-
National Health Systems as Market Interventions MILTON I.
ROEMER
r D ~ HE stucture and functioning of national health systems in
the modern world are the result of long historical
i 2 developments in science and society. Advances in sci- t z ,
5 ence made possible countless technologies for the pre-
vention of disease and for its treatment if prevention failed.
Changes in society have fostered the application
of many of these technologies to the needs of people.
HEALTH SYSTEM EVOLUTION
From the earliest times, the provision of health service was
regarded as a matter of value, warranting some sort of
compensation. Like com- modities, health care was bought and sold
in a market. When religious groups realized that some people were
too poor to pay for care they obviously needed, charitable
hospitals were established, and later dispen- saries. This was
market intervention through the motives and resources of
religion.
As industrialization developed, it was propelled by the profit
incentives of capitalism. Science advanced, universities grew,
cities multiplied, and a working class took shape. For workers,
acute or chronic illness meant a loss of livelihood, against which
sickness insurance could be a protec- tion. This was another market
intervention by planned group action of working people, leading
eventually to social security for health care in some 7o
nations.
As doctors and other health care providers became more numerous,
governments recognized the need for assuring their competence.
Specified education became required for a license to practice
-constituting one more strong intervention against free trade in
the marketplace.
With vastly increased knowledge on prevention of disease, public
health agencies were organized; they rendered environmental and
per- sonal health services that could not be expected in the normal
medical market. To provide comprehensive health care efficiently,
furthermore, doctors and other personnel in scores of countries
were brought together
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 63
in teams stationed in health centers, as distinguished from
individual practitioners functioning as small autonomous
entrepreneurs.
The more complex that national health systems became, the more
they called for planning. A hierarchial structure of activities was
organized in nearly every country. Concepts of equity and social
justice gradually came to replace a free market philosophy in
decisions on many aspects of national health systems. Forty years
ago, a conservative capitalist power, the United Kingdom,
transformed comprehensive health service into a public good for
everyone. Every other industrialized country has been moving,
slowly sometimes, in the same direction. While marketplace values,
of course, are still found in health systems -more in some than in
others -the concept of health service as a social right has gained
ascendancy in most countries of the world.
MEANING OF HEALTH SYSTEMS
What then is a national health system? It is the complex of
activities intended to result in the provision of health services.
A health service, in turn, is an action whose primary purpose is
the protection or improve- ment of health. Food affects health, as
does housing, clothing, or athletics, but health improvement is not
their primary or principal purpose. Many features of living and of
society, of course, influence health-probably even more than health
services -as epidemiologists have known for a long time. On the
other hand, many harmful effects of the physical or social
environment can be prevented or ameliorated by appropriate health
service.
Because of the countless determinants of health, besides health
service, the World Health Organization emphasizes the importance of
"intersec- toral collaboration" in the drive to achieve Health for
All. Numerous sectors, such as agriculture, industry, employment,
housing, education, even international relations, have enormous
impacts on health. Health workers, therefore, must attempt to
influence policies in all social sectors, insofar as they impinge
directly on health. (See Figure I.)
Even within the health sector or health system (defined as the
social machinery producing health services), the tasks are numerous
and difficult. Most national health systems, at least in theory,
have become motivated by concepts of social justice more profoundly
than other sec- tors such as agriculture or housing. The
implementation of principles of justice, however, may be difficult.
We see the problem today in the incur- sion of for-profit
investor-owned corporations into the field of hospitals,
-
FIGURE I
Determinants of Health
PHYSICAL SOCIAL ENVIRONMENT ENVIRONMENT
Geography, Climate, Education, Occupation, Food, Housing, Water,
Income, Relationships,
etc. Urbanization, etc.
I~
r ~STATUS Age, Sex, Immunity, Genetic Background,
etc.
POPULATION'S PHYSICAL, MENTAL
and SOCIAL WELL-BEING
HEALTH SERVICES Health Promotion, Disease Prevention,
Treatment, Rehabilitation, etc.
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ROEMER HEALTH SYSTEMS AS MARKET INTERVENTIONS 65 FIGURE 2
Model of a National Health System Showing its Components &
Their Relationships to Health Status
----------------------------------------------_-------__________________z
w z M o
ORGANIZATIO
z~~~~~~~~~~~
long identified with non-profit or public sponsorship. The
dependence of most countries, especially the less developed ones,
on drugs produced by multinational corporations earning high
profits, causes serious economic difficulties. Yes, even within
strong national health systems, the dynamics of various component
activities are complex.
