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Health System Design and Context

Understanding institutional characteristics of health care systems is essential for carrying out comparative analysis of policies and strategies to improve system performance. System features such as regulation of health care supply and demand, incentives for providers, level of public/private funding or the extent of coverage, among others, have a direct impact on system functioning and hence on its performance. Researchers and policymakers need to understand the strengths and limitations of different systems including their own by analysing countries according to common institutional characteristics or policies. There are several different ways a "health system" or "health care" can be defined and conceptualized (see Frameworks) which will ultimately determine the focus of organizational and institutional analysis.


The table below provides a summary of principle dimensions that capture the features of health care systems potentially relevant for explaining cross-country differences in health system performance. These can be grouped under four dimensions: i) health financing and coverage; ii) healthcare provision; iii) healthcare resources and allocation and iv) governance.


The dimensions highlighted in the table below provide guidance and the structure for a range of additional descriptors that can help define a health care system's design and provide the necessary context for performance assessment. International health system profiles contain links to data sources with descriptive information about the health care systems of a wide range of countries. In addition, more specific information for the EuroREACH project member countries – Austria, Estonia, Finland, France, Germany, Israel, Luxembourg and United Kingdom - is also available in the national data source page.


  • Main sources for funding the health care system
  • Characteristics of public system financing (e.g. automatic/compulsory/voluntary; single/multiple insurers)
  • Role of private insurance
Pooling of funds
  • How are revenues accumulated at the population level
  • Level of competition (number of purchasers, integration of public/private insurers, risk equalisation etc.)
Purchasing of health services
  • Level of Contracting
Coverage policy:
  • Population covered by primary insurance
  • Scope of primary coverage
  • Depth of service covered
  • Free at point of use or cost sharing (OOP spending)
  • Interventions of the public sector to ensure coverage of high-risk or low-income people in non-NHS systems
  • Protection against excessive OOP
HEALTHCARE PROVISION Payment of healthcare providers
  • Payment for primary care, specialist, hospitals (e.g. FFS, capitation, salaries etc.)
  • Performance linked provider payment for primary care, specialist, hospitals (e.g. bonuses, penalties etc.)
Structure and organisation of supply
  • Public/private mix of primary care, specialists, hospitals
  • Organisation of primary care, specialists, hospitals (e.g. individual/group practice)
  • Co-ordination of care
  • Role of primary care
    • Registration with GP compulsory
    • Gatekeeping
Choice and information
  • Level of choice for patient
  • Information on quality and prices
  • Information on processes of care
Organisation of specific services
  • Dental care
  • Long-term care
  • Mental health care
  • Rehabilitation care
  • Health care for specific populations
  • Pharmaceuticals
  • Social care
  • Public health and prevention
    • Screening (e.g. national programme for breast cancer screening)
    • Prevention and health promotion (e.g. smoking, alcohol, obesity, road accidents)
    • Communicable disease control
    • Environmental risks
  • Distribution
  • Density
  • Hospital autonomy for staff recruitment and remuneration
  • Regulation and monitoring of health provider activity
Physical resources and technologies
  • Level & Distribution
  • Health information management
GOVERNANCE Budget settingPriority setting and public health targets
  • Use of health technology assessment (HTA)
  • Definition of benefits basket
  • Definition of public health objectives
  • Definition and containment of health care budget
Regulation of the workforce and providers
  • Supply, distribution, density
  • Provider activity and quality
Degree of decentralisation of decision making
  • Degree of decentralization to sub-national governments
  • Degree of delegation to insurers
Regulation of:
  • Payers/insurers
  • Prices/fees for provider services
  • Degree of intersectorality
  • Patients’ rights and involvement in decision making

 Note: Dimensions chosen are based on the WHO 2000 framework