. Hospitals are semi-autonomous self-
               Primary care                                                         governing public trusts that contract with groups of
               1.13 GPs act as gatekeepers and are brought together in              purchasers. Consultants are salaried.
                    Primary Care Groups/Trusts with budgets for all care of
                    enrolled populations. Most ambulatory care is provided
                    by GPs in group practices. Private general practice is
                    very small. Physicians are paid directly by the
                    Government through a combination of methods: salary,
                    capitation, and fee-for-service.
appendix one




 32
                                                                                                         INTERNATIONAL HEALTH COMPARISONS




1.3 Financing of healthcare in England, 1999


                                                                                                                       Financial flows
                                                                                                                       Service flows
                                                                                                                       Referral flows

                      Risk related, voluntary premiums            Private Health
                                                                    Insurance




                                                                  Department of
                                                                     Health
                       General taxation and                                         Global budgets for HCHS* and
                       National Insurance contributions          NHS Executive      prescribing set by weighted capitation

                                                                    Regional
                                                                     Offices




                                                                     Retail
                                                                   Pharmacists                      GP remuneration
                                                                                                    and expenses
                                          Prescripton
                                          charges
                                                                          Prescribing



                                                 Prescribed
                                                 drugs
        Population
                                                                   Primary Care         GP remuneration
                                                                   Groups (can          and expenses                 Strategic
                                          GP and practice           evolve into                                       Health
                                          nursing services         Primary Care         Global budgets              Authorities
                                                                      Trusts)           for HCHS* and
                                                                                        prescribing


                                                              Referrals      Commissioning
                                                                             of most HCHS*


                                          Hospital and
                                          community
                                          health services          Hospital and
                           Patients                                                          Commissioning of highly
                                                                   Community
                                                                   HealthTrusts              specialised HCHS*


                                                     Direct
                                                     payments



                                                                     Private
                                                                    Hospitals                Direct payments


                        Reimbursement
    Source: Department of Health, England
                                                                                                                                            appendix one




    NOTE

    *     HCHS: Hospital and Community Health Services

    Source: OECD Health Data 2002
                                                                                                                                             33
               INTERNATIONAL HEALTH COMPARISONS




               France                                                            In-patient/secondary care
               1.17 All legal residents are covered by public health             1.20 In-patient care is provided in public and private hospitals
                    insurance. They have no choice to opt out. Most have              (not-for-profit and for-profit). Doctors in public hospitals
                    additional private insurance to cover areas that are not          are salaried whilst those in private hospitals are paid on
                    eligible for reimbursement by the public health                   a fee-for-service basis. Some public hospital doctors are
                    insurance system and many make out of pocket                      allowed to treat private patients in the hospital, within
                    payments to see a doctor. Health care is purchased and            limits. A percentage of the private fee is payable to
                    paid for by health insurance schemes and the                      the hospital.
                    Government and provided by private (self-employed)
                    practitioners and public and private (for-profit and not-    1.21 Most out-patient care is delivered by doctors, dentists
                    for-profit) hospitals, Figure 1.4.                                and medical auxiliaries working in their own practices
                                                                                      (62 per cent are in sole practice, the remainder are
                                                                                      in groups). Out-patient care is also provided to a lesser
               Role of the Government                                                 extent in hospitals and marginally in health centres (run
                                                                                      by local authorities or mutual associations).
               1.18 The French Government regulates contribution rates
                    paid to sickness funds, sets global budgets and salaries
                    for public hospitals, and supervises national fee
                    schedule negotiations.


               Primary care
               1.19 French patients have free choice of provider. They can
                    visit any GP or specialist practising privately or working
                    in hospital out-patient, without referral or any limit on
                    the number of consultations. Ambulatory care is mainly
                    provided by professionals practising privately. Most GPs
                    and specialists are paid on a fee-for-service basis
                    according to agreed fee schedules. Patients pay
                    physicians' bills and are reimbursed by sickness funds
                    (public reimbursement model). GPs have no formal
                    gatekeeper function. The Government introduced a non-
                    obligatory gatekeeping mechanism in 1987 but only
                    1 per cent of the patients and 10 per cent of GPs signed
                    up to this.




