Health Care Systems: An International Comparison

Strategic Policy and Research Intergovernmental Affairs May 2001
1

Most industrialized countries have established hybrid systems in which the public sector, which has the greater share of responsibility, works alongside the private sector, both in the funding of health care …
Health system’s main source of financing Taxes Australia (1992) Canada (1990) Denmark (1993) France (1990) Germany (1989) Italy (1988) Japan (1991) Netherlands (1983) Norway Sweden Switzerland (1991) United Kingdom (1994) United States (1990) 4 4 4 4 4 4 4 4 4 4 4 4 4
2

Social Security Funds

Private Insurance

Source: Blanchette, Claude, “Public and Private Sector Involvement in Health Care Systems: An International Comparison,” Bulletin 438E, Library of Parliament, 1997

… and in the delivery of hospital care
Main Delivery Entity of Hospital Health Care (as percentage of hospital beds) Public Australia (1992) Canada (1990) Denmark (1993) France (1990) Germany (1989) Italy (1988) Japan (1991)* Netherlands (1983) Norway Sweden Switzerland (1991)* United Kingdom (1994)* United States (1990)** 75 98 Most 65 51 80 19 15 Most Most 46 5 27 Non-Profit ------16 35 20 --85 ----32 90 59 Private 25 2 --19 14 0 81 0 ----22 5 14
3

* As percentage of hospitals ** As percentage of acute-care hospital beds Source: Blanchette, Claude, “Public and Private Sector Involvement in Health Care Systems: An International Comparison,” Bulletin 438E, Library of Parliament, 1997

With the exception of Germany and the United States, most of the industrialized countries have universal publicly funded health care systems
Percentage of Total Population with Public Insurance (1997)
100.0 100 90 80 70 60 100.0 100.0 100.0 100.0 100.0 100.0 99.5 92.2

%

50 40 30 20 10 0
Australia Canada Denmark Italy Japan Sweden United Kingdom France Germany

45.0

United States 4

Source: 2000 OECD Health Data

The payment of user fees is a common practice in most OECD countries, but this practice is less widespread in Canada
Public Health Care User Fees 1993 ($CDN) Physician/ specialist Australia Canada Denmark France Germany Italy Japan Netherlands Norway Sweden Switzerland United Kingdom United States Drugs Hospital X-Ray/ laboratory ------35% --30% 10%-30% --$11 --10% --20%>$100D
5

$5-$8 $11 ----D/C* ----0%-50% --25% 30%-100% 20%<30days+$6/day --$1.25 $3<14days $0/$7-$8 $3+50% or $0 --10%-30% 10%-30% 10%-30% --fixed-price --$11/$16 25% (max $43) --$6-$9/$0 D $15 and $1/drugs $8 10% $7 $7 --$4-$5/drug or $65/annual --20%>$100D 100% $676<60days

D: Deductible, C: Co-insurance *Depending on provinces Source: Blanchette, Claude, “Public and Private Sector Involvement in Health Care Systems: An International Comparison,” Bulletin 438E, Library of Parliament, 1997

Not counting the United States, Canada has among the most limited publicly funded extended care coverage in the OECD countries
Public coverage of complementary care Countries covering almost all care Germany Italy Belgium Denmark Finland Greece Iceland Luxembourg Norway Spain Drugs Canada1 United States Australia United Kingdom2 Portugal3 Sweden2 Countries not covering the following care Glasses Dental care Prostheses Canada United States Australia United Kingdom France Japan Austria Other

Canada Canada Canada4 United States United States United States Australia France Japan 5 France Portugal New Austria Zealand 6

1. The Canadian system covers only drugs received in hospitals. Drugs prescribed outside hospitals are paid in part or entirely by consumers, by private insurance or by public provincial insurance. 2. Affordable Drugs 3. Some pharmaceutical products 4. Private hospital care and sanatoria 5. Medical check-up, private room and injection 6. Outpatient care
Source: Blanchette, Claude, “Public and Private Sector Involvement in Health Care Systems: An International Comparison,” Bulletin 438E, Library of Parliament, 1997

