Bernard Merkel from the European Commission highlights six things Canadians should remember when they look to European models. —Report from a presentation at the 2008 conference of the MUHC-ISAI

1. European averages are nonsense

What we call “Europe” is almost 450 million people, 27 different national health systems and, in most countries, health services that are highly devolved by region. EU averages include both very good health systems such as the Swedish and French systems, and the really appalling systems. There are also major health inequalities within the EU. Life expectancy for men is 14 years longer in the best performing EU country (Sweden) than in the worst (Latvia, Lithuania).

2. Universality and equity are not in question

Within the EU there is no debate whatsoever about the state’s responsibility for health care and the key principles of universality, access to good quality care, solidarity and equity. The only debate is how you actually provide this in practice. The state is not expected to be hands on and run health care, but no member nation has even considered reneging on its responsibility and leaving things to the private sector. There is no question of this commitment changing and it is actually being reinforced through different statements and legal declarations.

Table 1. Financing models in the EU Source: EC Directorate General for Health and Consumers

Table 1. Financing models in the EU
Source: EC Directorate General for Health and Consumers

3. Everyone is insured

There may be competition between insurance funds but all people are covered in one way or another. Each country runs its health care system according to different financing models, all under the umbrella of state responsibility for health care and universal coverage. There are three main groups of countries: those that are taxation based, those that are mainly social insurance based, and those that use bits and pieces of both (see Table 1).

4. Countries employ different means of rationing health care

In some EU countries, the general practitioner (GP) serves as gatekeeper for access to the system; in others, patients can access specialists and hospitals directly. In certain EU countries, waiting times are an important issue; others, such as France and Germany, have enough medical capacity (even overcapacity) to deal with everything that comes their way.

5. There is huge variation in spending within the EU

Unlike the OECD, which is made up of mainly richer countries, the EU includes some quite poor countries where less is spent on health per capita and a smaller percentage of GDP goes to health.

6. EU countries provide extensive social support for the chronically ill and disabled

This fact means that in EU countries health care is truly an investment and not just an expense. There is quite a lot of evidence that inadequate expenditure on health leads to long waits for care, to people not being properly treated, to people taking early retirement or withdrawing from the workforce, and finally to a serious economic problem. EU countries can make a perfectly sensible case for spending more on access to good quality health care in order to avoid the huge economic and social costs to the state of supporting people who are ill or disabled, out of the workforce, with their families preoccupied by caring for them.

Current challenges for the EU

The six factors above describe the context in which EU countries are tackling different problems in different ways within their health care systems. Our role at the European Commission (EC) is to try and make the thing work better as a whole, recognizing that we cannot have a sustainable entity with all these countries if some of their health systems are not working. This is true in public health (inadequate surveillance of communicable disease in one country would create major problems in other countries) and in health care systems (a health system that falls apart and compromises the economics of one country creates problems for other countries). The EC is currently working on three policy areas: portability, quality and health human resources.


There are three compelling reasons to improve the portability of care across the EU: the desire to be treated close to home (which in Europe is often in a different country), rapid access to care, and the availability of specialized care. One solution for countries like the UK which has long waiting lists is to allow people to go to countries where there is available capacity. This is especially relevant for rare diseases.

Court cases similar to cases in Canada have led to policy initiatives in Europe as well. The most recent case involved a British woman who needed a hip replacement and was not prepared to wait the six months she was told it would take. She paid to have the hip replacement in France and then demanded reimbursement from the UK government. This was refused. However, the European Court found against the UK government, ruling that the surgery was medically necessary and that the woman had a right to reimbursement.

On the basis of this and other judgments, citizens of countries in the EU now have a legal right to go to another country for treatment and have this paid for by their home country. The European Commission is looking to put in place a system to facilitate this practice and enhance cooperation between different health systems.

Patient safety

The European Commission is now producing policy guidelines on patient safety that will deal with medical error, hospital infection rates and other issues. At present, only four member states are regarded as having all the necessary infrastructure and training in place to promote patient safety.

Health professionals

There are huge salary differentials between Europe and North America, but equally huge differentials between Europe and developing countries. Right now, countries are in competition for human resources. Demographic changes will exacerbate this migration. The EC is looking at policies to ensure that Europe is training enough health professionals and using them in the most effective way.