                                                                                 NOTES FOR FIGURE 1.4 (OPPOSITE)
                                                                                 Fully private health insurance concerns only a minority of extra-
                                                                                 territorial workers, or cross border workers.
appendix one




                                                                                 (1) ACOSS = Central Social Security Account
                                                                                 (2) CANAM = Health Insurance Fund for self-employed
                                                                                 (3) MSA = Health Insurance Fund for farmers
                                                                                 (4) URSSAFF = Body collecting social contributions
 34                                                                              Source: OECD Secretariat
                                                                                                            INTERNATIONAL HEALTH COMPARISONS




1.4 Financing of healthcare in France, 1999


             "Mutuelles" &                                          Private health                                Reimbursement
             private health                                           insurance                                     of patients
               insurance
               premiums


                                                                                                                  Reimbursement
                                                               "Mutuelles", Social                                  of patients
                                                              Security, Mandatory
                     State financial                             Sickness Funds
                         funds,
                     Refinancing of                                  Main health
                         deficits                                  insurance funds                                 Fee-for-service
                                                                      (CNAMts)                                     Private clinics


                      ACOSS (1)                                     CANAM (2)

                                                                                                                    Payment of
                                                                      MSA (3)                                     global budgets
                                                                                                                    to hospitals


                                            Control
                                                              Ministry of Social
                                                             Affairs, Secretary of                                 Regulation of
                                                             State for Health and                                     supply,
                                Ministry of Finance          other public bodies                                  hospitals, drugs
                                  and Industry,
                                controls balancing
                                     accounts
                                                            National target                                 Regional hospital
                                                              for health                                      supervisory
                                                              spending                                          agencies

                        Obligatory
                    employer/employee              Target for
                                                medical spending          Public hospitals
                    social contributions                                                                          Allocation of
                                                  (ONDAM)                 and equivalent
                           (CSG)                                                                                 global budgets
                                                                             hospitals


                 URSSAFF (4)           Tax services                             Private
                                                                                clinics
                                                                                                                     Local
                    Population and Enterprises                                                                    government
                                                                            Community
                                                                           health centres
                                                                                                                 Agreement with
                                                                                                                retail pharmacists
                                                                             Doctors:                             RE: generic &
                                                                            Generalists,                        substitution drugs
                                                                            Specialists
                                            Patients

                                                                        Prescribed auxiliary
                                                                          and ambulatory
                                    Copayments and                            services                            Economic Regulatory
                                     other patient                                                                  Agency for health
                                    direct payments                                                                    products
                                                                         Retail pharmacies                           (Drug Agency)
                                                                             and drugs
                                                                                                                                               appendix one




                                                                                                                        Contracts
                                                                                           Pharmaceutical
                                                                                              industry




    Source: OECD Health Data 2002                                                                                                               35
               INTERNATIONAL HEALTH COMPARISONS




               Germany                                                           Primary care
               1.22 92 per cent of the population is covered by statutory        1.24 All ambulatory care, including both primary care and
                    health insurance, and just under 8 per cent by private            out-patient secondary care has been organised almost
                    health insurance but 0.2 per cent is not covered at all.          exclusively on the basis of office-based physicians.
                    Ambulatory care and hospital care have traditionally              Their premises, equipment and personnel are
                    been distinct domains with almost no out-patient care             financed by the physicians' associations. Ambulatory
                    delivered in hospitals, Figure 1.5. Ambulatory care is            physicians offer almost all specialties with all
                    delivered by private office-based physicians                      technical equipment up to MRI scanners. Besides
                    (generalists and specialists). Hospital in-patient care is        GPs, the most frequented specialists are internists,
                    provided by a mix of public and private providers,                gynaecologists and paediatricians. They are paid on a
                    although only a small proportion of total beds is in              fee-for-service basis. All treat public and private
                    for-profit hospitals.                                             patients. There is no formal gatekeeping system as
                                                                                      patients are free to choose their doctor.

               Role of the Government
                                                                                 In-patient/secondary care
               1.23 The Government regulates the sickness funds. However,
                    it has increasingly tended to reduce its interventions in    1.25 Except in emergency conditions, access to in-patient
                    favour of a self-regulating system.                               care requires a referral from an ambulatory physician.
                                                                                      Hospitals are public and private (for-profit and not-for-
                                                                                      profit). They are staffed with salaried junior doctors and
                                                                                      fee-for-service senior doctors.
appendix one




 36
                                                                                                   INTERNATIONAL HEALTH COMPARISONS




1.5 Financing of healthcare in Germany, 1995 (Values in Billion DM)




                    General                                    Public and                               Private
                   Government                                    private                              households
                       98                                      employers                                 211
                                                                  198

                  6    57    35                                                                      172     39
                                            16                       121


                                             ■   Mandatory Health Insurance                  237
                                             ■   Mandatory long-term care insurance           10
                                             ■   Pension Fund                                 39
                                             ■   Mandatory Accident Insurance                 16
                                             ■   Private Health Insurance                     26

                                                                                         26                        Expenditure on
                                                                      247
                                                                                                                   administration

                                             ■   In-patient Care                             123
                                             ■   Ambulatory Care                              87
                                             ■   Medical Goods (including denture)            82
                                             ■   Other benefits                               67

                            61      55




                   Benefits-in-cash
                  (income transfers)                           Benefits-in-kind




                                                          Private households



                Source: Adapted from Federal Office of Statistics, 1998


    NOTE

    The benefits-in-cash which are not included in most of the diagrams are included here.


    Source: OECD Health Data 2002
                                                                                                                                      appendix one




                                                                                                                                       37
               INTERNATIONAL HEALTH COMPARISONS




               Italy                                                            In-patient/secondary care
               1.26 The main providers are local health units (consisting of    1.29 Access to secondary care is through a GP referral.
                    health districts, hospitals and health promotion                 Referred patients are free to choose their provider
                    divisions), public hospital trusts and private accredited        among those accredited by the health service.
                    hospitals, Figure 1.6. Local health units are responsible        Specialised ambulatory services are provided either by
                    for maintaining the balance between the funding                  local health units or by accredited public and private
                    provided by the regions and expenditure for service.             facilities with which local health units have agreements
                                                                                     and contracts.

               Role of the Government                                           1.30 In-patient care is provided by hospitals. The major
                                                                                     hospitals are given the status of independent trusts. The
               1.27 Regional government, through regional health
                                                                                     rest of the public hospitals are kept under the direct
                    departments, is responsible for ensure the delivery of a
                                                                                     management of local health units. Hospital physicians
                    benefit package through a network of local health units
                                                                                     delivering secondary care earn a monthly salary.
                    and public and private accredited hospitals.


               Primary care
               1.28 Primary care is provided by general practitioners,
                    paediatricians and self-employed and independent
                    physicians working alone under a Government contract
                    who are paid a capitation fee based on the numbers on
                    their list.
appendix one




 38
                                                                                                              INTERNATIONAL HEALTH COMPARISONS




1.6 Financing of healthcare in Italy, early 1990s




        Compulsory                            Tax subsidies
                                                                     Ministry                    Regional health                 Local Health
        social              Treasury
                                                                     of Health                     authorities                   Offices (LHO)
        contributions



                                                                                                                   Payments to
                  Private insurance        Private insurance    Reimbursements
                      premiums                companies            to patients                                Preventative
                                                                                                                  care




                        Health funds         Supplemental       Reimbursements
                                              health funds         to patients                             Public
                                                                                                          hospital Private
                                                                                                          service Service        Budgets




                                           Private structures   Reimbursements
                                                                    of private
                                                                sector to patients                              Clinics



                                    Direct
                                   payment
                                                                                                          of which:
                                                                                                          the main Other
                                                                                                           services care*

          Population and
          Enterprises
                                              Reimbursement of patients


                                              Pay beds and intramural professional activity

                            Patients          Prescription charges




                           Prescription
                           charges
                                          List                         Salary                      Per diem                      Capitation
                                          prices


                                                       Specialists                    Hospitals
                                                    operating within                                              General
                           Pharmacists                                          under contract to NHS
                                                        the NHS                                                 practitioners
                                                                                 and nursing homes
                                                    'convenzionati'                'convenzionati'
                                                                                                                                                   appendix one




    Source: Salvini, R. (1991), Il sistema sanitario italiano, ISPE, not published and Hoffmeyer et al, Financing Health Care, Romel, NERA 1994.

