COMPARATIVE HEALTH-CARE SYSTEMS

At the dawn of the twenty-first century, access to health-care services, their cost and quality constitute key social, political, and economic issues for virtually every country in the world. Identifying the conditions under which health-care systems function most effectively has become a vital, albeit elusive, goal. One point is certain: It is impossible to fully understand the dynamics of health-care systems without comparative health-care research. Knowledge of systems other than one's own provides the observer with multiple vantage points from which to gain a fresh perspective on strengths and weaknesses at home. Studying other systems, including their successful as well as failed health-reform efforts, provides a global laboratory for health-systems development. While some countries have been quick to draw upon the health-care innovations of their neighbors, the United States has been relatively slow to look internationally for health-reform ideas. Fortunately, the proliferation of comparative health-care studies promises that such insularity will be much less likely in the future.

The comparative study of health-care systems focuses on two broad types of issues. The first involves describing the range of health-care services in populations or societies, particularly their organization and functioning. By far the most common type of research, descriptive studies, brings together statistical indicators and factual explanations about how various national systems operate (van Atteveld et al. 1987). Some of this work incorporates an analytical dimension by categorizing systems in terms of conceptual schemes or typologies. Less attention has been paid to the second type of research, which looks more closely at the dynamics of how health-care systems behave. The intent in this type of research is to analyze the patterns among system characteristics, especially with the idea of anticipating the outcomes that are likely with specific types of system arrangements. Still in its infancy, this work promises an in-depth yet practical understanding of how health-care can be organized and financed to achieve desirable levels of both quality and access.

Interest in cross-national studies of health-care systems increased dramatically in the early 1990s as a result of national debates over reorganizing American health-care. Rapidly aging populations in many advanced, capitalistic countries, in combination with the expanding scope of high technology medicine, resulted in increased public demand for health-care. At the same time, poverty and other forms of social inequality as well as ineffective societal institutions created major public health problems in many developing countries, such as hazardous water, inadequate or harmful food supplies, poor air quality, unsafe homes and workplaces, and the swift spread of infectious diseases. In both cases, health-care systems have been severely challenged and often cannot meet the needs of citizens. Because of these problems and also due to enhanced global cooperation, social scientists and policy makers are increasingly turning their attention to the experience of other countries.

KEY CHARACTERISTICS FOR THE COMPARISON OF HEALTH-CARE SYSTEMS

Drawing on the work of Anderson (1989) and Frenk (1994), a health-care system can be defined as the combination of health-care institutions, supporting human resources, financing mechanisms, information systems, organizational structures that link institutions and resources, and management structures that collectively culminate in the delivery of health services to patients. Within this broad framework, the methodology for comparing health-care systems can vary widely. A standard approach would include some or all of the dimensions outlined below.

The most fundamental comparative dimension is the organization, financing, and control of a health-care system. This involves comparing which health services are provided; how they are paid for; how they are configured, planned, and regulated; and how citizens gain access to them. Among countries with advanced economies, health-care services today look much the same to the casual observer; however, the financing arrangements and policy-making mechanisms that underlie them vary widely. The role of government is perhaps the most significant organizational variable in international health-care. All governments, with the notable exception of the U.S. government, accept responsibility for the health-care of citizens (Evans 1997). Some governments take it upon themselves to actually provide health services and, therefore, own their own clinics and hospitals and hire their own physicians and staff—examples are Sweden and Denmark. Within the U.S., the Veteran's Administration operates its own healthcare system this way. In a variation of this model, the government acts as the purchaser (but not the owner) of health-care services, obtaining services from private providers on behalf of patients, such as in Canada or the reformed health-care system in Britain. In Finland, local governments can purchase from either public or private providers. In another model, illustrated by Germany and Japan, the government avoids acting as the major payer, and instead takes the role of an overseer, setting mandates for health coverage, including the type and level of coverage, and regulating the terms of what is largely a private system. Due to economic pressures, national governments in both Germany and Japan provided increasing subsidies to support their systems in the 1990s.

