2. Britain versus the world
An overview of:
3. UK
4. France
5. Germany
6. Spain
7. Sweden
8. Feedback and comments
The UK’s National Health Service has been described as one of the greatest social achievements of the 20th century with its promise to care for the British people from cradle to grave.
But times have changed since it was set up in 1948 to provide free healthcare for all the residents of the UK. Today, we are constantly looking for ways to improve our healthcare service.
This guide gives you an overview of how health systems work in France, Germany, Spain and Sweden, and how well the UK compares.
1. World health systems: how they rank
The first-ever official ranking of the performance of health services was launched in The World Health Report 2000. Britain came 24th out of 191 health systems in the world.
Although Britain did not fare well compared to some of its fellow European countries like France (4th) and Spain (6th), the league table can only be seen as a rough guide. This is because the WHO report does not take into account external factors, such as infant mortality rates or diet. For example some of the top ranking countries, including France, Greece, Portugal and Spain all benefit from healthy Mediterranean diets – known as the “olive oil” effect.
However, it’s worth taking a look at the table to give you an idea of where Britain and other countries - especially our European partners – rank.
Health systems: how they rank1Oman2Malta3Italy4France5San Marino6Spain7Andorra8Jamaica9Japan10Saudi Arabia11Greece12Monaco13Portugal14Singapore15Austria16United Arab Emirates17Morocco18Norway19Netherlands20Solomon islands21Sweden22Cyprus23Chile24United Kingdom72United States of Americasource: World Health Organisation
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2. Britain versus the world
The Members of the Committee of Public Accounts, a government body, commissioned the National Audit Office to produce a report on International Healthcare Comparisons in 2003.
The report looked at healthcare systems and health achievements.
Private insurance
An important difference between healthcare systems is the extent to which individuals have private insurance. In the USA, private insurance is the only means of cover for much of the population, while in the UK private insurance is held in addition to cover provided by the government. In France, private insurance is widely used to cover out-of-pocket payments, such as some prescription costs.
Public spending
Sweden and the UK have the highest publicly financed share of total health spending. While in the USA, only 45% of the money comes from the public purse.
Financing
The methods of public and private financing vary between countries but are usually a combination of general taxation, social insurance, out of pocket payments and private insurance.
OECD health data 2004
UK, Italy and Sweden use general taxes as the main source of public funds.
France and Germany finance the majority of health spending through specific social insurance contributions.
Out-of-pocket expenditure is highest in Italy. France, Germany and the Netherlands have systems which combine consumer choice, health insurance and a measure of personal payment in different ways.
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3. UK
Expenditure on health
The Organisation for Economic Cooperation and Development data shows that total health spending in recent years as a percentage of Gross Domestic Product was lower in the United Kingdom than in other country (except Japan). However, the government estimates that it will increase total spend on healthcare to 9.4% of GDP by 2007/2008, up from 7.3% in 2000.
The UK’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% of the population also have private medical insurance, usually for reasons of faster access.
NHS care is free if you go to your GP or need surgery, but you are charged a levy on prescription drugs, ophthalmic services and dental services. There are exemptions, for example for children, elderly and the unemployed and 85% of prescriptions are exempt from the charge.
See also the Action Network guides on , , and .
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4. France
Similarly to the UK, public health is financed from taxes and compulsory social health insurance contributions from employers and employees.
Sickness Insurance Funds
The population has no choice of insurer. They are automatically affiliated to a health insurance scheme on the basis of their professional status and place of residence. The insurers are non-government, non-profit agencies and employers pay a premium for them.
Seventy percent of a person’s healthcare costs are covered by social security. To cover the remaining 30%, they pay their ‘mutuelle’, an annual premium equivalent to £1,500 a year that guarantees them a single room should they need to go to hospital. Employers bear a heavy part of the cost.
Dental care
Dental care is not covered by the public health scheme and dental practitioners operate in a free market.
Reform monitor has more detail on the French health system
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5. Germany
There are around 450 so-called sickness funds, or public health insurance companies, which the employee and employer must pay into to fund Germany’s public healthcare system.
Contributions are shared equally between the insured and their employers. The average contribution rate is 13.5%, so the employee will contribute 6.75% out of their pre-tax income and the employer will pay the same amount in addition to wages.
Your right to choose a sickness fund
Everyone has the right to choose which fund they want to belong to. This had led to a competitive market among funds, so some funds have merged and others have closed.
If employees earn less than around 322 Euros, then only the employers will have to pay a contribution.
The unemployed, homeless and immigrants are covered through a special sickness fund financed through general tax revenues.
Private healthcare
A person can also get private healthcare if they wish. Currently, 8% of the population (the affluent, self-employed and civil servants) have private health insurance.
Patient contributions
Patients pay a flat rate payment (between 7 and 9 Euros per day) for inpatient hospital care and the charges apply for the first 14 days in hospital or rehabilitation each year, ambulance transportation and some dental treatments, but some groups are exempt such as low income and the elderly. There is cost –sharing for drugs.
Read more on Germany.
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6. Spain
The Spanish health service is mostly financed out of general taxation which has replaced a more insurance-orientated system. Funding is collected centrally and is allocated to the regions, which manage these resources with varying degrees of independence.
Compulsory insurance covers 99 % of the population and is financed by contributions and taxes. They have free access to in-patient and ambulatory healthcare.
Employed people may also have private insurance. The poor are insured by INSALUD, which is means-tested and financed by taxes.
Benefits covered by Spain’s national health system include:
- Primary healthcare
- Specialised healthcare - in the form of outpatient and inpatient care, like acute care
- Pharmaceutical benefits (with exceptions)
- Extra benefits such as wheelchairs and prostheses
Working people pay 40% towards the prices of medication.
There is a 10% reduction for certain special medicines. But there is no charge for pensioners or patients undergoing in-patient hospital care.
Social and community care
Social and community care is very under-developed in Spain and was not included in Spain’s national healthcare cover until 2000 when proposals were introduced to add this to their public healthcare system.
However, there is still a severe lack of care for the disabled and elderly. But mental healthcare is provided by the public system.
Dental care
Dental care is part of private health care – apart from the Basque Country and Navarra where children’s treatment is included in public healthcare treatment.
For more information on Spain’s healthcare system, look at the WHO report.
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7. Sweden
Healthcare in Sweden is financed through taxes. Responsibility for these services rests primarily with the county councils, which levy taxes to raise the financial resources required and also operate almost all the services provided – out of central government control.
Hospitals are mostly publicly owned with only a minority of private providers. Although health care is largely free, the Swedish regions determine the levels of low cost payment that a patient may need to pay, depending on the type of treatment.
Since 1998 families with children of all income no longer have to pay fees for health services. There is a yearly limit on what patients contribute to the health service. The limit entitles the patient to free care and medicine for the remainder of the year.
Dental care
All individuals under 20 years of age are provided with free dental care. Anyone aged 20 and over is insured by a general dental insurance scheme that provides partial coverage for dental treatment costing more than a certain amount.
For more information on the Swedish healthcare system, look at the article on the Reform Monitor site.
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8. Feedback and comments
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