    NOTE

    *     Out-patient care, household advisory bureau, therapeutic appliances and thermal services, care for poor people, for Italians who
          live abroad and for foreigners who live in Italy.
                                                                                                                                                    39
    Source: OECD Health Data 2002
               INTERNATIONAL HEALTH COMPARISONS




               Japan                                                             Primary care
               1.31 Japan's healthcare system offers universal coverage and      1.33 Physicians have no formal gatekeeper function. Most are
                    stresses preventative care. Provision is mainly private,          in private practice and are paid through a uniform fee
                    with 80 per cent of Japan's hospitals and 94 per cent of          schedule. Medical and pharmaceutical practices are
                    its physician run clinics being privately owned,                  often combined, and a large proportion of physicians'
                    Figure 1.7. Investor-owned for-profit hospitals are               incomes is derived from prescriptions.
                    prohibited. Patients are free to select care providers.

                                                                                 In-patient/secondary care
               Role of the Government                                            1.34 Hospitals are mainly private, although there are some
               1.32 The Japanese Government acts as regulator and insurer.            public ones. Hospitals combine acute and long-term
                    It determines a fee schedule in consultation with                 care functions and are paid according to a uniform fee
                    providers and consumers. All doctors receive the same             schedule. Hospital based physicians are salaried.
                    salary regardless of experience. It also subsidises health
                    care spending for the elderly, small business employees,
                    and the self-employed.
appendix one




 40
                                                                                                  INTERNATIONAL HEALTH COMPARISONS




1.7 Financing of healthcare in Japan, early 2000



                                                                                                                   Financial flows
                                                                                                                   Service flows




                                                                        Insurers
                          Employer                                  for Employees
                                                                (Society-Managed HI &
                                                               Government-Managed HI)




                                                                        Insurer
                                      Contributions                for Government                    transfers
                                      (41.7% of THE                 Employees etc.
                                     or 52.9% of NME
                                          in 1998)


                                                                       Insurers
                                                                  for Self-Employed
                                                                    (National HI)




                                                 Subsidies                                                       Social Insurance
                                              (25.4% of THE                                                       Medical Care
                                             or 32.2% of NME                                                            Fee
                        Government
                                                 in 1998)                     Medical Aid                         Payment Fund
                                                                             Programme etc.



                                                                                                                         Reviews &
                                                                                                                         Payments
                                                                                                                         (67.1% of THE
                         Taxes         Subsidies                                                                         or 85.1% of NME
                                                                   Public Health                                         in 1998)
                                                                    Programmes


                                                                   Health Centres
                                         (Half the cost for
                                           elderly care
                                        except copayment)

                                                                   Health Service                mixed payment
                                                                    Facilities for
                                                                                                (half the cost for
                                                                    Elderly etc.
                                                                                                  elderly care
                                                                                              except for copayment)
           Population
                                                                     Pharmacy                    fee-for-service
                                       Patient Copayment
                                         (11.7% of THE
                                        or 14.8% of NME                                          fee-for-service
                                            in 1998)               Doctor's Clinic
                                       and non-covered
                                             services
                         Patients                                     Hospital
                                                                     (Including
                                                                  special function
                                                                                                                                           appendix one




                                                                                                 fee-for-service
                                                                      hospitals,
                                                                       geriatric
                                                                      hospitals)




    Source: OECD Health Data 2002                                                                                                           41
               INTERNATIONAL HEALTH COMPARISONS




