Health Services in Western Europe

Monograph
May 1963

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Britain is not unique in having a health service. Practically every European country has accepted the provision of medical care as a community responsibility. Amongst the sixteen countries in Western Europe, only the Finns have not yet introduced an extensive compulsory pre-payment scheme of some sort and they are to do so in 1964.

The schemes are, however, remarkably varied. At one extreme there are the comprehensive schemes predominantly financed out of general taxation and characterised by the National Health Service in Britain. This covers the entire population, including in emergency even visitors from abroad. It provides a full range of personal medical care at nominal cost to the patient. A scheme very nearly as comprehensive exists in Sweden, although patients are left to pay a higher proportion of the cost of some parts of the service. In many countries, however, the health services are not operated directly by the central government. Such schemes provide fewer benefits, and these may be available to only a proportion of the population, so that the upper income groups pay their own medical and hospital bills, or cover them by private insurance. In these cases, there is still a distinction between the public health services, such as the treatment of mental illness and infectious diseases, and the provision of other types of medical care. The former are available to the whole population, but the latter are only provided for those persons and their dependants who compulsorily or voluntarily have contributed towards their cost.

Many of the present health services have grown out of voluntary insurance schemes started in the nineteenth century. Since then the principle of compulsory insurance has gradually become accepted in order to provide medical care for the old and the chronic sick. Both these groups require a greater amount of attention than the rest of the population and therefore often cannot be protected by private and voluntary health insurance.

For centuries before compulsory or national insurance was introduced it was usual for the State, the churches or other charities to provide medical services for the needy; and free medical care is still available for poor people in countries where health service contributions are not compulsory for the whole population. In some countries public assistance of this sort plays a substantial part in the provision of medical care. For example the lowest paid Portuguese workers are specifically excluded from having to pay health insurance contributions on the understanding that medical care will be made available to them free of charge. In many countries, as in Britain, private insurance of the type provided by the Provident Associations exists in addition to the National Health Service.

The health schemes in the European countries usually form part of a general scheme of social security. They are, however, organised in many different ways. Some, for example the Swedish scheme, are organised and controlled directly by the central government. Others are provided by the local municipal or provincial governments, as in the case of Germany where the Lander administer the health service under the general direction of the Federal Government. In some countries, for example Austria, the health service is provided by a number of public boards comparable in status to corporations such as the B.B.C. or B.O.A.C. Occasionally, as in Holland, private insurance companies or friendly societies organise a State scheme. This is similar to the situation which existed for general practitioner services in Britain before 1948. Because of these variations, and because some types of medical care are provided independently by the public health authorities, the term 'health service' has very different meanings in different countries.

Under the public boards and private insurance companies, each board or company is frequently responsible for the health service provided for one particular section of the population, such as agricultural workers, or railway employees, and their dependants. The schemes for the different groups of workers may vary considerably.

There are also variations between different schemes in one country when these are provided by the provincial or municipal governments. The contributions paid and the benefits provided may vary and different categories of people may bel egally required to join the scheme. Generally, however, these variations within a country must fall between broad limits laid down by the central government.

Except in Denmark, Eire and the United Kingdom, health insurance contributions are graduated depending on salary or income. In the other Western European countries the employee usually pays a fixed percentage of his salary, so that this contribution increases proportionately to his earnings. There is, however, an upper limit to the contributions, which therefore do not increase indefinitely. Almost invariably, the employer also makes a graduated contribution calculated as a percentage of salary. In addition to the money raised by these contributions some part of the benefits provided under the health service are usually financed from central or local government funds. Sometimes a capitation payment is made by the government to the 'sick funds' and sometimes the government have agreed to provide a proportion of the revenue in order to balance the funds. In other cases, notably Belgium, the funds were originally intended to be self-supporting, but in practice the government has to make a contribution to cover their deficit.

There are three main distinctions between the financial methods on the continent and those in Britain. First of all Britain relies on a basic flat rate contribution independent of earnings or income, whereas on continent contributions increase with salary. Secondly in Britain most of the cost of the Health Service is met from general taxation, whereas in the continental countries a greater part of the cost of the medical care is usually met from contributions as a comparatively small part of the cost has to be met by general taxation. Thirdly higher proportion of the cost of the continental schemes is financed by direct payments by the patients.

In Britain the part of the employer and their employers' National Insurance contribution allocated to the Health Service averages less than two percent, of earnings and these contributions meet about 16 percent, of the total cost of the National Health Service. Under the continental and Scandinavian schemes their combined contributions to the health service usually amounts to between five percent, and ten percent earnings, and they provide a much greater proportion of the finance.

In all countries participation in the health service is compulsory at least for employees who are being paid less than the average earnings in the country and their dependants. In many of the countries it is a compulsory for the more highly paid employees and for some professional and self-employed people. In addition scheme may be open to members of the population for whom it is not compulsory. The proportions of the population included appears to have been rising in most of the countries and now the majority-often more than nine-tenths-of the people are covered.

In Britain since the introduction of the health service covering the whole population in 1948 there has been a steady growth in private health insurance. By 1963 about two percent, of the population had made private arrangements either to cover the cost of certain medical services outside the National Health Service, or to supplement the benefits provided by it. In other countries the health services usually started on limited scale and have gradually been made available to larger sectors of the public. They also appear to be approaching the situation where only a small proportion of people choose to be independent of the service.