6

Canada spends about the same percentage of GDP on health care as the G7 average, while the US spends substantially more

14 12 10 8 7.4 2.4

Health Spending as a percentage of GDP (1997)

2.5

%

2.9

2.8

1.4 2.8 7.2

1.3 2.3 6.7 1.5 1.0

6 4 2 0
US Germany France G7 Average Canada Sweden Australia Denmark

6.5

8.3

7.1

6.4

6.4

5.6

5.3

5.7

5.8

Italy

Japan

UK

Public Spending
Source: 2000 OECD Health Data

Private Spending

7

The United States spends a larger percentage of its GDP on health care mainly because of higher labour, administrative and malpractice insurance costs Administrative Costs as a Percentage of Health Spending
10
8.3

8 6

7.5

7.8 5.9 3.6 3.7

6.9

%
4 2 0 Germany United States

3.1

0.8

0.2

Australia

Canada

France

Public Spending

Private Spending

* 1994 for Australia, Canada, Switzerland, 1995 for Germany and 1996 for France and United States. Source: 1998 OECD Health Data

8

Canada’s public spending as a percentage of overall health care spending is lower than in many industrialized countries but higher than in the US

Public Health Spending as a Percentage of Total Health Spending
% 100
90 83

90 80 70 60 50 40 30 20 10 0

84 85

84 84 78 70

78 80

76 77

75

70

75 74 67 67 56 59 46 41

Sweden

UK

Denmark

Italy

Japan

Germany Canada

France

Australia

1990
Source: 2000 OECD Health Data

1997

G7 Average

US

9

Per-capita health care spending in Canada is lower than the G7 average, while it is subtantially higher in the United States

4,000 3,500 3,000 2,500 2,194

Per-Capita Health Spending 1997

$US

2,000 1,500 1,000 500 0 1,901

1,126

542 658 527

330 635 293 354 485 214

1,621

1,822

1,517

1,520

1,712 1,274

1,469

1,406

1,128

1,177

US

G7 Germany Canada Average

France Denmark Australia Sweden

Japan

Italy

UK

Public Spending

Private Spending

Source: 2000 OECD Health Data * Data in US dollars converted with purchasing power parity.

10

Growth of per-capita public spending during the 1990s was substantially below the G7 average in Canada, while it was above the G7 average in the United States
Average Annual Growth of Per-Capita Health Spending 1990-1997
%

20 18 16 14 12 10 8 6 4 2 0

19.1

9.2

9.7 8.2 7.7 4.0 7.1 6.8 5.4 5.0 5.3 2.1 5.1 4.8 4.9 3.9 1.9 1.1 1.0 0.3 7.5 6.0

Germany

US

Japan

G7 Average

France

UK

Australia

Canada

Italy

Sweden Denmark

Public Spending

Private Spending

Source: 1998 OECD Health Data

11

While the share of public spending allocated to health care is lower than the G7 average in Canada, it is higher in the United States
Public Health Spending as a Share of Total Government Spending
20

25 20
17 17 14

16 15 15

16 14

15

14

14

15 12

15 13 13 12 13 11 11 13 12

%
10 5 0

US

Germany

G7 Average

Japan Australia Canada

UK

France Denmark

Italy

Sweden

1990

1997
12

Source: 2000 OECD Health Data

Health care delivery in Canada is dependent on a smaller number of physicians than the average for the G7 countries
Number of Physicians* and Nurses** per 1,000 persons, 1997
12 10 8 6 4 2 0 Italy Germany Sweden France Denmark G7 Average US Australia Canada Japan UK
5.8 4.9 3.4 3.1 3.0 2.9 2.7 2.7 2.5 5.9 4.5 2.1 1.8 9.5 10.2 8.3 7 7.4 9.5 7.6 7.4

1.7

Physicians

Nurses

* 1996 for Japan, United Kingdom, Denmark, Sweden and the G7 average. **1996 for Italy, Japan, United Kingdom, Australia, Denmark, Sweden and the G7 average. Source: 2000 OECD Health Data 13

Physicians’ incomes are substantially higher in the United States than in other industrialized countries

Annual Average Income of Physicians 1996**
240,000
199,000

200,000 160,000

$US*

120,000 80,000 40,000 0 US

104,700

100,781 62,273 62,007 58,416 55,944 52,547

40,774

Germany

Canada

Japan

France

Denmark Australia

UK

Sweden

* Data in US dollars converted with purchasing power parity. ** 1991 for UK, 1992 for Canada and Germany, 1995 for Sweden and 1997 for France and Japan. Source: 2000 OECD Health Data

14

Canada has far fewer scanners and magnetic resonance imaging machines per capita than the United States and the G7 average

80 70 60 50 40 30 20 10
18.8 28.1 69.7

Units of Scanners and MRIs per one million persons*

26.9 20.8 16.0 11.3 6.2 2.9 4.1 17.1 14.6 13.7 6.8 9.7 2.5 8.1 1.7 6.3 3.4 5.8 2.5

0
Japan (1996) G7 Average US (1993) (1995) Australia (1995) Germany (1997) Italy (1997) Sweden (1993) (1995) France (1997) Canada (1997) UK (1993) (1995) Denmark (1990)

Scanners
Source: 2000 OECD Health Data

Magnetic Resonance Imaging
15

Life expectancy in Canada compares favourably with the other G7 countries, while the United States compares less favourably

Number of years

Life Expentancy 1997

80

77
80.0 79.0 78.5

78.2

78.1

78.1

74

77.2

77.2

76.7

75.7

71 Japan Canada Sweden Italy France G7 Average UK Germany US Denmark

Source: World Health Report 1999

16

Canada and the United States rank poorly on some health status indicators, although Canada outperforms the United States
Health Indicators
Rank Infant Mortality Rate per 1,000 births (1997*) Japan (3.7) Sweden (4.0) Germany (4.8) France (4.8) Australia (5.3) Denmark (5.6) United Kingdom (5.9) Canada (6.0) Italy (6.2) United States (7.8) Cancer Mortality Rate per 100,000 persons (1995**) Japan (156) Sweden (158) Australia (177) United States (183) Canada (184) Germany (184) France (186) Italy (195) United Kingdom (192) Denmark (227) Heart Disease mortality 1 per 100,000 persons (1995***) France (173) Japan (178) Canada (227) Australia (255) Italy (271) Sweden (273) United States (280) United Kingdom (282) Germany (308) Denmark (328)

1 2 3 4 5 6 7 8 9 10

* 1995 for Italy, 1996 for Canada, Denmark, United States and Sweden ** 1993 for Denmark and Italy, 1996 for United States and Sweden, 1997 for Germany and United Kingdom *** 1993 for Denmark and Italy, 1994 for Japan, 1996 for United States and Sweden and 1997 for Germany and United Kingdom 17 1 Includes ischaemic heart diseases, acute myocardial infarction, cerebrovascular diseases and others. Source: 2000 OECD Health Data

Only 23 percent of Canadians, compared with over one third of Americans, feel that their health care system needs to be completely rebuilt

% of public saying:
completely rebuild the health care system system works pretty well, only minor changes needed recent system changes will harm quality of care they did not get needed care in past year it is very difficult for themselves or family members to see a specialist or consultant they had problems paying medical bills in the past 12 months amount spent in the past year on medical bills not covered by insurance was more than US $750 the medical care they and their family received in the past 12 months has been excellent or very good

Australia Canada New Zealand 30% 19% 28% 8% 35% 10% 19% 23% 20% 45% 10% 47% 5% 9% 32% 9% 38% 12% 34% 15% 10%

UK 14% 25% 12% 10% 29% 3% 1%

US 33% 17% 18% 14% 40% 18% 29%

54%

54%

54%

50%

49%
18

Source: The Commonwealth Fund 1998 International Health Policy Survey