               New Zealand                                                        In-patient/secondary care
               1.35 New Zealand's healthcare system covers all residents.         1.38 Patients access secondary care via a GP referral.
                    All essential services, including hospital and out-patient,        Specialist physicians and surgeons provide ambulatory
                    are provided free through the public health system, with           care in community-based public or private clinics or in
                    the exception of dentistry and ophthamology. Public                hospital out-patient departments. Hospital out-patient
                    hospitals account for just over half the total bed stock           departments play a larger role in the health system
                    including the large tertiary sector. The costs of primary          than in other countries since treatment is free
                    health care are met or subsidised for certain groups.              while consultations with community based
                    About 40 per cent of the population hold concession                practitioners are charged.
                    cards (usually low-income patients, children and higher
                    users of the services). Health services are delivered by a    1.39 Publicly owned hospitals provide most secondary and
                    mix of public and private providers, Figure 1.8.                   tertiary care, while the growing private sector specialises
                                                                                       mainly in elective surgery and long-term care. Public
                                                                                       hospitals are not permitted to treat private patients.
               Role of the Government                                                  Hospitals are semi-autonomous Government owned
                                                                                       companies that contract with the Health Funding
               1.36 New Zealand's Government is a purchaser and provider
                                                                                       Authority. Consultants are salaried.
                    of healthcare and has responsibility for legislation and
                    general policy matters.


               Primary care
               1.37 General practitioners act as gatekeepers and are
                    predominately private practitioners with two-thirds
                    working in group practices. Patients have a choice of
                    GPs and are free to see more than one GP, although in
                    practice continuity of care is high. They provide most
                    primary medical services. They are self-employed and
                    are paid through a combination of payment methods:
                    fee-for-service, partial Government subsidy, and
                    negotiated contracts with Health Funding Authority
                    through Independent Practitioner Associations.
appendix one




 42
                                                                                                    INTERNATIONAL HEALTH COMPARISONS




1.8 Financing of healthcare in New Zealand, 1998



                                                                                                                          Financial flows
                                                                                                                          Service flows


                                          Central                           Ministry
                                        Government                          of Health




                        General Taxation           Accident
                                                 compensation
                                               corporation (ACC)
                        Levies/Premiums




               Population and                        copayments
               Enterprises
                                                                         Pharmacists*              contracts/
                                                                                                  subsidies**




                                                           Fees          Independent
                                                                                                capitation
                                                                         Practitioners
                                                                                              budgets and
                                                                         Associations
                                    Patients                                                 fee for service
                                                                                               subsidies**
                                                           Fees
                                                                       Non IPA GPs and
                                                                       other independent                        Health Funding
                                                                          practitioners    fee for service        Authority
           Broad risk                                                                         subsidies/
           related                                                                         budget-holding
           premiums                                                                          capitation**
                                                                       Hospitals and
                                                                       Health Services                  contracts
                  Reimbursement         Fees                              (HHSs)




                                                                        Voluntary and                   contracts
                      Private
                                                                       Private Providers
                     Insurance




                                                                          Community                     contracts
                                                                            Trusts




                                                                            Private                     contracts
                                                                           Hospitals
                                                                                                                                            appendix one




    * and other providers such as laboratories and radiology clinics
    ** relating to contracts with the Health Funding Authority


    Source: OECD Health Data 2002


                                                                                                                                             43
               INTERNATIONAL HEALTH COMPARISONS




               Sweden                                                          Primary care
               1.40 Ambulatory care is provided by a mix of public doctors,    1.42 Patients can choose between primary care centres or
                    private doctors and hospital out-patient departments.           hospital out-patient departments as the first point of
                    Hospitals are publicly owned but have independent               contact. Higher fees are applicable for out-patient visits
                    status, with the extent of privatisation varying between        compared to visits to primary care centres.
                    counties, Figure 1.9.