It is important also to compare health-care systems in terms of physician characteristics and provider arrangements for primary care and prevention. The supply of medical personnel (e.g., the number of physicians per unit of population) is a key comparative indicator. Interestingly, there is significant variation in the number of physicians in advanced economy nations, ranging per 10,000 population from fifty-five in Italy to thirty-four in Germany to twenty-six in the United States, which is more typical, to seventeen in the United Kingdom (Anderson and Poullier 1999). Equally interesting is that there is no apparent corresponding variation in the health status of these populations. A more complex issue is how different systems organize and divide medical work between various professions and occupations. In some countries, such as Sweden, Finland, and the Netherlands, midwives or nurse midwives have primary responsibility for normal prenatal care and childbirth; in others, such as the United States, physicians have responsibility for these tasks and midwives are relatively rare. Practice arrangements between generalist and specialist physicians are another point of comparison. The United States is unique among its peers because primary care physicians working in ambulatory settings also have hospital privileges, and, therefore, have the right to admit patients and to treat hospitalized patients. In Britain, Sweden, Germany, and many other countries, on the other hand, only specialists comprise the hospital medical staff and only they can treat patients there.

Hospitals and long-term care arrangements constitute another dimension in comparing health-care systems. Countries vary widely in how they use hospitals, as well as in how and where citizens with chronic illnesses and other debilitating conditions receive ongoing, nonacute care. Many Western countries today are in the process of shifting from institutional to community-based care. There are many factors affecting this transition, including whether alternatives to institutional care, such as home health and support programs, are readily available. In countries such as Japan and Germany, that through the 1990s have relied on informal family caregiving arrangements rather than institutions or community-based services, sociodemographic changes (elders living longer as well as changes in the work force participation of caregivers) are producing a long-term care crisis.

Health-systems also can be compared according to the degree to which care is integrated and coordinated between various sectors and levels of services. Systems that have rigid boundaries between ambulatory and hospital services, or between general medical and mental health services and that are so highly specialized that patients are required to transfer among multiple providers, illustrate arrangements where communication across "borders" is vital for optimal patient care. The Nordic countries, in particular, have been highly conscious of gaps in the coordination and continuity of care, and have developed reforms to bridge them. Finland has adopted a model that integrates the basic education of both health-care and social care personnel, a strategy intended to link the biomedical and social aspects of health and health-care at the very beginning of professional education.

Perhaps the most common basis for comparing countries' health-care systems is various outcome statistics such as economic characteristics, personnel resources, utilization rates, and population health status measures. The proportion of the population covered by government-assured health insurance stands as the indicator with the least international variation. Of the twenty-nine countries analyzed by the Organization for Economic Cooperation and Development in 1998, governments in twentyfour countries assured coverage to 99 percent to 100 percent of their population. The five exceptions were Germany with 92 percent coverage, Mexico and the Netherlands with 72 percent, Turkey with 66 percent, and the U.S. with 33 percent (Anderson and Poullier 1999). Other indicators in the same report vary widely. In per capita health-care spending, the United States spends just less than $4,000, an amount that is substantially more than for the other nations, which range from Switzerland's $2547 to Turkey's $260. Contrary to what one might think, the amount a country spends on health-care is not reflected in the longevity of its population. Men in twenty-one countries live longer than do men in the United States (up to an average of 77 years in Japan compared to 72.7 in the United States). Similarly, women in nineteen countries live longer than American women (up to an average of 83.6 years in Japan versus 79.4 in the United States). In fact, relatively few of the high-spending countries appear among those with the greatest longevity.

Detailed comparisons of statistical characteristics have limited value when neither issues of measurement nor the contextual meanings associated with each measure are immediately clear. Each country has its own distinctive set of sociohistorical and cultural characteristics; these should be considered in comparative research, since they often play an important role in explaining the origin and development of health-care systems (Payer 1996). For example, Starr (1982) has posed and explored the question of why the United States ignored national health insurance at the same time most European countries were adopting such programs. National insurance, he argues, was a form of social protectionism and was, therefore, most likely to be enacted by paternalistic regimes such as Germany and only later by more liberal states such as France and the United Kingdom. In addition, the United States' long history of rejecting national health insurance reflects its decentralized government, the relative lack of domestic unrest, and the failure of major interest groups (labor, business, and medicine) to provide support. Regarding the same issue, Steinmo and Watts (1995) contend that the structure of American political institutions creates conditions that work against the adoption of national health insurance.

