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Comparing Health Policy: An Assessment
of Typologies of Health Systems
VIOLA BURAU* and ROBERT H. BLANK**
*University of Aarhus, Denmark; **New College of Florida, USA and University of Canterbury,
New Zealand
ABSTRACT Typologies have been central to the comparative turn in public policy and this paper
contributes to the debate by assessing the capacity of typologies of health systems to capture the
institutional context of health care and to contribute to explaining health policies across countries.
Using a recent comparative study of health policy and focusing on the concept of the health care
state the paper suggests three things. First, the concept of the health care state holds as a set of
ideal types. Second, as such the concept of the health care state provides a useful springboard for
analyzing health policy, but one which needs to be complemented by more specific institutional
explanations. Third, the concept of the health care state is less applicable to increasingly
important, non-medical areas of health policy. Instead, different aspects of institutional context
come into play and they can be combined as part of a looser ‘‘organizing framework’’.
Comparative policy analysis has become a ‘‘growth industry’’. Advances in
information technology have expanded the availability and dissemination of data
across many countries, while at the same time many policy fields have become
increasingly internationally oriented. The greater interest in information about
policies in other countries has also been fostered by the perception of shared policy
challenges arising from economic and welfare state crises. Deleon and Resnick-Terry
(1999) refer to this development as the ‘‘comparative renaissance’’. The comparative
perspective is now widely used in both the academic field of public policy analysis
and in more applied policy studies (see for example Castles 1999, Heidenheimer et al.
1992). Parallel to discussions about the insights generated by comparative analyses is
a debate about the methodologies of cross-country comparison (for comparative
Viola Burau is Associate Professor in Public Policy at the University of Aarhus in Demark. She received
her PhD in Political Science from the University of Edinburgh. Her research interests lie in comparative
health policy, the politics and policies of care work and the governance of expertise. She has published on
the occupational governance of nursing, the politics of health care reform and local policy making in
elderly care. Together with Robert H. Blank she has also written a book on Comparative Health Policy
(Palgrave, 2004). She currently co-ordinates an international research project on the new governance of
medical performance. Robert H. Blank is currently a Research Scholar at the New College of Florida and
Visiting Professor at the University of Canterbury in New Zealand. He received his PhD in political
science from the University of Maryland. Research interests focus on comparative health policy,
reproductive policy and biomedical technology assessment. He has published 35 books including: New
Zealand Health Policy (Oxford, 1994), The Price of Life (Columbia, 1997), Brain Policy (Georgetown,
1999), End of Life Decision Making: A Comparative Study (MIT Press, 2005) and with Viola Burau,
Comparative Health Policy (Palgrave, 2004).
Correspondence Address: Viola Burau. Department of Political Science, University of Aarhus, Bartholins
Alle
´DK-8000 Aarhus C, Denmark. Email: viola@ps.au.dk
Journal of Comparative Policy Analysis,
Vol. 8, No. 1, 63 – 76, March 2006
ISSN 1387-6988 Print/1572-5448 Online/06/010063-14 ª2006 Taylor & Francis
DOI: 10.1080/13876980500513558
politics see for example Lane and Errson 1994, Peters 1998; for comparative social
policy, see for example Clasen 1999, Hantrais and Mangen 1996).
The use of typologies has been central to the comparative turn in policy analysis
and they have been used to conceptualize the (institutional) context in which policies
are embedded. Prominent examples include: Castles’ (1993) notion of ‘‘families of
nations’’, which describes different clusters of cultural, historical and geographical
features of nations; Esping-Andersen’s (1990) welfare state regimes, which identify
distinct welfare state logics; and Lijphart’s (1999) and Blondel’s (1990) typologies
of democratic and state regimes respectively. Cross-country comparison generates
an abundance of information and ordering this information through typologies is
central to using comparison to build, review and revise explanations about policy
emergence, policy making and policy cycles.