I spoke of a health system as "the machinery producing health
ser- vices," and in Figure 2 I have tried to show in a very simple
model how this machinery operates. The "health needs" on the left
are fed into the 5-part system, and the product emerging
constitutes "health results" hopefully improvement. This is, of
course, a great oversimplification, which requires more careful
explanation.
HEALTH SYSTEM COMPONENTS
A more complete portrayal of the component parts of a national
health system is shown in Figure 3. The most conspicuous feature of
any national health system is the "organization of programs" that
occupies the central
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66 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989 FIGURE 3
National Health System: Components, Functions, and Their
Interdependence
MANAGEMENT
Planning Administration
Regulation
RESOURCE PRODUCTION ORGANIZATION OF PROGRAMS SERVICE
PROVISION
Manpower Ministry of Health--all levels Primary Health Promotion
Facilities Other Public Agencies & Prevention
Commodities (drugs,etc) Voluntary Agencies Primary
Care--treatment Knowledge Enterprises Secondary Medical Care
Private Market Tertiary Medical Care Rehabilitation
ECONOMIC SUPPORT
Governmental Revenues Social Security
Insurance (Voluntary) Charity
Personal Households Foreign Aid
conceptual box in this model. It is more logical, however, and I
trust more lucid, if we start the analysis with the "production of
resources," and then proceed through the steps that end with the
provision of health services.
Production of Resources Essential for the operation of any
health system are several basic resources which somehow must be
produced or obtained. The manner in which these resources are
acquired differs enormously among countries, but in their simplest
form they include (a) health manpower, (b) health facilities, (c)
commodities, such as drugs, and (d) knowledge. It may be noted that
financing or money is not regarded as a resource; it is rather a
medium of exchange, convertible into resources or services, as we
will see.
The production of all resources requires inputs from various
other social sectors, such as education, construction,
manufacturing, and so
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 67
on. The quantity and quality of resources in a health system
depend largely, but not entirely, on the wealth of a country. Some
relatively poor countries may develop abundant health resources
because of a political will that assigns high priority to the
health system.
Health manpower includes physicians, pharmacists, nurses,
dentists, technicians, and scores of other types of personnel. With
the growth of health technology and the expenditure of increasing
shares of national wealth on health systems, the numbers and types
of health manpower have expanded enormously. In the less developed
countries, traditional healers (with or without some formal
training) still play significant but declining roles. Almost all
countries have also been making increasimg use of a great variety
of medical assistants or community health work- ers -trained for
relatively brief periods and working under supervision to extend
primary health care to populations at relatively low cost.
Health facilities are also of many types. Historically oldest
are general hospitals for treatment of the seriously sick, although
their range of functions has steadily broadened. Special hospitals
have been developed for the mentally ill, for leprosy patients, for
maternity and women's disorders, for children, for general
infectious disease, for military person- nel, and for other special
purposes. While founded originally by religious groups, an
increasing proportion of hospitals have become sponsored by units
of govenment, by voluntary nonprofit organizations, and even by
private entrepreneurs. The organized facility for ambulatory health
ser- vice is much younger historically, but in recent decades it
has acquired increasing importance. In most developing countries,
in all socialist coun- tries, and in many industrialized and
welfare-oriented countries, the health center or polyclinic has
become the conventional setting for mod- ern ambulatory
service.
Among health commodities required in every health system, drugs
and vaccines are crucial. Over the centuries, drugs derived from
nature- mainly from plants or animals -have gradually become
replaced by chemically synthesized products. Large pharmaceutical
companies, often linked to the chemical industry, have come to
dominate the field. These firms, based in a few countries, are
responsible for most of the drugs in the developing world -both
those sold in pharmacies and those dis- pensed in hospitals and
health centers. Because imported drugs are costly, drug
expenditures may absorb 30 percent or more of a Ministry of
Health's budget. The dynamics of medical supplies and modem
diagnos- tic and therapeutic equipment are similar.
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68 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989
Knowledge, the fourth resource, is produced by observation and
re- search. The knowledge of the past, of course, is recorded in
books, and most new knowledge is reported in journals or at
conferences. Unfortu- nately new knowledge is often communicated
slowly, especially in de- veloping countries and in the rural areas
of all countries. Even when knowledge is available, its application
in practice may be retarded by deficiencies in other aspects of
health systems.
Organization of Programs In order to mobilize the several types
of resources to achieve certain ends, they are typically organized
into programs. As governments have as- sumed increasing
responsibility for the general operation of health sys- tems, the
major public agency to play this role has been a Ministry of Health
or some broader body encompassing such a ministry. The initial
functions of the Ministry of Health were usually to assure a
sanitary environment and carry out other preventive activities. In
time Ministries have come to operate facilities for medical care,
to train personnel, to formulate and enforce technical standards,
to do epidemiological surveil- lance, and to provide other forms of
supervision of health services throughout a system.
In most countries, the geography and population require, for
sound administration, the subdivision of the territory into
provinces or states, and these in turn into districts or counties.
The basic form of government in one country, such as Canada, may
endow each province or state with great autonomy; in another
country authority may be highly centralized; and in a third country
one may find a balance between centralized and decentralized
powers. Whatever the distribution of power, most Health Ministries
seem to be trying to maximize the involvement of local au-
thorities in health programs, while also maintaining at the top
uniform national policies and standards.
Numerous other governmental agencies play roles in national
health systems. Ministries of education are usually responsible for
training physicians and certain other personnel. Social security
programs, includ- ing health insurance, may be directed by a
special ministry or be within another ministry, such as labor or
social welfare. Ministries of labor look after occupational safety
and health at workplaces. There may be special authorities for
public works, social welfare, environmental protection, and for the
"interior" -all of which are relevant to certain aspects of
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 69
health. The military establishment of almost every country
maintains its own medical service.
Still other organized programs function outside of government
-usu- ally for quite focused purposes. Voluntary nonprofit agencies
may con- centrate their efforts on certain diseases, such as
tuberculosis or cancer; on certain population groups, such as
children or the elderly; on certain services, such as blood banks
or home nursing. Voluntary agencies may also operate health
insurance programs. Associations of professional personnel often
represent their members in negotiations with government and they
monitor ethical behavior.
Still another form of non-governmental agency with a role in the
health system is the industrial enterprise that provides health
services for its workers and sometimes their families. Whatever may
be the motive-to promote a healthy workforce, to paternalistically
discourage unioniza- tion, or to reduce the insurance costs of
worker's compensation for industrial injuries -such services are
relevant in a health system.
Finally, the entire private market, in which medical care,
drugs, and other health services are provided, must be considered
part of this compo- nent of health systems. While not "organized"
in the usual sense, private services are bought and sold through a
process governed by supply and demand, price, and some degree of
competition. The strength of the private market in a health system
tends to be reciprocal to that of public programs; if Ministries of
Health and other organized agencies are weak, the private market is
usually strong, and vice versa.
Economic Support Supporting the development of all health
resources, their organization into programs, and ultimately the
provision of services, requires every national health system to
have sources of economic support. To some extent in every country,
private individuals finance health services, typi- cally for the
treatment of personal health problems. Charitable donations are
another source of support, and these may take the form of donated
labor as well as money. Non-governmental or voluntary health
insurance is another source of great importance in certain
countries.
Under government, of course, general taxation is a source of
economic support for the health system in all countries. The exact
types of taxa- tion-on land, on income, on purchases, on selected
products (e.g., al- cohol and tobacco) -vary widely in their use
for health purposes. The
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70 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989
political levels (national, provincial, local) at which they are
collected, also vary in their relative importance. Everywhere tax
revenues are used for general prevention, and in most countries
also for health manpower training, for facility construction, for
medical care of the poor, and for many other health purposes. With
exceptions in certain African countries and a few others, the
percent of all national health expenditures derived from public
revenues has been rising. This has contributed to greater shares of
total national wealth (gross national product or GNP) being devoted
to the health sector.
Mandatory insurance or social security is a special form of
government strategy contributing money to health system support in
about 70 coun- tries. This method establishes one or more earmarked
funds, which may only be used for financing the health care of
persons who have made payments and, usually, their families.
Because of their separate status, social secutity funds do not
usually require parliamentary or governmen- tal decision for their
use, nor do they compete with other programs of government
depending on general revenues. Social Security may be con- ceived
as organized self-help by workers and employers. For these reasons,
the use of social security funds for health purposes has been
politically attractive and has steadily broadened over the last
century, protecting larger proportions of national populations for
a wider range of health services.
In many countries, still another form of economic support for
health systems-often for hospital construction and operation-comes
from public lotteries. This gambling unfortunately attracts money
dispropor- tionately from low-income people who can least afford to
spend it. A final source of health system support is foreign aid,
going to developing countries from international agencies or from
certain affluent indus- trialized countries; as a percentage of the
costs of national health systems in developing countries, these
funds are seldom very large-usually well under 5 percent.
The relative proportions of these several sources of economic
support influence health system policies in many crucial ways.
Support from private individuals obviously channels resources,
programs and services to those who have the money to spend, much
more than to those with the greatest health needs. Fortunately for
health system development, the share of national wealth (GNP) being
devoted to all health purposes has been rising in almost all
countries. Over the last half-century, it has been expanding in
developing countries from z or 3 percent to 4 or 5 percent;
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 7I
in developed countries it has risen from 4 or 5 percent to 8 or
iO percent (in the United States to i i percent). Within those
health expenditures, the proportion derived from government and
other collectivized sources has also been increasing, implying an
extension of principles of health equity. Even though
private-market spending has risen in the last few years, the
long-term trend has clearly been toward the public side.
Management A second form of support for the operation of a
health system is manage- ment, which is meant to include several
forms of social control-plan- ning, administration, regulation, and
legislation. Each of these processes may be carried out with
different degrees of rigor in various health programs. All four of
them are operative to some extent in programs under both public and
private auspices.
Planning may be done at central or local levels of health
systems or at both levels with respect to different functions. It
applies most often to the production of resources, but may also be
applied to the development of organized health programs or the
provision of specific services. In many ways, planning may be used
to influence the performance of the private medical market.
Administration encompasses many functions -the exercise of
author- ity, organization of resources, delegation of
responsibility, supervision, communications, coordination, and
evaluation. Sometimes the term "ad- ministration" is used
interchangeably with "management," but-what- ever the
terminology-the purpose is to mobilize human and physical resources
to reach a goal with maximum efficiency and effectiveness.
Regulation involves the enforcement of certain standards of
perfor- mance. It may apply in an organized program, but is used
more often to monitor and control performance in the open market.
Much regulation is by government -for example, surveillance over
the method of manu- facturing drugs by a pharmaceutical company. It
may also be non- governmental, such as the regulation of
physicians' services by the or- ganized medical staff of a
voluntary hospital. Despite much political rhetoric to the
contrary, abuses in the free market of health care have led to
increasing types of regulation in most health systems.
Legislation is the instrument of government used for
crystallizing and clarifying health policy, so that it may become
known to everyone. Whether a country is ruled by a parliamentary
government, a military dictatorship, or some other political
structure, various laws may be estab-
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72 JOURNAL OF PUBLIC HEALTH POLICY * SPRING 1989
lished to govern the health system. These laws may facilitate
the produc- tion of resources, authorize various programs, provide
for social financ- ing of health services, control the quality of
performance of health care providers, or prohibit behavior
injurious to health.
Provision of Services
Operation of the four components of a health system just
described leads to the final component: provision of health
services to people. This in- cludes all forms of service-health
promotion, disease prevention, diag- nosis, treatment, and
rehabilitation. In terms of the complexity of the specific
activity, the services may be designated as primary, secondary, and
tertiary.
The types of personnel, facilities, work settings, and
patient-provider relationships differ substantially among the
health systems of countries. They differ also among various
programs in one country. A health pro- gram addressed to poor
people usually provides services in a manner quite different from
conditions in a free private market serving the af- fluent. Health
services for military establishments are provided through highly
organized arrangements in all countries. In Latin American coun-
tries with Social Security programs, covering perhaps zo or 30
percent of their population, the insured workers are typically
provided services of higher quality than other persons served by
Ministry of Health facilities.
Primary health care, according to WHO (World Health
Organization) principles, includes a wide range of preventive
services, along with the treatment of uncomplicated, common
ailments. WHO does not intend "care"l to have its restricted
meaning of "treatment." Since the Alma Ata Conference on Primary
Health Care in 1978, almost all nations have adopted WHO's concept
of primary health care (PHC) -to embrace all basic strategies of
health promotion and disease prevention. The person- nel and
setting for providing PHC, of course, differ greatly among coun-
tries.
Secondary care has been variously interpreted, but I believe it
should include specialized medical services to the ambulatory
patient, relatively commonplace hospital care, non-medical
specialist care (such as phys- iotherapy or prescribing
eyeglasses), and low-intensity long-term care. Tertiary care refers
to services requiring highly specialized skills and sophisticated
technology, typically in a teaching hospital. Finally,
rehabili-
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 73
tation can provide services that help the disabled patient to
return to a socially independent life.
Health services for certain populations, such as aborigines, or
certain illnesses, such as mental disorders, are often provided
under quite sepa- rate arrangements. Health resources and methods
of program organiza- tion are usually quite different from
circumstances in the rest of the system. Typically these services
are more highly organized, publicly financed, and managed in a
manner oriented to the special circumstances.
*> * *
This completes our analysis of the structure and functions of a
national health system. We should now consider briefly the
different types of system that operate in the world. Among the
approximately i6 coun- tries on earth, no two systems are exactly
alike, but one can understand them better by clustering the systems
into certain major types.
DETERMINANTS AND TYPES OF HEALTH SYSTEMS
The combined characteristics of all five health system
components define the type of health system found in each country.
The determinants of these characteristics must be sought in past
history, geography, culture, and other social conditions. Examined
today, however, the health system can be identified quite well by
two social features-economic and polit- ical. More precisely, the
system is shaped by the wealth or economic level of the country and
by the political ideology governing its health system.
The economic levels of countries can be quite readily scaled in
terms of their gross national product (GNP) per capita. The GNP
index tells us nothing about the distribution of income in a
country, but this, in fact, is dependent on political ideology,
which is a separate question. Countries with relatively high GNPs
per capita are, of course, mainly industrialized, and those with
low per capita GNPs are mainly agricultural. Deviation from this
relationship has occurred in several petroleum-exporting coun-
tries, which currently have relatively high GNPs without being
indus- trialized.
The political ideology of a health system can be scaled along
another axis, yielding a matrix of systems portrayed in Figure 4.
The scaling of this dimension is not so readily achieved as that of
the economic level, but I believe it is valid to base it on the
degree of market intervention in the operation of the health system
-ranging from minimal to maximal.
Market intervention replaces, in effect, the "unseen hand" of
free trade
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74 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989 FIGURE 4
Types of National Health Systems Classified By Economic Level
& Health System Policies
ECONOMIC HEALTH SYSTEM POLICIES (Market Intervention) LEVEL (GNP
per Capita)
Entrepreneurial Welfare-Onented Universal & Socialist &
& Permissive Comprehensive Centrally Planned
United States West Germany Great Britain Soviet Union Affluent
& Canada New Zealand Czechoslovakia
Industnalized Japan Norway
1 ~~~~~2 3 4
Thailand Brazil Barbados Cuba Philippines Egypt Nicaragua North
Korea
Developing & South Africa Malaysia Transitional
5 6 7 8
Ghana India Sn Lanka China Bangladesh Burma Tanzania
Very Poor Nepal
9 10 11 12
Gabon Libya Kuwait Saudi Arabia
Resource - Rich
13 14 15 16
and competition with planning; it replaces individual purchases
with group financing; it replaces isolated vendors with teams of
providers; and so on. In a word, it replaces entrepreneurial
autonomy with social organi- zation, and this may occur to varying
degrees.
Even with the relatively simple classifications used in Figure
4, the i 6 conceptual cells may be sufficiently distinct to clarify
how the main types of health system work. In all but one of the I 6
cells the names of various (3 I) countries are given, simply as
examples. If every country in the world
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 75
were placed in one or another cell, some cells would doubtless
contain many countries and others only a few. Moreover, the
countries in various cells would change from year to year, as
economic and political influences modified their health
systems.
To explore the matrix in Figure 4 somewhat further, we may
consider simply the scaling along each dimension. Thus,
economically the top row refers to countries with GNPs of $ ooo per
capita or more per year. The second row refers to countries with
annual GNPs per capita between $ ooo and $5oo. The third row refers
to countries with under $ oo GNP per capita per year. The
resource-rich countries all have relatively small populations and
per capita GNPs of more than $5,ooo or even $2o,ooo per year.
The gradations along the political dimension cannot be so
quantita- tively precise. The "Entrepreneurial" colunm refers to
countries in which most of the health system, as reflected in
overall expenditures, operates through a private market.
Government's role in the system is relatively weak. In the second
column for "Welfare-oriented" countries, market intervention has
been substantial with respect to the financing of the system.
Health care for most, nearly all, of the people is a public respon-
sibility. A private medical market continues, however, and much
govern- ment money is spent on payments to private providers.
In the third column for countries with "Universal and
Comprehensive" health systems, government has intervened in the
market even more extensively. Both the financing and the provision
of health services have become highly organized. The total
population has become entitled to virtually complete health service
as a civic right at least to the extent of available resources. The
fourth column for socialist countries refers to health systems
which have been almost completely removed from market dynamics.
Government has become responsible for all health services; all
health resources, physical and human, have come under government
control. Private buying and selling of health care has not been
prohibited, and it exists, but to a very small degree.
TRENDS
These comments on the major types of health system in the world
are inevitably over-simplifications. There are some exceptions to
any generalization, and yet the matrix may help to put some order
into numerous national health systems that otherwise appear like a
jungle.
Of course, no health system is static; every system is
continually chang-
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76 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989
ing. This is in response not only to economic and political
forces, but also to changes in the demography of the population,
the capabilities of technology, urbanization, increased involvement
of people in public af- fairs, and many other social circumstances.
The effect of these pressures is to drive virtually all health
systems in the direction of greater organiza- tion. This applies to
all five components of health system structure.
With mounting government support, the production of health re-
sources -manpower, facilities, and knowledge -is expanding. Ratios
to population of hospital beds, doctors, nurses, and others are
rising. The production of drugs by private industry is increasing
due to strengthened economic support to purchase them, even though
this support is mainly from public sources.
Organized programs are growing under both public and private
aus- pices. Economic support is becoming more collectivized, mainly
through government revenues, but in some countries (France, West
Germany, Latin America, Middle East, Japan, South Korea,
Philippines, etc.) largely through social insurance. Private
spending is also increasing in certain countries, both developed
and developing.
Management is certainly becoming more sophisticated, especially
in planning, regulation, and legislation. The provision of services
in nearly all countries is shifting from solo practitioners to
organized teams of health personnel, working usually in clinics or
health centers, as well as in hospitals.
Some people fear that all this organization yields impersonality
and insensitivity to the feelings and needs of each person.
Bureaucracy is, indeed, a hazard of any large organization. The
benefits, however, in accessibility to health care, in quality
assurance, in economy, and in equity are of overriding importance.
The increasing organization of health systems is helping more
people to obtain those benefits. The chal- lenge is to achieve
Health for All without sacrificing the personal interests of any
human being.
Acknowledgment: This paper is based on a Rosenstadt Lecture,
presented at the University of Toronto (Toronto, Ontario, Canada),
March I 5, I98 8.
ABSTRACT
National health systems have developed in all countries; their
features have been shaped largely by organized interventions in the
free market of health service.
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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 77
Any health system can be characterized through analysis of five
major compo- nents: (i) its production of resources, (2)
organization of programs (including a residual private market), (3)
sources of economic support, (4) modes of man- agement, and (5)
patterns of providing services. The diverse types of health systems
in the world may be categorized in a matrix derived from two dimen-
sions: (a) the economic level (four steps), and (b) the political
ideology of the health system, scaled (also four steps) from highly
entrepreneurial (minor market intervention) to socialist (nearly
complete market intervention). Every national health system would
fit into one of the i6 cells of this matrix, although positions
change as a result of economic and political dynamics.
Article Contentsp. 62p. 63p. [64]p. 65p. 66p. 67p. 68p. 69p.
70p. 71p. 72p. 73p. 74p. 75p. 76p. 77
Issue Table of ContentsJournal of Public Health Policy, Vol. 10,
No. 1 (Spring, 1989), pp. 1-142Front Matter [pp. 1-4]Guest
EditorialTime Will Reveal Our Primitive Priorities [pp. 5-6]
An Agenda for Public Health [pp. 7-18]"The Future of Public
Health": The Institute of Medicine's 1988 Report [pp. 19-31]The
Cigarette Advertising Broadcast Ban and Magazine Coverage of
Smoking and Health [pp. 32-42]Development of Behaviorally-Based
Policy Guidelines for the Promotion of Exercise [pp. 43-61]National
Health Systems as Market Interventions [pp. 62-77]The Health Status
of Cuba: Recommendations for Epidemiologic Investigation and Public
Health Policy [pp. 78-87]DocumentsComments on the Institute of
Medicine's Report: "The Future of Public Health": United States
Conference of Local Health Officers [pp. 88-94]NACHO's Response to
the IOM Report: "The Future of Public Health": National Association
of County Health Officials [pp. 95-98]Health Care in Rural America:
The Crisis Unfolds: Joint Task Force of the National Association of
Community Health Centers and the National Rural Health Association
[pp. 99-116]
From Our Corresponding EditorsTowards Public Sector Goals: New
Zealand's Recent Experience in Health Services Reorganization [pp.
117-122]
CommunicationGovernment Procurement Leverage [pp. 123-125]
Book ReviewsReview: untitled [pp. 126-129]Review: untitled [pp.
129-131]Review: untitled [pp. 131-134]Review: untitled [pp.
134-136]Review: untitled [pp. 136-137]Review: untitled [pp.
137-139]
Back Matter [pp. 140-142]