A final means of comparing health-care systems is on the basis of specific problems, including assessments of citizen satisfaction (Donelan et al. 1999). Closely related comparisons focus on the various strategies for reform that countries have implemented in an attempt to address their problems (Graig 1993). Much can be learned by studying and comparing which solutions seem to work best for certain types of problems, as well as observing patterns of failure across multiple systems.

FRAMEWORKS FOR COMPARING HEALTH-CARE SYSTEMS

While it is useful to compare health-care systems on the basis of a series of characteristics, in-depth understanding of the variation in systems requires a more analytical approach. Most frameworks proposed by comparative health-system researchers can be characterized as typologies that, though they add a conceptual basis for distinguishing among systems, offer limited analytical complexity or depth. These typologies typically emphasize political or economic criteria, and several of the more complex schemes attempt to integrate the two. Graig (1993) organized the six countries she analyzed on a continuum with public systems (e.g., the United Kingdom) at one end, private systems (the United States) at the other, and mixed or "convergence" systems, such as Japan, Germany, and the Netherlands, in the middle. Roemer (1991) developed a sixteen-cell typology that combines political and economic elements, describing systems in relation to government policies (entrepreneurial/permissive, welfare oriented, universal/comprehensive, and socialist/centrally planned) as they intersect with economic conditions (affluent, developing, poor and resource rich). These and similar approaches offered by Anderson (1989) and Light (1990) offer descriptive distinctions, but do not emphasize the theoretical basis for the particular category schemes.

Mechanic (1996) hypothesizes that health-systems internationally are converging, based on the idea that medicine forms a world culture in which knowledge and health-care ideas are quickly disseminated. He proposes six areas of convergence: nations' concerns with controlling cost and improving the efficiency and effectiveness of health-care, nations' realization that population health outcomes are largely a product of circumstances outside the medical care system, nations' concern and attempts to address inequalities in health outcomes and access to care, nations' growing interest in patient satisfaction and consumer choice, and the increasing attention nations are placing on the linkage between medical and social factors in health-care, and the struggle all nations are having between technology, specialization, and the need to develop primary care. Field (1980) also theorizes a progression of health-system development with a scheme placing systems along a continuum according to the extent to which health-care is seen as a social good. He identifies five system types in order of their progression toward a socialized system: anomic, pluralistic, insurance/social security, national health service, and socialized health-care.

Elling (1994) takes issue with the notion of "automatic convergence" and with typologies that posit unidirectional evolution or change, pointing out that countries are involved in ongoing, dynamic class struggles in the development of health-systems. His neo-Marxist framework, influenced by Wallerstein's world-systems theory, allows for countries to move back and forth among five types: core capitalist (e.g., the United States and Germany), core capitalist/social welfare (e.g., Canada, Japan, Sweden, United Kingdom), industrialized socialist-oriented (e.g., pre-1990s Soviet and eastern European systems), capitalist dependencies in the periphery and semi-periphery (e.g., Brazil and India), and socialist-oriented, quasi-independent of the world system (e.g., China and Cuba).

In 1990, Esping-Andersen (1990) contributed an important theoretical framework to the field of comparative welfare states research, that can also be useful in distinguishing among health-care systems in advanced capitalist nations. Esping-Andersen conceptualizes all welfare activities, including health-care, as a product of a state-market-family nexus. His typology organizes "welfare regimes" around this nexus, specifically as it results in the decommodification of workers in a country; that is, the degree to which a citizen can obtain basic health and social welfare services outside of the market. In terms of health-care, this would mean a citizen's ability to access health-care services without having to purchase them "out-of-pocket." Esping-Andersen identifies three types of systems: conservative or corporatist, liberal, and socialist or social democratic. In The Three Worlds of Welfare Capitalism, he constructs measures of decommodification that he applies to data from eighteen nations in order to assess where each nation's welfare regime ranks according to the three types. Under Esping-Andersen's scheme, social democratic systems include the Nordic countries and the Netherlands; liberal systems include Canada, Japan, and the United States; and the conservative or corporatist welfare states include France, Germany, and Italy. These placements appear similar to what Graig proposed using a much simpler public-private dimension; however, Esping-Andersen's methodology is unique in its theoretical approach and because it can be operationalized quantitatively to allow precise distinctions among a large number of nations.