This paper contributes to the debate in comparative policy analysis by analyzing
the uses and limitations of typologies of health systems in the comparative study of
health policy. This is an area of comparative analysis that has grown significantly
over the last 20 years (for an overview of the literature see Marmor et al.
forthcoming), but it has featured less prominently in the mainstream literature on
comparative policy analysis and social policy analysis.
Using a recent comparative study of health policy the paper assesses the use of
typologies of health systems and their capacity to capture the institutional context of
health care and thereby to contribute to explaining health policies across countries.
More specifically, based on Moran’s (1999, 2000) typology of health care states the
paper suggests three things. First, modeled on paradigmatic cases the concept of the
health care state holds as an ideal type. Second, as such the health care state provides
a useful springboard for the analysis of health policy, but one which needs to be
complemented by more specific institutional explanations. Third, the concept of the
health care state is less applicable to increasingly important, non-medical areas of
health policy. Instead, different aspects of institutional context come into play and
they can be combined as part of a looser ‘‘organizing framework’’.
The paper begins by reviewing the comparative literature on health policy and
suggests that while the OECD typology of health system has been influential, studies
have more or less explicitly adapted the definition of the health system. A prominent
example is the concept of the health care state developed by Moran (1999, 2000). The
following two sections apply the typology to a recent comparative study of health
policy that included a wide range of countries and areas of health policy. From this,
the concluding discussion summarizes the uses and limitations of typologies of health
systems.
Typologies of Health Systems in Comparative Health Policy
The comparative analysis of health policy often uses typologies of health systems to
help capture the institutional context of health care and contribute to explaining
health policies across different countries. In this regard, the typology developed by a
series of OECD studies has been particularly influential (see Figure 1). The typology
defines the health system as an ideal typical set of macro-institutional characteristics
based on variations in the funding of health care and corresponding differences in the
organization of health care provision. This reflects the fact that the public funding of
64 V. Burau and R. H. Blank
health care (or lack of it) is often seen as the defining characteristic of the degree of
public involvement in health care (Freeman 1999).
The first of these studies was especially influential (OECD 1987: 24) and classified
the health system on the basis of a dichotomy between patient sovereignty (and the
predominance of incentives) and social equity (and the predominance of control),
and introduced three basic models of the health system. The national health service
(or Beveridge) model is characterized by universal coverage, funding out of general
taxation and public ownership and/or control of health care delivery. Although this
model is most identified with the UK, New Zealand created the first national health
service in its 1938 Social Security Act that promised all citizens open-ended access to
all health care services they needed free at the point of use. Sweden is another
example of the national health service model, although all three countries, to varying
degrees, have moved away from this pure model.
In contrast, in the social insurance (or Bismarck) model compulsory, universal
coverage is as part of a system of social security. Health care is financed by employer
and employee contributions, through non-profit insurance funds, and the provision
of health care is in public or private ownership. Germany, Japan, and the Netherlands
are often viewed as examples of this type. Singapore, with its compulsory Medisave
system is a variation on the theme of social insurance, although in terms of the
sources of funding, private insurance dominates.
Finally, in the private insurance (or consumer sovereignty model), employer based
or individual purchase of private health insurance is key. Health care is funded by
individual and/or employer contributions and health delivery is predominantly in
private ownership. This type is most clearly represented by the US and until recently
by Australia, but many systems contain some elements of this type.
The initial typology developed by the OECD is a descriptive categorization of how
health care is organized in different countries and reflects its specific origins in
applied policy analysis. As Freeman (2000) observes, the typology emerged from a
search, dominated by economists, for better solutions to common problems. This
corresponds to a focus on the internal workings of health care rather than on its
political and social embeddedness. However, this situation has changed with the
wide use of the basic typology in the comparative analysis of health policy (see for
example Freeman 2000, Ham 1997, Raffel 1997, Scott 2001, Wall 1996). Together
with the increasing interest in neo-institutionalism, the typology has been a
facilitator for critical analyses of the health system as the institutional framework
in which health policies are embedded and how the institutions of health care
(among others) shape health policies (and politics). Scott (2001), for example, uses
the typology as part of her framework to analyze public and private roles and
Figure 1. Types of health care systems by provision and funding
Comparing Health Policy 65
interfaces in health care across different countries. In contrast, Ham (1997) in his
cross-country comparative analysis focuses more explicitly on health reform. The
same applies to Freeman (2000), who specifically looks at the politics of health in
relation to a range of areas of health policy.
