Does the Health System Model Shape Prevention? Evidence from 22 OECD Countries (2004-2023)

This study analyzing 22 OECD countries from 2004 to 2023 finds that the share of health expenditure allocated to prevention is largely independent of a healthcare system's structural organization (financing and provision), suggesting that investment in prevention is driven more by external political and strategic factors than by the system's inherent design.

The Gist

Imagine the healthcare system of a country as a giant, complex garden.

For decades, gardeners (policymakers) have been arguing about the best way to run this garden. Some say, "The government must own the tools and water the plants" (State-run systems). Others say, "Insurance companies and private groups should manage the water" (Society-run systems).

The big question this paper asks is: Does the way we organize the garden determine how much we spend on prevention?

In gardening terms, "prevention" is like planting seeds, pulling weeds early, and fertilizing the soil so the plants don't get sick later. "Curative care" is like buying expensive medicine to save a plant that has already turned brown.

Here is the simple breakdown of what the researchers found:

1. The Big Picture: A Mixed Bag of Gardens

The researchers looked at 22 European gardens (countries) over 20 years (2004–2023). They wanted to see if the "owner" of the garden (the government vs. private groups) dictated how much money was spent on keeping plants healthy before they got sick.

• The Trend: In most gardens, the amount of money spent on prevention slowly went up. In a few gardens, it actually went down.
• The "Pandemic Spike": Like a sudden storm, the COVID-19 pandemic caused a massive, temporary spike in prevention spending in 2020–2021 (mostly for vaccines and testing). But as soon as the storm passed, spending dropped back down, almost as if the gardeners forgot to keep the sprinklers running.

2. The Main Discovery: The "Owner" Doesn't Matter

The researchers ran a complex math test (a regression analysis) to see if the type of garden owner changed the spending habits.

The Result: It didn't matter much.
Whether the garden was run by the State (Government), Society (Insurance/Unions), or Private groups, the amount of money spent on prevention was roughly the same.

• The Analogy: Imagine two chefs. One is a strict head chef (State), and the other is a rotating team of guest chefs (Society). You might think the head chef would be more disciplined about buying fresh ingredients (prevention). But the study found that both chefs bought about the same amount of fresh ingredients. The "recipe" (the healthcare system model) didn't determine the "shopping list" (the budget).

3. The One Tiny Exception

There was one small difference found. Gardens run by Society (where insurance funds and unions manage the rules) seemed to have a slightly faster acceleration in spending on prevention compared to State-run gardens.

However, the authors warn this might just be a fluke caused by the pandemic years, rather than a deep rule about how these systems work.

4. Why Do We Spend So Little on Prevention?

If the system type doesn't matter, why is prevention spending still so low in most places?

The paper suggests it's not about the structure of the system, but about human nature and politics.

• The "Quiet" Policy: Prevention is like buying a fire extinguisher. You hope you never need it. It's boring to talk about.
• The "Loud" Cure: Fixing a broken leg or treating a heart attack is urgent and visible. Politicians love to cut ribbons on new hospitals (cure) because voters see the immediate result. They are less excited about funding a vaccination program (prevention) because the "reward" (people not getting sick) is invisible.
• The Short-Term Trap: Politicians often want quick wins to get re-elected. Prevention takes years to show results. So, even if a country has a "perfect" system, if the leaders are focused on short-term savings, they will cut the prevention budget.

The Bottom Line

You can't just "design" a healthcare system to force people to care about prevention.

Changing the rules of the game (who runs the hospital) won't automatically make the game more about prevention. Instead, preventing disease depends on political will and public pressure.

The Takeaway for Policymakers:
Don't just rely on changing the organizational chart of your healthcare system. If you want more prevention, you need to actively campaign for it, make it a political priority, and explain to voters why "buying the fire extinguisher" is worth the cost, even if the house isn't burning down yet.

In short: The type of healthcare system is like the color of the garden fence; it doesn't determine how well the plants grow. What matters is whether the gardener is willing to water them.

Technical Summary

1. Problem Statement and Research Gap

• Context: Global health challenges, population aging, and rising costs have made preventive care a critical policy priority. However, preventive spending often remains a small fraction of total health expenditure and is frequently subject to budget cuts due to its long-term benefit horizon.
• The Gap: While previous literature has explored the relationship between healthcare system organization and preventive spending, most studies rely on traditional, tripartite classifications (e.g., Beveridge vs. Bismarck models). There is a lack of research utilizing multidimensional, contemporary classifications (specifically Böhm's framework) to analyze long-term trends (20 years) across a large sample of European OECD countries.
• Objective: To analyze trends in preventive care expenditures (as a percentage of total health expenditure) from 2004 to 2023 across 22 European countries and determine if specific structural dimensions of healthcare systems (regulation, financing, provision) are associated with different expenditure trajectories.