Reviewing various health-care system frameworks shows a wide variety of approaches and scholarly emphases. Comparative research is in the process of moving beyond simple typologies to focus on the conditions under which different types of systems emerge and under which they change. This work demonstrates the value of a broad approach, integrating the key aspects that affect the development of health-care systems, including historical, cultural, political, and economic factors.

REVIEW OF SELECTED HEALTH-CARE SYSTEMS

Comparative international research on health-care systems requires information that is both detailed and current. Obtaining data is complicated by the fact that health-systems throughout the world operate in a state of constant flux. These summaries present the most recent information available for the health-care systems of selected countries. Among countries with advanced economies, Sweden and the United States often occupy opposite extremes when it comes to health-care organization and financing. For this reason, Sweden is the first country discussed along with three countries that have similar systems—Finland, the United Kingdom, and Canada—followed next by Germany, Japan, Russia, and China, with additional discussions of France, Mexico, Argentina, Chile, Colombia, and Ghana.

Swedish health-care reflects three basic principles: equality among citizens in access to health-care; universality in the nature of services (the idea that everyone should receive the same quality of services); and solidarity, the concept of one social group sacrificing for another group in the interest of the whole society (Zimmerman and Halpert 1997). Solidarity in this context refers to taxing those who use fewer services at the same rate as those who use more—for example, similar health-care taxation for younger persons or affluent persons versus the elderly or the poor). The Swedish health-care system is predominantly a publicly owned and funded system; thus, approximately 85 percent of Swedish health-care is publicly funded, whereas in the United States the public portion is just under 50 percent (Lassey, Lassey, and Jinks 1997). The differences between the two systems are more startling in terms of the growth of overall spending. In the early 1980s, both countries were spending approximately 9.5 percent of their Gross Domestic Product on health-care. By the end of the century, the situation had changed dramatically; in 1999, Sweden was spending 8.6 percent ($1728 per capita) compared to 13.5 percent ($3924 per capita) in the United States (Anderson and Poullier 1999). Populations in the two nations also differ markedly on several basic health status indicators. Infant mortality Sweden is four deaths per thousand live births compared to 7.8 in the United States. Swedish men live nearly four years longer on average than American men, and Swedish women live two years longer than their American counterparts. These favorable statistical indicators compel a closer look into how the Swedish health-care system is organized.

The Swedish welfare state, including health-care and social services, is one of the most comprehensive and universal in the world. Health-care in Sweden is the responsibility of the state, which delegates it, in turn, to each of Sweden's twenty-one county councils (Swedish Institute 1999). Elected officials in each county are charged with providing comprehensive health services for residents, and with levying the taxes to finance them. The system is decentralized; each county by law must provide the same generous common core of services to all residents, although just how they decide to do it can vary. In the 1990s, Sweden embarked on a series of reforms in order to increase health-care quality and efficiency. As a result, Swedish citizens now have greater freedom in choosing their own primary care physicians. The vast majority of these doctors are employed by the county councils to practice in small group clinics and health centers distributed geographically throughout the country. Specialist physicians practice in hospitals where they also see outpatients on both a referral and self-referral basis. The medical division of labor also includes district nurses, physical therapists, and midwives, all of whom are used extensively to deliver care through local health centers (maternity clinics in the case of midwives). Midwives also work in hospitals where they have responsibility for normal cases of labor and delivery. Sweden's elderly constitute an increasing proportion of the population, creating significant challenges for both current and future health and social services. Sweden's social policy emphasizes that citizens should be able to live in their own homes for as long as possible, meaning that nursing home placement occurs only when absolutely necessary. Services for the elderly may involve as many as five or six home nursing visits per day in order for the disabled and elderly to remain at home in the community.

Swedish citizens are taxed heavily to maintain the quality and level of services they expect; at the same time, they have shown high levels of political support for maintaining their expensive system. In the 1980s, many services were entirely free; however, today there typically is a modest copayment. The copayment for a primary care physician visit, for example, currently ranges from $12 to $17 depending on the county council. For specialist physician visits the copayment ranges from $15 to $31, and for hospital stays it is fixed at $10/day. The Swedish system includes a high-cost ceiling so that, after a person spends approximately $113 out-of-pocket each year, health-care services are free. Medications must be purchased by the individual until they have reached a threshold of a little more than $100. Prescriptions are then discounted until the patient has spent $225, at which point medications become free (Swedish Institute 1999). These amounts have increased somewhat during the 1990s, but due to Swedens already high taxation rate, county councils were hesitant to ask patients to pay more. Reforms during the same period included establishing internal performance incentives or "public competition" (Saltman and Von Otter 1992), a structural arrangement that arguably enabled Sweden to maintain the basic features of its health-care system without large tax or out-of-pocket increases. Some have expressed concern that the system is stretched to its limits. Regardless of which view is correct, the Swedish system requires a healthy economy in order to continue, given continuing cost pressures and an increasingly aged population.