However, these analyses also have in common their consideration of other aspects
of the institutional context of health care in addition to the typology of health
systems. Freeman (2000), for example, explicitly includes in his analysis the
mechanisms by which health care is co-ordinated (‘‘health care governance’’). This
inclusion clearly demonstrates that applying the typology of health systems to a
wider range of cases has also led to its adaptation. As Collier and Levitsky (1997;
similarly Collier and Mahon 1993) note, such a process is characterized by a tension
between increasing analytical differentiation in order to capture the diverse forms of
the phenomenon at hand, while avoiding the pitfalls of conceptual stretching and
applying the concept to cases that do not fit. The literature on comparative health
policy has addressed this tension by adding, although more or less explicitly, new
attributes to the definition of the health system.
Moran’s work (1999, 2000) is particularly interesting here as he explicitly sets out
both to better account for the institutional embeddedness of health care and to revise
the typology of health systems. He starts with the observation that health policy is
about more than health care and that modern health care systems are about more
than delivering a personal service: ‘‘Health care facilities in modern industrial
societies are great concentrations of economic resources – and because of this they
are also the subject of political struggle’’ (Moran 1999: 1). This means shifting the
focus of the analysis from the organization to the governance of health care. Moran
goes on to argue that with its emphasis on the access to health care the OECD
typology only captures one aspect of the governance of consumption and also misses
out on other important dimensions of governing health care. On that basis, he
introduces the concept of the health care state that consists of the institutions related
to governing the consumption, provision and production of health care.
The institutions of governing the consumption of health care are concerned with
the mechanisms by which individual patients have access to services (such as social
citizenship and earned insurance entitlements) and the mechanisms that decide on
the total volume of resources allocated to the financing of health care (such as
governing through public management and setting regulatory frameworks). In
contrast, the institutions of governing the provision of health care include the
mechanisms for regulating hospitals (such as the amount of public regulation and the
mix of differently owned hospitals) and the regulation of doctors (especially different
forms of private interest government). This reflects the centrality of hospitals and
doctors for the provision of health care. Finally, the institutions of governing the
production of health care focus on the mechanisms regulating medical innovations.
The three sets of institutions vary in terms of the relative degree of public control and
on that basis Moran constructs four different types of health care states.
The remainder of the paper applies the typology of health care states to a recent
cross-country comparative study of health policy. The analysis uses examples from a
recent comparative study of health policy (Blank and Burau 2004) that is distinct
because it covers both a diverse range of countries and multiple areas of policy. With
its emphasis on complexity and inclusiveness, the study is well suited to offer new
66 V. Burau and R. H. Blank
insights into the uses and limitations of typologies of health systems and, specifically,
the concept of the health care state. The study includes nine countries (Australia,
Britain, Germany, Japan, New Zealand, the Netherlands, Singapore and the US)
that differ not only in relation to the key dimensions of the health care state, but also
on other factors that impact on health policy such as type of political system and the
wider cultural, economic and societal context. In addition, the study incorporates a
wider range of areas of health policies than often studied, including home and
community based public health policies. Although both have traditionally been
marginal, they have become increasingly central to health policies. This shift reflects
demographic changes, especially the ageing of population, and the increasing focus
on the responsibilities of the individual for his or her own health.
