Medicine and books: European Health Care Reform: Analysis of Current Strategies
Authors: Sakari Karjalainen
Journal: BMJ (1998)

Richard B Saltman, Josep Figueras 

WHO Regional Office of Europe, £13, pp 310 

ISBN 92 890 1336 2 

Back to Bismarck: Eastern European Health Care Systems in Transition

Jorgen Marree, Peter P Groenewegen 

Ashgate Avebury, £32.50, pp 138 

ISBN 1 85972 617 8 

Bismarck, Beveridge, and Semashko—what do these names have in common? Each man has given his name to a model that describes one of the predominant types of statutory financing of Europe’s healthcare systems. In fact, the Semashko model, used by countries of the former Eastern bloc, does not exist any more. However, it was the starting point for all countries of central and eastern Europe and of the Commonwealth of Independent States when they decided to move towards the social insurance system (Bismarck model). 

Models have always been used to describe and simplify complex things. Reading European Health Care Reform reminded me of the breathtaking moment when I first saw the large map of “Biochemical pathways” on the laboratory wall. Nothing is simple in planning, financing, and delivering health care. Whatever you change in the system, it has both anticipated and unexpected consequences, which may be positive or negative. This makes reforming health care extremely challenging. 

Everyone who has something to do with health care—as provider or purchaser, patient or doctor—knows that there are many things that could and should be changed. Some kind of reforms are, indeed, taking place in all European countries at the moment. 

As already mentioned, the countries of the former Eastern bloc are experiencing a heavy transition period. In other parts of Europe the growing costs of care, ageing of the population, higher levels of chronic disease and disability, increased availability of new treatments, and rising public expectations have increased the pressure to spend more on health care and use the available resources more efficiently. 

European Health Care Reform succeeds remarkably well in revealing the complex nature of the challenges faced by physicians, policy makers, and others involved in healthcare reforms. The main, and competing, challenges are to improve the quality of health care, maintain and improve equity, and increase efficiency. This book illustrates Europe’s heterogeneous arrangements. The authors concentrate on horizontal comparisons while simultaneously summarising developments in individual countries. The old Western democracies and the countries of central and eastern Europe and the former Soviet states are compared and evaluated in a balanced, useful, and informative way. Being a WHO document, it is surprising that it does not read like a consensus report. 

The book has four main headings. The first describes the pressures for reform, and the second presents the main reform strategies. The third part deals with four horizontal themes that are important in the whole discussion: the changing roles of state and market; decentralisation to lower levels of the public sector or to the private sector; patients’ empowerment, rights, and choice; and the evolving role of public health. The fourth part assesses a number of key strategies that countries have adopted or proposed or are considering. 

The text relies on over 30 background papers written by experts and researchers from Europe, Canada, the World Bank, and the WHO. Richard Saltman and Josep Figueras have succeeded extremely well in an almost impossible task. Everything in the complex world of health care makes sense after reading this book — why things have developed in the way they have, why reforms are needed, and what options are available. 

The authors use much empirical data in describing the current health situation in Europe and indicating the performance of healthcare systems. However, the conceptual approach is even more interesting. Expertise from several specialties is used: epidemiology, public health, economics, political science, organisational behaviour, and management theory. This type of multidisciplinary approach is seldom successful, but here it works well. The book is, at least for a physician, an excellent introduction to health policy, health economics, and healthcare management. 

Back to Bismarck deals with similar questions but only in the countries of central and eastern Europe. It gives a thorough overview of five countries. The book provides useful background material for those who want to know more about recent reforms in these countries, but the approach is much less detailed than in the WHO book.