The Swedish model of a publicly owned and financed health-care system shares common features with systems in several other countries, including the United Kingdom, Finland, and Canada. The British National Health Service (NHS), like its Swedish counterpart, provides publicly funded, comprehensive health-care to the population, and enjoys a solid base of citizen support, albeit under ongoing criticism. What distinguishes the NHS from health-care systems in other Western countries is its frugality. Characterized by long waiting lists and what Klein (1998) refers to as "rationing by professionally defined need," Britain runs the cheapest health-care system in Europe, outside of Spain and Portugal. In the early 1990s, the NHS went through a series of dramatic changes, creating "internal markets," a system of inside competition intended to increase productivity and further decentralize its historically large and unwieldy bureaucracy. These reforms—several of which were adopted by Sweden—reorganized primary care practices and shifted physician payment from fixed salary to capitation. NHS hospitals also entered into new arrangements where they have greater structural independence and compete among themselves. In 1997, the British government introduced new proposals that changed course yet again. The direction of the NHS in the twenty-first century is unclear (Klein 1998).

Finland's health-care system also is publicly owned, financed through general taxation, and decentralized. In fact, Finland operates with more health-care decentralization than Sweden. Since 1993, Finnish funding for health-care has been incorporated into block grants from the national government that are given annually to each of the country's 455 municipalities, some of which form partnerships for purposes of delivering health-care (Hermanson, Aro, and Bennett 1994). Within the parameters of national guidelines, elected officials in each of these jurisdictions (similar to the county councils in Sweden) have the responsibility to obtain and deliver health-care services to the population. High standards, a comprehensive array of services, as well as modest out-of-pocket payments, make the Finnish system comparable to the Swedish system. Canada also provides health-care to its entire population. The Canadian system is administered by the provinces and is financed largely by public taxation, roughly three-quarters of which is from the provincial government. While basic services remain constant, some specific provisions of health-care in Canada vary considerably from province to province. Unlike in Sweden, Finland, and the United Kingdom, Canadian physicians are paid on a fee-for-service basis. Furthermore, Canadian primary care physicians act as gatekeepers to specialists and hospitals (much as they do in Finland and the United Kingdom, but not in Sweden). As is the case with all the countries in this group of four, Canadians have extreme pride in their health-care system. They appear resolute in maintaining it, although a number of controversial cost-cutting measures and as yet unsolved problems raise considerable concern about the future (Lassey, Lassey, and Jinks 1997).

Germany and Japan, as well as France, have achieved comprehensive and universal coverage (92 percent in the case of Germany) with a model that is closer to that of the United States than the social democratic model of Sweden discussed above (U.S. General Accounting Office 1991). In all three of these countries, medical care is provided by private physicians, by both private and public hospitals, and patients can choose their physicians. Benefits are comprehensive and mandated by the national government, which also regulates enrollment, premiums, and reimbursement of providers. In contrast to the four countries discussed earlier, financing in Germany, Japan, and France is predominantly private with multiple payers. Workplace-based insurance (financed typically through payroll deductions) covers most employees and their dependents while other payers cover the remainder of the population. Patients make copayments for physician visits and hospital stays, ranging from a nominal amount in Germany to as much as 20 percent or 30 percent of the fee in France and Japan. There is national regulation to ensure consistency. Coverage and care conditions vary from fund to fund, resulting in greater inequalities of benefits compared to the public systems of Sweden, Finland, Canada, and the United Kingdom. Arguing that such systems actually help maintain social divisions and inequality, Esping-Andersen (1990) refers to them as conservative or corporatist.