The next section applies the concept of the health care state to the nine countries
included in our study and discusses the importance of institutional embeddedness
beyond the health care state. The subsequent section assesses the use of the concept
of the health care state in relation to non-medical health policies and explores an
alternative ‘‘organizing framework’’. The key question here is if the concept of the
health care state also captures the new cases presented in the study. Or, to
paraphrase Harrop (1992: 3; similarly Arts and Glissen 2002), does the concept of
the health care state help to discover how countries vary (or are similar) in the health
policies they adopt and to gain insights into why these differences (or similarities)
exist.
Health Care States and Institutional Embeddedness
Based on the distinction between institutions related to the governance of
consumption, provision and production, Moran (1999, 2000) constructs different
types of health care states, three of which are especially relevant for our set of
countries. In entrenched command and control health care states, the governance of
consumption consists of extensive public access based on citizenship and extensive
control of resource allocation through administrative mechanisms. This gives the
state a central role in governing the collective consumption of health care. The same
applies to the governance of provision with hospitals in public ownership and subject
to extensive public control, and with the private interest government of doctors
closely circumscribed. There are also moderate constraints on medical innovation,
which is at the heart of the governance of production.
In contrast, in the corporatist health care state funding through social insurance
contributions makes for de facto public access to health care and gives public law
bodies (such as statutory, non-profit insurance funds) an important role. This limits
the public control over health care costs. The same is true for the governance of
provision, where private hospitals are often prominent and where there are only
some constraints on the private interest government of doctors, who therefore play a
potentially influential role in the governance of provision. Not surprisingly, there are
only some constraints on medical innovation.
The role of providers is even more extensive in the supply health care state, where
funding through private insurance limits public access to health care as well as the
public control of costs. Similarly, private hospitals not only dominate, but also
remain relatively unchecked. The same applies to doctors, and private interest
Comparing Health Policy 67
government is strong. There are also de facto no constraints on medical innovation.
Table 1 maps out our countries using the typology of health care states developed by
Moran.
Looking at the health care states in our countries across the different types and
respective dimensions of governing health care several findings stand out. Only four
out of the nine countries included in the study fully fit one of the three types of health
care state. In contrast, the remaining countries are more or less close approximations
of the individual ideal types. This highlights the fact that the institutional contexts of
governing of health care are more complex than suggested by the definition of the
health care state. Instead, institutional contexts are often highly specific in terms of
how individual aspects combine themselves in individual countries. Such specificities
also point to additional aspects of institutional context. Consequently, within a
country the two sets of institutions associated with the governance of consumption
may actually fit different types of health care states thus making categorization
problematic. The same problem might also apply to the governance of provision and
production.
According to the typology, public control of the total resources allocated to health
care can be expected to be highest in entrenched command and control health care
states with access to health care based on social citizenship and lowest in supply
health care states where access to health care is based on private insurance, with
public control in corporatist health care states lying in between. This is true for four
of our countries, but the picture is more complex in the remaining five countries,
pointing to the importance of country-specific institutional contexts. In Australia,
for example, federalism combined with the legacy of the private insurance systems
weakens government authority over funding (Palmer and Short 2000). In contrast,
the unitary political system in Japan helps to concentrate authority in the hands of
central government (Campbell and Ikegami 1998). Despite significant decentraliza-
tion of health services and insurance plans, for example, all billing and payment in
Japan is centralized through the payment fund of the National Health Insurance.
The Netherlands and Singapore are particularly interesting examples of how
country-specific institutional contexts shape the public control of health care costs,
thus making differences between countries particularly pertinent. In the Netherlands,
the high public control of funding reflects the unusual combination of a social
insurance with strong universalist elements (for an overview see Exter et al. 2004,
Maarse 1997). Health funding combines a considerable diversity of sources,
including private insurance for acute medical risks for those earning above a certain
ceiling, and compulsory social insurance contributions in case of exceptional medical
risks. This reflects the historical legacy of a society segmented into different
groupings and the gradual weakening of this legacy in the Netherlands. The semi-
federal political system also helps to concentrate authority in the hands of the central
government, and, in contrast to Germany, corporatism is confined to the national
level.
