Health Economics, Policy and Law


Are health problems systemic? Politics of access and choice under Beveridge and Bismarck systems

Zeynep Ora1 c1, Chantal Casesa2, Melanie Lisaca3, Karsten Vrangbæka4, Ulrika Winblada5 and Gwyn Bevana6

a1 Institute for Research and Information in Health Economics, Paris, France

a2 Institute for Research and Information in Health Economics, Paris, France

a3 Bertelsmann Foundation, Guetersloh, Germany

a4 Department of Political Science, University of Copenhagen, Denmark

a5 Department of Public Health and Caring Sciences, Uppsala University, Sweden

a6 Department of Management, London School of Economics and Political London School of Economics and Political Science, UK


Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless, the nature and intensity of the reforms required are largely determined by each country’s basic social security model. Most reforms in Beveridge-type systems have sought to increase choice and reduce waiting times while those in major Bismarck-type systems have focused on cost control by constraining the choice of providers. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of healthcare system, which underlie these differences? Have recent reforms been effective?

Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms. Thus, while countries may share similar problems in terms of improving healthcare performance, adopting a ‘copy-and-paste’ approach to healthcare reform is likely to be ineffective.


c1 Correspondence to: Zeynep Or, Institute for Research and Information in Health Economics, 10 rue Vauvenargues, 75018, Paris, France. Email: