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Challenges to European healthcare systems at a glance

A comparative analysis of 9 EU countries in times of Covid-19


Health systems around the world are striving to address the well-known challenges of ageing populations and the rise in chronic diseases, as well as growing technical possibilities and public expectations. In the past, to address these challenges a greater percentage of GDP has been spent on healthcare in OECD countries, with Europe being no exception. The negative effects on the economy of the great recession in 2009 has markedly changed this strategy and has increased concerns about the overall sustainability of this state of affairs.

European healthcare systems are already experiencing significant demographic and economic pressures and more will come over the next years. The elderly population is expected to increase, both in numbers and in proportion to the working age population, leading to a doubling in the ratio of elderly people to those of current working ages. At the same time, availability of new treatments is pushing up healthcare costs per patient, determining substantial new costs, with important spillovers also for the social care and the pension payment systems. Overall, these growing number of major health challenges are putting unprecedented pressures on public health systems. To counterbalance these pressures there is a need for action on the social determinants of health so as to improve the health status of the overall population, but particularly among the most vulnerable.

The healthcare system, as we have known it for years, cannot deliver these improvements alone anymore. Action is required across the whole of society. As main actors responsible for the delivery and financing of healthcare, generally based on the principle of social solidarity, they need to identify policy solutions also outside the health sectors to best address these challenges. This opens up new scenarios for the healthcare systems and the role they will have to play in the future. As thoroughly discussed in the Farmafactoring Foundation 2019 Report 1 (Fondazione Farmafactoring, 2019), healthcare systems are increasingly becoming interconnected with other systems in a way that makes them less independent in achieving specific health goals.

Traditionally, health systems have long been considered linear hierarchical structures that could be managed as mechanistic systems where the interactions between the different components are regulated by specific cause-effect relationships. For some years, a different vision has emerged in the scientific literature that characterizes healthcare activities in terms of complex systems theory, where the concept of complexity has often been defined in a vague and varied way, with meanings ranging from “not simple”, to “complicated”, to “intractable”' (Kannampallil et al., 2011). According to these developments, health systems are increasingly assimilated to complex entities governed by non-linear laws of interaction, self-organization and “emergent phenomena” and are paradigmatic examples of human organizations that merge a multitude of different professional characteristics and disciplines in critical performance environments. 

Many factors may have contributed to this change, not least the numerous technological innovations, both bio-medical and digital. These latter have allowed to significantly increase the components of the complex system and the interrelationships between them. According to Toth (2010), in the last 30 years health systems have seen at least three different phases that have led to rethinking their structure and the objectives to be achieved. During the 1980s, when the prevalence of the liberal culture and the hope in the market's ability to consolidate economic development was prominent, a first series of transformations led to a split between the purchase and supply of healthcare services, raising the competition between the various actors. In the 90s, a second phase, more oriented towards integration and regulation, began: the excesses of competition were to be mediated by regulatory activity. Finally, from the early years of the new millennium a third phase took off, focused on the quality of services provided and on patient rights, which begin to assume greater centrality. As discussed in Vrooman (2013), these are the years when new elements, typically external to health systems, are considered as important in the design of welfare policies and the health systems find themselves as one of the many stars in a constellation: they shine, but are no longer the only one.

Since then, the new prevalent vision among policy makers has been that population health status depends on several factors including, among others, a country’s financial conditions, individual and family incomes, genetics, diet, education, lifestyles, socio-demographic and environmental characteristics, resources and programs dedicated to healthcare. As such, population health depends on the interaction of these and many other elements according to mechanisms that bring out unexpected and difficult to understand phenomena if interpreted under a reductionist approach that only takes into account the usual categories seen up to then. The main consequence of this change of perspective is that the boundaries of health systems are no longer traced exogenously by policy makers, but become endogenous as they are strictly linked to the socio-economic structure of the countries, to the political system to which they belong, to the cultural matrix that orients the behaviour and the claiming capacity of the various actors (professionals, citizens, public decision-makers), and to the characteristics and strategic behaviour of the third sector and profit-making enterprises. In addition, during this phase more attention and analyses are devoted to reconsider the healthcare system, shifting the centre of care provision from the hospital to the community.