In Singapore, country-specific institutional contexts are such that public control is
strong not only in relation to health care costs but also other key aspects of health
care (for an overview see Barr 2001, Ham 2001). Strong government control of
funding co-exists with health care funding that is predominantly based on individual
responsibility and limited familial risk pooling. Health care is funded by individual
68 V. Burau and R. H. Blank
Table 1. Health care states across nine countries
Governance of consumption Governance of provision
.extent of public access to
health care
.extent of public control of
hospitals*Governance of production
.extent of public control of
total health care costs
.extent of constraints on private
interestgovernmentofdoctors**
.extent of public constraints
on medical innovation
Entrenched command & control
health care state
BRITAIN
SWEDEN
BRITAIN
SWEDEN
BRITAIN
SWEDEN
.extensive public access, high
public control of costs
Australia (access)
New Zealand (access)
New Zealand Netherlands
New Zealand
.high public control of
hospitals, highly constrained
private interest government
Netherlands (cost control)
Singapore (cost control)
Australia (cost control)
.moderate constraints on
medical innovation
Corporatist health care state GERMANY GERMANY GERMANY
.de facto public access,
moderate public control
of costs
Japan (access)
Netherlands (access)
New Zealand (cost control)
Australia
Japan Netherlands
Singapore
Australia
Japan
.moderate public control of
hospitals, some constraints
on private interest government
.some constraints on medical
innovation
Supply health care state US US US
.limited public access, low
public control of costs
Singapore (access) Singapore
.little public control of
hospitals, few constraints on
private interest government
.de facto no constraints on
medical innovation
*share of hospitals in public ownership together with the degree of public regulation used as proxy for extent of public control of hospitals.
**share of publicly employed (hospital) doctors together with the degree of professional self-regulation used as proxy for extent of constraints on
self-government of doctors.
Comparing Health Policy 69
savings accounts, which are compulsory. The government also caps contribution
rates, while out-of-pocket payments are high. As such, Singapore defies the dictum
that private funding is unlikely to make for public control. The strength of
government control reflects not only the spatial concentration of political power
typical of city-states, but also a strongly centralized approach to health policy.
Government education programs are aimed at lowering the demand for health care
and also emphasize the importance of primary health care and prevention over
hospital care. Not surprisingly, public health policies are strong, and the
government heavily subsidizes health promotion and disease prevention programs
that emphasize the responsibility of the individual to look after his or her own
health.
The importance of country-specific institutional contexts also applies, though to a
lesser extent, to the governance of provision and production. In the Netherlands and
Singapore the respective institutions fit different types of health care states and
together with the institutional specificity of the governance of consumption, the two
countries emerge as hybrids. As noted earlier, in relation to the governance of
consumption the Netherlands combine access based on social insurance contribu-
tions with extensive public control of health costs. This ambivalence extends to the
other dimensions of governance. The governance of provision is closest to the logic
of the corporatist health care state. Private, non-profit hospitals dominate, but are
subject to extensive public control through centralized hospital planning. The same is
true for doctors and, for example, while many hospital specialists are independent
entrepreneurs they work under a public contract. In contrast, the governance of
production resembles the logic of entrenched command-and-control health care
states, where central regulation together with hospital planning put moderate
constraints on medical innovation.
Singapore, for its part and as mentioned above, has a highly controlled health
system but one based on individual savings accounts that give the impression of
minimal government control over consumption. Thus, it crosses the line between a
corporatist and supply health care state. Furthermore, Singapore gives those persons
with sufficient Medisave account balances considerable freedom of choice as to
public and private doctors and hospitals as well as allowing them to purchase private
insurance with their account should they so desire. While provision and especially
production appear to best fit a supply health care state, a large proportion of health
care is provided in publicly-owned hospitals by government-set salaried doctors.
