11.1. Factors determining the performance of health services

11.1.1. Introduction

Health systems contribute to the health status of European citizens in many ways. Life expectancy, disease prevention and treatment, and quality of life of citizens are influenced to a differing extent by the existence and performance of a country’s health system. Health systems are composed of all actors, institutions and resources meant to improve the health of citizens – both at an individual and population basis. Even if difficult to quantify or measure, the explicit goal is to improve the population’s health, although there also other important goals, such as the responsiveness of the system towards the expectations of a population or the fair distribution of the financial burden to operate the systems.

Although all actions of a health system are meant to increase the population’s health, it is to be kept in mind that the contribution of health systems to the health status of the targeted population is partial. Important measures of population health such as life expectancy and morbidity are largely affected by broader determinants such as social and educational policies, socio-economic and living conditions, inequalities, nutrition and other lifestyle factors. Moreover, some estimates suggest that health care might account for less than 20 percent of health improvement observed in the past century (Bunker et al, 1994). At the same time, particularly since the 1990s, advances in health care and medicines in particular, have witnessed an increasing attention paid to the positive role a well-performing health system can play in contributing to individuals’ and population health.

To this end, the World Health Organization, in its 2000 World Health Report, developed a conceptualization of health system functions into four dimensions: generating resources; financing; providing services; and stewardship. The objectives of health systems can be further delineated into instrumental and final (outcome) goals. For the former these include: affordability, equity, accessibility, sustainability and quality; whilst the latter encompass health status, fair financing, and responsiveness. While the report’s subsequent international ranking of countries’ health systems has drawn criticism, mainly on methodological grounds, the framework itself remains a useful tool for conceptualizing the role and organizational management underpinnings of a health system.

The aim of this chapter, therefore, is to familiarize the reader with the main features, structures and functions of health systems (in Europe). Given the variance in health status and different disease incidence between countries as highlighted in other chapters, and the fact that each country’s health system influences these indicators to various degrees, an examination of the different elements which characterize the health systems is therefore important. This chapter thus provides an overview of health care systems in Europe, with a focus on recent trends and key features. More specifically, it outlines the performance, provision, resources and financing of health systems in the European Union.

Primarily a descriptive chapter, the discussion begins with a section on health systems performance with emphasis on access to care, quality of care and responsiveness to patients and on technical efficiency, including provider payment methods. It then moves to a discussion of the trends in the provision of care, beginning with personal care and then public health and prevention. While long-term care, community and home care represent important services in European health and social care systems, these fall outside the scope of this chapter. The supply of resources and training of personnel are then discussed, including health care facilities, providers, and pharmaceuticals. The last part examines the financing of health care, including trends in expenditure, sources of financing, progressiveness of funding and benefit packages. It is important to highlight at the outset that while this chapter adopts a European comparative perspective, there are considerable difficulties and limitations associated with making such comparisons. For instance, definitions and measurement of key health care terms and data inevitably vary across countries, due to cultural, technical, political and social factors. Cross-country comparisons should, therefore, always be interpreted with caution.

As all European health systems face their own challenges and must serve the requirements of their own populations, it befalls national policy-makers to select the tools and mechanisms suitable to their own context based on well-informed comparative research. The challenge is then to develop health care policies to improve the health status of the local population and to do so based on an appropriate mix of relevant measures. As it is only through a solid grasp of the different elements and functions of a health system and an understanding of their relative effectiveness across countries that such a challenge can be pursued, the purpose of this chapter is to provide a solid starting-point.