Although Germany privately finances much of its health-care system, the national government plays a strong role. All but the most wealthy of German citizens are required by law to join one of Germany's 750 insuring organizations, called "sickness funds." In practice, all but about 10 percent of the population opt to join the system, encouraged to participate by the great difficulty of getting back in later on. Sickness funds are private, nonprofit organizations that collect premiums or "contributions" for each member—half paid by the individual and half by the employer—and, in turn, contract for health services with physician organizations and hospitals. One of the biggest problems for the German system is continuing cost pressures, exacerbated by the reunification of East and West Germany in 1991. The system uses fixed budgets for hospitals and strict fee schedules for physicians, with punitive measures for inordinate increases in volume, to combat the problem. These were tightened in a major 1993 reform that imposed strict three-year budgets on all major sectors of the system as well as longer-term structural reforms. Early results have been positive (U.S. General Accounting Office 1994).

Japanese health-care follows much the same private, multi-payer model as in Germany, with health-care provided to all citizens through 5,000 independent insurance plans. The plans fall into three major groups, each enrolling about a third of the population: large-firm employees, small-firm employees, and self-employed persons and pensioners. In the case of the first two plans, as is the case with the German sickness funds, the employer pays approximately half of the premium and the employee pays the remaining portion. The similarity to the German system is no accident; Japan has consciously patterned its health-care syatem after Germany's, dating back to its modernization in the late nineteenth and early twentieth centuries (Lassey, Lassey, and Jinks 1997). Despite these similarities, Japan's health-care system presents some unique and somewhat startling features compared to the other systems discussed here.

Compared to other systems with a significant private component, the Japanese system costs considerably less (Andersen and Poullier 1999). In 1997, for example, per capita health-care spending in Japan was $1741, less than in the United States, Canada, France, Germany, and many other European countries. Of the nations discussed here, only the austere British system ($1347 per capita) and efficiency-conscious Finnish system ($1492 per capita) spent less. Japan's economical approach to delivering health-care raises two paradoxes. First, the low levels of spending would seem to contradict the fact that Japan currently has the longest life expectancy and the lowest infant mortality in the world. In addition, utilization rates in Japan are high, which some would argue indicates a sicker rather than a healthier population. Specifically, the Japanese visit physicians two to three times more frequently, stay in the hospital three to four times longer, and devote considerably more health spending to pharmaceuticals than the other nations discussed here. How can these contradictions be explained? Ikegami and Campbell (1999) argue that, in part, the paradox can be explained by the country's much lower incidence of social problems related to health, such as crime, drug use, high-speed motor vehicle accidents, teen-age births, and HIV infections. Less aggressive medicine and lower hospital staffing and amenities also are thought to keep down costs in Japan.

Health-care arrangements in nations where the political economy is neither "advanced" nor a stronghold of capitalistic democracy can also be instructive. During the latter part of the twentieth century and until today, both China and Russia have been faced with the monumental challenge of providing health-care with very limited financial resources to huge, diverse populations, many of which live under poor social conditions. Their health-care systems, however, are quite different and their current problems reflect the distinctive political and economic trajectories of the two countries. Russian health-care at the dawn of the twenty-first century is a system in crisis. Based on socialist principles of universal and free access, the old Soviet system included a primary care network of local clinics ("polyclinics") typically connected to a general hospital, as well as more specialized hospitals. This means that a regional city might have separate hospitals for emergencies, maternity, children, and various infectious diseases (Albrecht and Salmon 1992). Funding came directly from the central government until 1993 when a new health insurance law was approved, shifting the source of financing to employer payroll deductions. There are major questions, however, as to whether such a system can be effective during the current period of resource scarcity and instability in major social institutions (Lassey, Lassey, and Jinks 1997).

Chinese health-care, for most Westerners, evokes images of acupuncture and other forms of Eastern medicine, as well as the idealized "barefoot doctors" of the 1960s and 1970s, practitioners with basic medical training who provided primary care in rural areas. In reality, traditional Chinese medicine exists alongside an increasingly dominant Western medical establishment, and the barefoot doctors have all but disappeared. Since new leadership took over the Communist Party in the late 1970s, China has encouraged privatization and decentralization in health-care. By the 1990s, nearly half of all village health-care was provided by private practitioners (Lassey, Lassey, and Jinks 1997). These changes reportedly have been accompanied by a decline in preventive care and public health efforts in rural areas. At the same time, the situation in urban areas seems to have improved. China's revolutionary-era network of local and regional clinics and hospitals has been modernized, although resource shortages continue to limit the level of technological advancement. The most significant change in China is the growing impact of privatization, which appears to be bringing China many of the same problems that have plagued privatized systems elsewhere: lack of insurance coverage, increasing costs, maldistribution of providers, and inequalities in the overall quality of care (Liu, Liu, and Meng 1994). As in the United States, the gap between the health-care received by the rich and that received by the poor is growing (Shi 1993).