Despite this, there are few controls on medical intervention in Singapore because in
the end individuals have the choice of what services to use with their compulsory but
private accounts.
What does the analysis presented so far say about the concept of the health care
state and its capacity to capture the institutional arrangements across our countries
and contribute to explaining health policies? The analysis suggests two things. First,
the concept of the health care state holds as an approximation of ‘‘real’’ health care
states. It is therefore a classical ideal type that is useful as a heuristic device that
simplifies the complex real world of governing health care (following Weber 1949).
Thereby, the concept of the health care state helps to move the analysis beyond the
specificity of individual cases and towards more generalized observations, over-
coming a salient tension inherent in comparative enquiry (Goodin and Smitsman
70 V. Burau and R. H. Blank
2000). The health care state as an ideal type, therefore, does not need to fit the real
types completely in order to be useful.
Second, it is important to remember, however, that it is primarily through the
comparison and contrast with real types that explanations can be advanced (see Arts
and Glissen 2002). The central question, then, is how to explain the extent to which
‘‘real’’ health care states do or do not fit the ideal types of health care states. The
different degrees of ‘‘misfits’’ among these nine countries and the types of health
care states presented in the analysis raises many such ‘‘why’’ questions. In turn, this
underlines the fact that the concept of the health care state indeed only provides a
starting point for a comparative analysis and must be complemented by additional,
more specific institutional explanations. The importance of a detailed study of
institutional contexts is well recognized in the comparative study of health policy (see
for example Do
¨hler 1991, Immergut 1992, Wilsford 1994). Nevertheless, this point is
particularly significant in the present context, because the concept of the health care
state specifically aims to better account for the institutional embeddedness of health
care. In this respect, Moran (1999, 2000) emphasizes that understanding health
policy requires examining the ways in which health care is embedded in the broader
contexts of market economies and democratic competitive politics.
Significantly, then, there is institutional embeddedness beyond the health care
state. As the analysis of our countries suggests, governing health care is embedded in
institutional contexts that are broader than those institutions making up the health
care state, and institutional contexts that are often also highly specific to individual
countries. As the literature emphasizes (see for example, Campbell and Ikegami
1998, Feldman 2000, Ham 2001, Klein 2001, Raffel 1997) such contexts can
encompass a wide range of aspects, including social values and cultural factors, as
well as the legal and political systems together with social structures. Our analysis,
for example, points to the importance of the specific characteristics of political
systems (such as federalism in Australia), social structures (such as the legacy of
societal pillars in the Netherlands) and social values (such as the high degree of
individual self-reliance in Singapore). The governing of health care reflects specific
configurations of these different aspects of institutional context, all of which are
changeable over time. Therefore, more often than not, health policies follow
trajectories that are highly complex and specific.
Health Care States and Non-medical Health Policies
The analysis presented in the previous section suggests that the institutional context
of governing health care itself is highly complex. This echoes Freeman’s (2000: 7)
observation that the organization of health care is actually not very systematic. The
complex historical emergence of policies of health care often defies the order implied
by the notion of a system. As a result, the health system perspective may be looking
for order where there is little. Instead, the institutional context of governing health
care is highly differentiated, to the extent that such contexts are often somewhat
specific to individual countries. Importantly, there is also specificity in relation to
subsectors of health care and policy. This is particularly apparent in relation to those
subsectors that have traditionally been at the margins of the ‘‘health system’’, but
that are increasingly central to health policy. Focusing on home and community
Comparing Health Policy 71
based health care as an example, the present section assesses the use of the concept of
the health care state for capturing the institutions central to non-medical health care
and for explaining such ‘‘new’’ health policies across countries.