                                                                               In-patient/secondary care
               Role of the Government                                          1.43 Patients can access secondary care directly through a
               1.41 The county councils are responsible for the purchasing          hospital out-patient department. In many counties
                    of health services and either act as purchasers                 patients can also select which hospital to be treated at,
                    themselves or devolve this responsibility to other              and in some cases, without referral. Most hospitals are
                    purchasing agents.                                              publicly owned.
appendix one




 44
                                                                                                       INTERNATIONAL HEALTH COMPARISONS




1.9 Financing of healthcare in Sweden, 1999




               Around 2% of                                     Private Health
               health funds                                       insurance



                   Taxes &               National
                   employer             Government
                   fees


                          National pay roll tax              Social insurance
                                     General tax                  board
                                     equalisation
                                     & grants                            Grants (weighted capitation
                                                                         less FFS payments)

                                Around 72% of       21 County councils
                                health funds -
                                local payroll rax



                                         Municipalities



               Population and
                                                           Home health care
               Enterprises



                                                           Public hospitals &    Budgets
                                                             LT institutions
                                                                                                                   Some
                                                                                                                   central
                                                             Public primary      Salaries                        purchasing
                                                               physicians                                         agencies


                                                                                 Budgets    Mixed payment
                                                             Public primary
                                                                                               systems               Some
                                                             health centres
                                                                                              mainly FFS          devolved
                                                                                                                district health
                                                                                                                 authorities
                                                             Private general     FFS
                                                              practitioners



                                                            Private medical      FFS
                                                               specialists




                                                              Pharmacies                     Subsidised prices and
                          Patients                                                           prescribed out-patient
                                                                                                  medications
                                                                                                                                          appendix one




       Reimbursements
        and payments          Cash benefits




    Source: OECD Health Data 2002
                                                                                                                                           45
               INTERNATIONAL HEALTH COMPARISONS




               United States                                                     Primary care
               1.44 Health care services are mainly provided by private          1.46 General practitioners have no formal gatekeeper function,
                    practitioners, Figure 1.10.                                       except within some managed care plans. The majority of
                                                                                      physicians are in private practice and are paid through a
                                                                                      combination of charges, discounted fees paid by private
               Role of the Government                                                 health plans, capitation rate contracts with private plans,
                                                                                      public programmes, and direct patient fees.
               1.45 The federal Government is the single largest health care
                    insurer and purchaser. There are two principal schemes in
                    which the Government is involved: Medicaid and               In-patient/secondary care
                    Medicare. Medicaid is a jointly-funded, Federal-State
                    health insurance programme for certain low-income and        1.47 In-patient care is provided in public and private hospitals
                    needy people. It covers approximately 36 million                  (for-profit and not-for-profit). Hospitals are paid through a
                    individuals including children, the aged, blind, and/or           combination of charges, per admission, and capitation.
                    disabled, and people who are eligible to receive federally
                    assisted income maintenance payments. Medicare is a
                    health insurance programme for people 65 years of age
                    and older, some disabled people under 65 years of age,
                    and people with End-Stage Renal Disease (permanent
                    kidney failure treated with dialysis or a transplant). It
                    currently covers some 39 million Americans.
appendix one




 46
                                                                                                                       INTERNATIONAL HEALTH COMPARISONS




1.10 Financing of healthcare in the United States, early 1990s




                                                                                                    Premiums
               Federal                Budget/Trust Fund                                                                    Private Insurers
                                                                          Medicare
             Government
                                                                                                                     Traditional    Managed Care
                                                                                                                      Insurers        Entities

                    Budgets

                                                                   RBRVS
                State
             Governments                                                                                            FFS (Traditional)/




                                                                                                                                                             Various Contracts (Managed)
                                                                                                                    Various Contracts
                                                                                                                    (Managed)
                    Budgets




                                                                                                                                         FFS (Traditional)
                    State Medicaid          Discounted FFS
                     Programmes             and CPC


                                                                    Physicians
                  Negotiated
                    Prices                                                                                CPC
                                                                                                          (DRGS)
                                                                                                                             Hospitals
                                                                                                 Discounted FFS
                                                                                                 and CPC
                                                                     Co-pay & Out-of-Pocket




                     Pharmacists
                                                                                                FFS/Formularies

                                                                                                Copayments &
                                                                                                Out of pocket
                                  Copayments &                                                  payments
                                  Out of pocket payments

                                                                                                                   Reimbursement for Out of pocket/
               General Taxation                                                                                    Copayments (e.g. Medigap) other
                                                                                    Patients                       benefits (e.g. pharmaceuticals)
          General Taxation/Payroll Taxes
                                                             Tax-payers                       Consumers            (Mostly) Risk-Related Premia