As highlighted by Bertin (2014), openness to community care requires making the structure of health systems even more complex, due to the additional relationships that will be defined between doctors and patients, between different professionals and, finally, between health system operators and other community actors. The inclusion of the community within healthcare systems significantly broadens their sphere of action and incorporates new problems. Indeed, the community represents a system that is necessarily more open and dependent on the social dynamics that characterize the individual local contexts. As stated by Bertin (2014, p.27), "the spectrum of dynamics that activate demand is certainly broader, often linked to the presence of conditions of social hardship not always easily attributable to a clear nosologic picture ... The broad spectrum of activation of demand and the frequent multidimensionality that accompanies it have as a corollary the complexity of the system, attributable to the coexistence of different actors who can be called into question: moreover, these actors are not all belonging to the health system but operate autonomously in the same field of action: it follows that the organizational dynamics that characterize the relationships between these actors are not of a hierarchical type but recall the metaphor of the network. High complexity, strong openness of the territorial system and network dynamics imply a different configuration of the actors involved and the dynamics of power that connect them. The variability of situations, the multidimensionality of the causative factors that generate the demand and the consequent lower incidence of specialist knowledge call into question the roles and power relations between the actors. As a result, the political dimension, even in its territorial articulations (local authorities), ends up assuming a more relevant weight in strategic choices, but sometimes also in operational ones. In fact, outside the hierarchical dynamics, roles are more dynamic and less structured in terms of positions of power. In fact, it is the material and symbolic exchange processes that define the power relations between the actors of the territory.” In this context, health systems become complex adaptive systems, as they adapt and change according to the experiences, stimuli, communications and information they are exposed to. 

It is within this new holistic framework that all healthcare systems should be analysed and compared. Good health underpins economic and social welfare; a comprehensive and cross-sectoral policy approach to health will therefore deliver multiple benefits. For example, action on the social determinants of health can also contribute to other social benefits such as well-being, improved education, lower crime rates, balanced and sustainable development and improved social cohesion and integration. Investment in health equity can directly contribute to attaining other sectoral and government goals, challenging the notion that health drains public resources. Within this interpretational framework the aim of this report is to offer a comprehensive analysis and comparison of 9 healthcare systems in the EU, namely those in Croatia, Czechia, France, Greece, Italy, Poland, Portugal, Slovakia and Spain. These healthcare systems are based on different funding principles, as a result of heterogeneous economic conditions and societal views on issues related to income redistribution, presence of institutions and government interference with healthcare provision, frequently shaped by different historical and cultural footprints. Furthermore, they have different characteristics in terms of basic founding principles, financing, organization, management, and population size. The report is based on data obtained from official sources and an ad-hoc survey administered to 30 internationally renowned experts in the healthcare field. Among the participants, 51% of the experts were independent researchers or university scholars, another 33% were experts affiliated with hospitals or with other healthcare institutions, and the residual 16% covered other professional functions. Thanks the heterogeneity of their expertise, the report offers a multilevel overview of these healthcare systems, seeking to highlight common challenges and country specific issues that might be crucial from both practitioners’ and policymakers’ perspectives.

Finally, it is important to highlight that this is the second in a series of published reports, but different in serveral respects. First of all, there are plenty of dimensions across which the countries compared in this report differ from each other. From the viewpoint of this analysis, the most important distinction concerns the healthcare system organizational model each country has. On one side, we have a country whose system is based on the Beveridge model, which relates to public tax-financed systems (usually fiscal tools), managed by a National Health System, which provides universal coverage. On the other side, there is the Bismarck model, which implies that the funding of the healthcare system is obtained through compulsory social security contributions, usually paid by employers and employees. This type of system is frequently referred to as a/the Social Health Insurance System. Among the group of countries selected, the Beveridge system is shared by Italy, Spain and Portugal, while Poland, Czechia, Slovakia and France adopt the Bismarck group. Finally, there is the Private Health Insurance System, which can be interpreted as a hybrid between the two, and is adopted by Greece and Croatia. All results will be compared according to this classification. A second difference refers to the type of information provided in this report, which is now common to all countries and does not vary depending on the type of topic analysed. Finally, a specific section on COVID-19 has been added to understand how these countries have managed the pandemic during the first wave and how they have approached the second wave.


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[1] The study Il Servizio Sanitario e la gestione della complessità: sostenibilità, pluralità delle piattaforme e loro interazioni is available, in Italian, at http: