Primary Health Care Financing Systems:
International Comparisons and Lessons

JOHN MINOT, ARIJIT SARKAR

Methodology

Eleven major countries have been selected for comparison in this paper: the United States, the United Kingdom, Canada, Australia, France, Germany, the Netherlands, Singapore, Japan, Spain, and the Czech Republic. These were picked for various reasons, including availability of descriptive information on their health systems as well as outcome information for the countries as a whole. These systems were evaluated based on exactly how they finance primary care, specifically, on what basis patients pay for and receive care, how medical providers (almost always private physicians) are paid for care, and the restrictions, conditions, etc. that affect provision. The sources were largely from existing scholarly literature, with particular help from the Health Systems in Transition series from the WHO European Observatory, which describes a number of countries’ systems in great detail. Government websites also filled in some gaps.

After describing these countries’ systems in detail, they have been categorized by the salient features that divide these systems (primary care free versus at a charge; main funding from general revenue versus premiums or dedicated taxes; etc.). Then, information from OECD Health Data 2008 was used to make a rough measure of the efficacy of primary care, as separate from other care.

Two measures were created from the data, both based on preventable years of life lost (PYLL) due to conditions for which primary care is critical. The first measure, Prevention-related PYLL, is the sum of PYLL figures for the following conditions: infectious and parasitic diseases, respiratory diseases, and pregnancy and childbirth. The second measure, Detection-related PYLL, is the sum of PYLL figures for the following conditions: diabetes mellitus, ischemic heart diseases, breast cancer, cervical cancer, and lung cancer. All of these are numbers per 100,000 population between the ages of 0 and 69 years, except for breast and cervical cancer, which are per 100,000 females of the same ages; for these two, the figures have been divided by two so that the addition is meaningful. The figures’ date is the most recent available, which is 2003 to 2006 depending on the country. The OECD Secretariat calculated them based on WHO age-specific death statistics, broken down by ICD-10 categories in all cases, and standardized for age. Therefore, it is reasonable to use these figures for cross-country comparison.

In addition to PYLL figures, the average annual number of outpatient contacts per person was also taken for reference from the OECD Health Data. These numbers were collected from very diverse sources, including national statistical offices, health ministries, doctors’ associations, etc., and are less comparable than PYLL, so they will only be used secondarily. Data from the Commonwealth Fund’s surveys on the quality and accessibility of primary care in seven countries (United States, United Kingdom, Canada, Australia, New Zealand, Germany, and the Netherlands) was also used, but will not be dealt with here since no strong conclusions could be drawn (Commonwealth Fund 2004 and 2006).

As the main quantitative phase of this paper, the prevention-related and detection-related PYLLs were averaged out across countries that did or did not use various techniques of interest, in order to very roughly gauge the possible effect of these techniques.

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