       Source: Financing Health Care, Volume II, Hoffmeyer et al., 1994


     CPC: Cost-per-case
     FFS: Fee-for-service
     RBRVS: Resource-based relative value scale

      Source: OECD Health Data 2002
                                                                                                                                                                                           appendix one




                                                                                                                                                                                            47
               INTERNATIONAL HEALTH COMPARISONS




               Appendix 2                                                                                                                Death rates from the main
                                                                                                                                         cancers over time




                  2.1 Deaths from cervical cancer, 1980 to 1999

                                                                   8
                       Deaths per 100,000 females (standardised)




                                                                   7


                                                                   6


                                                                   5
                                                                                                                                                                                                New Zealand
                                                                                                                                                                                                Germany
                                                                   4                                                                                                                            United Kingdom
                                                                                                                                                                                                United States
                                                                   3                                                                                                                            Japan
                                                                                                                                                                                                Canada
                                                                                                                                                                                                Sweden
                                                                   2
                                                                                                                                                                                                Australia
                                                                                                                                                                                                France
                                                                   1                                                                                                                            Italy


                                                                   0
                                                                       80

                                                                             81

                                                                                   82

                                                                                         83

                                                                                               84

                                                                                                     85

                                                                                                           86

                                                                                                                 87

                                                                                                                       88

                                                                                                                             89

                                                                                                                                   90

                                                                                                                                         91

                                                                                                                                               92

                                                                                                                                                     93

                                                                                                                                                            94

                                                                                                                                                                  95

                                                                                                                                                                        96

                                                                                                                                                                              97

                                                                                                                                                                                    98

                                                                                                                                                                                          99
                                                                   19

                                                                            19

                                                                                  19

                                                                                        19

                                                                                              19

                                                                                                    19

                                                                                                          19

                                                                                                                19

                                                                                                                      19

                                                                                                                            19

                                                                                                                                  19

                                                                                                                                        19

                                                                                                                                              19

                                                                                                                                                    19

                                                                                                                                                          19

                                                                                                                                                                 19

                                                                                                                                                                       19

                                                                                                                                                                             19

                                                                                                                                                                                   19

                                                                                                                                                                                         19



                                                                                   Australia              Canada                   France                Germany                    Italy
                                                                                   Japan                  New Zealand              Sweden                United Kingdom             United States


                      Source: OECD Health Data 2002
appendix two




 48
                                                                                                                                                      INTERNATIONAL HEALTH COMPARISONS




2.2 Deaths from breast cancer, 1980 to 1999

                                                40


                                                35
    Deaths per 100,000 females (standardised)




                                                30
                                                                                                                                                                        United Kingdom
                                                                                                                                                                        New Zealand
                                                25                                                                                                                      Germany
                                                                                                                                                                        Canada
                                                                                                                                                                        France
                                                20                                                                                                                      United States
                                                                                                                                                                        Italy
                                                                                                                                                                        Sweden
                                                15                                                                                                                      Australia
                                                                                                                                                                        Japan

                                                10


                                                 5


                                                 0
                                                      80

                                                           81

                                                                82

                                                                      83

                                                                            84

                                                                                 85

                                                                                       86

                                                                                             87

                                                                                                   88

                                                                                                         89

                                                                                                               90

                                                                                                                     91
                                                                                                                          92

                                                                                                                                93

                                                                                                                                      94

                                                                                                                                            95

                                                                                                                                                 96

                                                                                                                                                       97

                                                                                                                                                             98

                                                                                                                                                                   99
                                                     19

                                                          19

                                                               19

                                                                     19

                                                                          19

                                                                               19

                                                                                      19

                                                                                            19

                                                                                                  19

                                                                                                        19

                                                                                                              19

                                                                                                                    19
                                                                                                                         19

                                                                                                                               19

                                                                                                                                     19

                                                                                                                                           19

                                                                                                                                                19

                                                                                                                                                      19

                                                                                                                                                            19

                                                                                                                                                                  19




                                                                Australia             Canada                  France                Germany                  Italy
                                                                Japan                 New Zealand             Sweden                United Kingdom           United States