Huge disparities between the rich and poor are characteristic of Latin America where they constitute a significant barrier to universal health coverage. Latin-American health-systems vary considerably, reflecting socioeconomic differences between countries as well as historical and political contingencies. The Mexican system illustrates many of the obstacles faced by developing nations, whether in Latin America or elsewhere. The Mexican constitution established federal responsibility for health-care in 1917, along with a centralized administrative tradition that still exists; yet, to date, the two major government insurance schemes cover only about 47 percent of the population, with another 7 percent insured privately. Ostensibly, there are programs for the remaining 46 percent of the population, most of whom are low income, but in reality, many low income areas and impoverished communities are poorly served. Some have argued that a basic health-care infrastructure is in place and that there are sufficient numbers of well-trained health-care professionals available (Lassey, Lassey, and Jinks 1997). They contend that, had it not been for several national crises in the 1980s and 1990s, coupled with a lack of political will, more of the Mexican population would now be covered by the health-care system.

Bertranou (1999) has compared Argentina, Chile, and Columbia, all of which have employed various ways to reform health insurance arrangements in recent years. Chile's reforms date back to its military dictatorship in the early 1980s. At that time, private health insurers were allowed to compete for worker payroll contributions. There was little regulation of the system which encouraged adverse selection, resulting in significant inequities within the system. Even so, approximately 70 percent of the Chilean population today is covered by insurance, compared to 64 percent in Argentina and only 43 percent in Colombia. Argentina faces numerous obstacles in reforming its complex and confusing system of three types of health-care arrangements (social insurance organizations, private health insurers and providers, and the public health-system). Its goals include universal coverage and a standard benefits package. In the case of Columbia, reform goals are more related to the relative poverty in the country and the fact that large segments of the population cannot afford health insurance. Per capita expenditures for health-care in Columbia are 42 percent of what they are in Chile and 20 percent of the expenditure level in Argentina. Instead of giving free access to public facilities, Columbia's reforms involve providing vouchers that allow low-income families to join the health organization of their choice. To be successful, all these reform efforts require social equilibrium where governments are able to maintain political and economic stability.

The political instability and socioeconomic inequality that have characterized Latin America are also a hindrance to health-care systems in Africa. An even more fundamental problem in Africa, however, is the formidable lack of resources to address overwhelming health-care needs (Schieber and Maeda 1999). Even where clinics, hospitals, and medical personnel exist, there is likely to be a lack of the required equipment and medicines. In Africa as a whole, 80 percent of the physicians live and practice in the cities where less than 20 percent of the population lives. According to Sanneh (1999), this continuing situation supports the prominent role of traditional healers, 85 percent of whom live in rural areas. The difficulties encountered by Ghana in implementing a system of primary care illustrate the situation affecting many African nations. In 1983, soon after the primary care system was adopted, the government attempted cost containment by introducing "user fees" in all public health facilities, clinics as well as hospitals. Two years later the fees were increased and, subsequently, a health insurance program was instituted. One must question the practical significance of these developments in a country where over half of rural residents and nearly half of those in urban areas live below poverty (Anyinam 1989). These circumstances are a reminder that developing countries contain 84 percent of the world's population, yet account for only 11 percent of global health-care spending (Schieber and Maeda 1999), making the task of designing strategies for effective health-care delivery in the developing world the true challenge for comparative health-care system researchers.

Comparing health-care systems entails a vast array of information, including historical background, cultural patterns and beliefs, geographic considerations, as well as social, economic, and political factors. It involves detailed descriptions of policies and procedures, complex statistical profiles, as well as an understanding of conceptual frameworks, theory, and comparative methods. The potential rewards of comparative work, however, balance the challenges. Whether there is convergence in the structure and functioning of health-care systems or not, many of the problems faced by nations in delivering health-care to citizens are similar. There are lessons to be learned from comparing health-care systems internationally that can only aid in addressing these problems.

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Mary Ko Zimmerman