2. Methodology

• Data Source: Secondary data from the OECD covering 22 European countries (Austria to the UK).
• Time Period: 20 years (2004–2023).
• Dependent Variable: The percentage of preventive care expenditure relative to total healthcare expenditure (calculated in Euros, PPP converted, 2020 prices).
• Classification Framework: The study utilizes Böhm's classification (based on Rothgang and Wendt), which categorizes healthcare systems along three structural dimensions:
  1. Regulation: State, Societal, or Private actors.
  2. Financing: State, Societal, or Private actors.
  3. Provision: State, Societal, or Private actors.
• Statistical Analysis:
  • Model: Hierarchical semi-log polynomial mixed-effects regression.
  • Structure: Random intercepts and random time slopes were included to account for unobserved heterogeneity across countries and the repeated-measures (country-year) panel structure.
  • Variables:
    • Fixed Effects: Linear time (year_linear), quadratic time (year_linear^2), and the three categorical health system dimensions (coded with "Statal" as the reference level). Interaction terms between dimensions and time were included to test for divergent trends.
    • Transformation: The dependent variable was log-transformed to handle convex/exponential patterns and facilitate multiplicative interpretation.
  • Inference: Due to the limited number of higher-level units (22 countries), uncertainty was quantified using parametric bootstrapping (1,000 replicates) to derive standard errors and 95% confidence intervals.
  • Software: R version 4.3.1 (packages: lme4, emmeans, bootMer).

3. Key Results

• Descriptive Trends (2004–2023):
  • Growth: 15 of the 22 countries showed an increase in the share of preventive expenditure, with Compound Annual Growth Rates (CAGR) ranging from 0.2% to 3.7%.
  • Decline: 7 countries (Hungary, Ireland, Iceland, Poland, Portugal, Slovak Republic, Switzerland) experienced a decrease, with CAGR ranging from -6.3% to -0.2%.
  • Pandemic Effect: All countries exhibited a sharp spike in preventive spending in 2021 (attributed to COVID-19 vaccination and testing), followed by a sharp contraction in 2022–2023, returning to pre-pandemic levels.
• Regression Analysis Findings:
  • Financing & Provision: No statistically significant association was found between the type of actor (State, Societal, Private) responsible for financing or provision and the trajectory of preventive spending.
  • Regulation: A significant difference was observed in the regulation dimension.
    • Countries with Societal Regulation (e.g., Social Health Insurance models) exhibited a more pronounced curvilinear (quadratic) trend compared to those with State Regulation.
    • Coefficient: $b = 0.0035$ (95% CI: 0.0013, 0.0057).
    • Interpretation: Societal regulation systems showed a faster acceleration in the increase of preventive spending share over time, particularly during the pandemic period, compared to statal systems.
  • Overall Correlation: The study concludes there is no general correlation between the broad type of healthcare system model and the share of expenditure allocated to prevention.

4. Key Contributions

• Novel Classification: This is the first study to apply Böhm's multidimensional classification (Regulation, Financing, Provision) to analyze preventive spending trends, moving beyond the traditional Beveridge/Bismarck dichotomy.
• Longitudinal Scope: It covers a 20-year period (2004–2023), capturing pre-crisis, crisis (financial), and post-pandemic dynamics, providing a more robust view of trends than previous short-term studies.
• Methodological Rigor: The use of mixed-effects models with parametric bootstrapping addresses the statistical challenges of small-N panel data in cross-country comparisons.
• Decoupling Structure from Policy: The findings challenge the assumption that specific system structures (e.g., National Health Service vs. Social Insurance) inherently dictate higher investment in prevention.

5. Significance and Implications

• Policy Implications:
  • Investment in prevention is not intrinsically determined by the organizational structure of the healthcare system.
  • Instead, preventive spending responds to external factors: political priorities, economic conditions, and public health strategies.
  • Policymakers cannot rely on "system design" alone to ensure preventive investment; they must actively commit to targeted policies and political will.
• The "False Economy" of Cuts: The paper reinforces the argument that cutting preventive budgets for short-term savings is a "false economy." It highlights the high return on investment (median ROI of 14.3:1) and the negative long-term societal consequences (increased inequality, higher curative costs) of underfunding prevention.
• Pandemic Lessons: The rapid return to pre-pandemic spending levels after the 2021 spike suggests that healthcare systems missed an opportunity to institutionalize long-term preventive investments, viewing the pandemic response as an emergency measure rather than a catalyst for structural change.
• Future Research: The authors call for studies focusing on political and contextual determinants to better understand how to guide healthcare policy decisions toward sustained prevention funding.

Conclusion: The study demonstrates that while preventive spending trends vary significantly across Europe, these variations are driven more by political and contextual factors than by the fundamental typology of the healthcare system. Only the dimension of regulation (specifically societal vs. state) showed a distinct trajectory, suggesting that the governance of the system's rules, rather than its funding or delivery mechanisms, may influence the agility of preventive investment.