Debates about ageing populations and their implications for health care costs and
services have put home and community based health care on the health policy
agenda. At international level it is indicative, for example, that long-term care for
elderly people was one of the components of the recent OECD Health Project
(OECD 2005). More specifically, the project reviewed policy developments across
countries as well as the organization of long-term care in terms of financing,
expenditure and care recipients. The OECD Health Project echoes developments
across the countries included in our study in which there are many examples of major
policy initiatives relating to home and community based health care (Glenndinning
1998, Jacobzone 1999, Jenson and Jacobzone 2000). Such policies often aim at the
expansion of existing services to support informal care givers by integrating home
and community based health care into the regular organization of health care. The
expansion of the social insurance in Germany and Japan is an indicative example.
Starting in the late 1980s, the government in Japan introduced a publicly funded
scheme, the so-called Gold Plan, to expand care services for older people. The
scheme was extended in the late 1990s and in effect became a separate branch of the
social insurance, funded by a mixture of social insurance premiums and taxes.
Considering the traditional strength of family responsibility for care of the elderly,
this is a significant policy development (Furuse 1996).
This emergence of non-medical based health care raises the question of how policies
related to home and community based health care fit into the concept of the health
care state. The concept focuses on institutions and policies related to medical care.
This is apparent in Moran’s (1999, 2000) definition of the governance of provision,
which is concerned with the institutions related to the regulation of doctors (as the key
providers of health care) and hospitals (as the key settings for the provision of medical
care). In contrast, home and community based health care is located on two sets of
interfaces: between formal and informal care, and between health and social care. In
relation to the first aspect, it is indicative that few older people receive home nursing
care and even when they do it only accounts for a small share of their care. Instead,
home care predominantly means unpaid (informal) care by women and often also
includes social care, such as help with domestic tasks. This reflects not only the
inadequacy of existing home nursing services, but also the fact many of the health care
needs of older people are often not principally medically related.
This puts a number of limitations on using the concept of the health care state for
capturing the institutions governing home and community based health care and for
explaining corresponding health policies. The institutions related to the governance
of consumption are relevant to the extent that home and community based health
care is part of the organization of medical health care. Traditionally, parts of home
and community based health care have by default been funded by the same scheme
as medical health care. At the same time, parallel funding schemes relating to social
care have existed. In Germany, for example, before the introduction of the long-term
care insurance, funding for home and community based health care came from both
the health insurance and locally funded social assistance schemes. In many cases this
organizational division continues and also applies to the newly established schemes.
72 V. Burau and R. H. Blank
This is also the case in Japan whereas in Australia, New Zealand, the Netherlands
and Sweden funding of home and community based health care is integrated.
Further, there tend to be formal or de facto limits to the scope of collective
consumption. Instead private consumption in the form of private payments for
formal services and informal care paid by lost income are important complementary
aspects of consumption. The last aspect even applies to countries like Sweden, where
the level of publicly funded services is relatively high. A study in the mid-1980s for
example found that informal care accounted for 64 per cent of the total care time
(OECD 1996: 166). There are even more extensive limitations in relation to applying
the definitions of the governance of provision and production. Medical technology is
of little importance for home and community based home care. The same applies to
hospitals as settings of care provision and doctors as providers of care. Instead, care
workers such as community nurses, care assistants and social workers together with
informal carers, all working in home and community based settings, are central to
the provision of this type of health care. Taken together this suggests that shared
values and beliefs (and corresponding practices) are important for understanding
non-medical health policies. Freeman and Ruskin (1999) refer to this as ‘‘cultural
embeddedness’’ and thereby point to diversity beyond the macro level and, notably,
a type of diversity that is shaped by organizational bases that are ethnic, gendered,
local and personal, rather than national and public.