    Source: OECD Heath Data 2002

                                                                                                                                                                                         appendix two




                                                                                                                                                                                          49
               INTERNATIONAL HEALTH COMPARISONS




               2.3 Deaths from prostate cancer, 1980 to 1999

                                                                     45


                                                                     40


                                                                     35
                          Deaths per 100,000 males (standardised)




                                                                                                                                                                                                            Sweden
                                                                     30                                                                                                                                     New Zealand
                                                                                                                                                                                                            Australia
                                                                                                                                                                                                            France
                                                                     25                                                                                                                                     United Kingdom
                                                                                                                                                                                                            Canada
                                                                                                                                                                                                            Germany
                                                                     20
                                                                                                                                                                                                            United States
                                                                                                                                                                                                            Italy
                                                                     15                                                                                                                                     Japan


                                                                     10


                                                                      5


                                                                      0
                                                                           80

                                                                                 81

                                                                                         82

                                                                                                83

                                                                                                       84

                                                                                                            85

                                                                                                                 86

                                                                                                                       87

                                                                                                                            88

                                                                                                                                     89

                                                                                                                                           90

                                                                                                                                                91

                                                                                                                                                         92

                                                                                                                                                              93

                                                                                                                                                                    94

                                                                                                                                                                         95

                                                                                                                                                                                  96

                                                                                                                                                                                         97

                                                                                                                                                                                               98

                                                                                                                                                                                                      99
                                                                          19

                                                                               19

                                                                                      19

                                                                                              19

                                                                                                   19

                                                                                                        19

                                                                                                             19

                                                                                                                      19

                                                                                                                           19

                                                                                                                                 19

                                                                                                                                          19

                                                                                                                                               19

                                                                                                                                                     19

                                                                                                                                                          19

                                                                                                                                                                   19

                                                                                                                                                                        19

                                                                                                                                                                              19

                                                                                                                                                                                       19

                                                                                                                                                                                            19

                                                                                                                                                                                                    19
                                                                                           Australia             Canada                    France              Germany                           Italy
                                                                                           Japan                 New Zealand               Sweden              United Kingdom                    United States


                   Source: OECD Health Data 2002


               2.4 Deaths from lung cancer, 1980 to 1999


                                                                     60



                                                                     50                                                                                                                                          United States
                                                                                                                                                                                                                 Canada
                   Deaths per 100,000 of population (standardised)




                                                                                                                                                                                                                 United Kingdom
                                                                                                                                                                                                                 Italy
                                                                     40                                                                                                                                          New Zealand
                                                                                                                                                                                                                 Australia
                                                                                                                                                                                                                 France
                                                                     30                                                                                                                                          Germany
                                                                                                                                                                                                                 Japan
                                                                                                                                                                                                                 Sweden
                                                                     20



                                                                     10



                                                                     0
appendix two




                                                                          80

                                                                               81

                                                                                      82

                                                                                              83

                                                                                                   84

                                                                                                        85

                                                                                                             86

                                                                                                                      87

                                                                                                                           88

                                                                                                                                 89

                                                                                                                                          90

                                                                                                                                               91

                                                                                                                                                     92

                                                                                                                                                          93

                                                                                                                                                                   94

                                                                                                                                                                        95

                                                                                                                                                                              96

                                                                                                                                                                                       97

                                                                                                                                                                                            98

                                                                                                                                                                                                    99
                                                                      19

                                                                           19

                                                                                    19

                                                                                           19

                                                                                                19

                                                                                                       19

                                                                                                            19

                                                                                                                  19

                                                                                                                       19

                                                                                                                                19

                                                                                                                                      19

                                                                                                                                           19

                                                                                                                                                    19

                                                                                                                                                         19

                                                                                                                                                               19

                                                                                                                                                                    19

                                                                                                                                                                             19

                                                                                                                                                                                   19

                                                                                                                                                                                          19

                                                                                                                                                                                                 19




                                                                               Australia               Canada                   France               Germany                           Italy
                                                                               Japan                   New Zealand              Sweden               United Kingdom                    United States
 50
                   Source: OECD Health Data 2002

								
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