Where does this leave capturing institutional arrangements as they apply to home
and community based health care and explaining corresponding non-medical health
policies across our countries? The concept of the health care state is of some use,
notably to the extent to which home and community based health care is part of
the organization of medical health care. However, beyond that, using the concept of
the health care state has clear limits, as some institutions do not have the same
importance, whereas others not included in the definition are central for under-
standing non-medical health policies. Considering the extent of such limitations
adding new attributes to the concept of the health care state is not necessarily an
option. Instead, different aspects of institutional context need to be taken into
consideration. This requires two things: first, redefining the institutions related to the
governing of consumption and provision so as to reflect the specific characteristics of
home and community based health care (and, where applicable, across the health and
social care divide); and second, to include gender as a set of social and cultural
institutions. In this respect Pfau-Effinger’s (2004) concept of ‘‘gender arrangements’’
is particularly useful. The concept consists of two components. Gender order
describes existing structures of gender relations not least as reflected in gendered
divisions of labor. Gender culture for its part refers to deeply embedded beliefs and
ideas about the relations between the generations in the family and the obligations
associated with such relations.
Against this background one way forward would be to combine the different yet
complementary aspects of institutional context discussed above as part of an
‘‘organizing framework’’. In the context of their study of multilevel governance
Bache and Flinders (2004: 94) define this as an analytical framework that provides a
map of how things relate and that leads to a set of research questions. The value of
such an approach is that it helps to explore complex issues and identifies interesting
areas for further research.
Comparing Health Policy 73
Putting Typologies of Health Systems in Perspective
The present paper set out to assess the use of typologies of health systems in the
comparative analysis of health policy. Here, the central question is to what extent
typologies help to capture institutions central to health care and thereby contribute
to explaining health policies across different countries.
The review of the literature demonstrates that the early typology of health systems
developed by the OECD has provided a springboard for many comparative analyses
of health policies that examine how sector-specific institutional contexts shape health
policies. The definition of the health systems, though, has changed in the course of
this process with new attributes being added, thus reaffirming the complexity of the
institutional context of health care. Moran’s concept of the health care state syste-
matically engages with both institutional embeddedness and typology building, and
as such provides a suitable basis for assessing the use of typologies of health systems.
Based on a recent study that included a diverse range of countries and areas of health
policies the analysis suggests three things.
First, modeled upon paradigmatic cases the concept of the health care state holds
as an ideal type and as a heuristic device to help capture theoretically relevant aspects
of the institutional context of health policy. Second, despite this contribution, as
with all typologies the concept of the health care state is historically and culturally
contingent. Not surprisingly, in our analysis only few countries fully match the ideal
types and some even emerge as hybrids. At the same time, it is also clear that cross-
country comparisons cannot do without a common framework. As Marmor and
Okma (2003: 749) observe, in comparative health policy analyses there is a need for a
framework that is applicable across different countries and that helps to describe and
understand the anatomy and the physiology of the organization of health care. So
what are the options? If the institutional context of health care is more diverse and
complex than the concept of the health care state, it needs to be treated first and
foremost as a starting point for more detailed analyses of the country-specific
institutions of health care. Such a complementary analysis has to take account of the
country-specific trajectories as well as the broader institutional contexts of health
care. It is, therefore, through analyzing the relative degree an individual country
matches the respective ideal type that a more detailed understanding of the country-
specific institutions emerges.
Third, complementing the concept of the health care state with more specific
analyses of the institutional context is particularly appropriate in the case of medical
health policies, whereas this is not necessarily possible in relation to the increasingly
important non-medical health policies. Here, it is more appropriate to work with a
looser organizing framework that brings together the very different and diverse
aspects of institutional contexts of non-medical health policies, such as those related
to home and community based health care. However, no matter how inclusive, such
a looser framework has its own limitations. As Mabbett and Bolderson (1999) argue,
the deconstruction of single broad-brush categorizations (and typologies) makes all
encompassing cross-country comparisons and contrasts more difficult. In relation to
non-medical health policies, however, limitations of this kind may be outweighed by
the advantage of being able to include a new set of policies in the comparative
analysis of health policy. Although this more complex approach might lack the
74 V. Burau and R. H. Blank
comfort that comes with the orderliness of typologies it more accurately reflects the
real world of health policy.
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