National health systems and policies

Evidence does not support pro-market health policies and reforms. Here are some (care quality, care accessibility, efficiency) clues derived from a comparison of commercial and publicly oriented health systems.

In Low and Middle Income Countries, we gathered a large array of clues spanning from clinical care to disease control programmes.  


International Health and Aid Policies. Editors: J.-P.Unger, P.De Paepe, K.Sen, W.Soors. Cambridge University Press, 2010 (275 pages).


A review of the same book: Journal of American Medical Association (JAMA) by David Chinitz, PhD. JAMA. 2012; 308(8): 819-820


In High Income Countries, we compared the performance of countries with mandatory private health insurance schemes to the other OECD countries


Unger, J.-P., & De Paepe, P. (2019). Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency? International Journal of Health Services, 49(3), 431–456.


In Latin America, we compared the operations and productivity of health systems that diverged in terms of marketization.


Colombia, a good student by international standards, had a quite poor health record


De Groote T., De Paepe P., Unger J.-P. Colombia: in vivo test of health sector privatization in the developing world. International Journal of Health Services 2005;35(1): 125–141.


Ingrid Vargas; Amparo Susana Mogollon-Perez; Pierre De Paepe; Maria Rejane Ferreira da Silva; Jean-Pierre Unger; Maria-Luisa Vazquez. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy and Planning 2016; doi: 10.1093/heapol/czv126


Ingrid Vargas, Irene Garcia-Subirats, Amparo Susana Mogollón-Pérez, Pierre De Paepe, Maria Rejane Ferreira da Silva, Jean-Pierre Unger, M.B. Aller, María Luisa Vázquez; Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Health Policy Plan 2017; 32 (4): 549-562. doi: 10.1093/heapol/czw168


Garcia-Subirats I, Ingrid I Vargas, Amparo Susana A.S. Mogollón, Pierre J De Paepe, Rejane R Ferreira da Silva, Pierre P Unger, Carme C Borrell and María Luisa ML Vázquez. Inequities in access to health care in different health systems. A study in municipalities of central Colombia and north-eastern. Brazil International Journal of Equity in Health. International Journal for Equity in Health 2014;13(10):1-15.


Garcia-Subirats I, Ingrid Vargas, Amparo Susana Mogollón, Pierre De Paepe, Maria Rejane Ferreira da Silva, Jean Pierre Unger, María Luisa Vázquez. Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Social Science & Medicine 2014; 106C:204-13.


Vargas I, JP Unger, A Mogollon, ML Vazquez. Effects of managed care mechanisms on access to healthcare: results from a qualitative study in Colombia. Int J Health Plan Manag 2013;28(1):e13-e33


The public services of Chile covered 84% of the population with half of the country’s expenditure on health. With this half, Chile managed to make the country a positive outlier on most health indicators related to health care. Efficiency of public services but no social justice….


Unger J.-P., De Paepe P., Arteaga Herrera O., Solimano Cantuarias G. Chile’s Neoliberal Health Reform: An Assessment and a Critique. PLoS Medicine 2008; 5(4) e79: 0001-0006.


Finally, in 2002, the US and Costa Rica, with its heterodox policy, had similar demographic and epidemiologic characteristics … while Costa Rica was spending 9 times less per capita than the US on health. We established the probable, causal relationship between health systems performance and the health services characteristics.


Unger J.-P., De Paepe P., Buitrón R., Soors W. Costa Rica: Achievements of a heterodox health policy. American Journal of Public Health 2008; 98(4): 636-643.


Not only hasn’t the WHO promoted the Costa Rican model instead of the US one, but UN agencies, and in particular the World Bank undermined its performance while promoting managed care techniques in Costa Rican public services. 


W.Soors, P.De Paepe, JP Unger. Management commitments and primary care: another lesson fro Costa Rica for the World? International Journal of Health Services, Volume 44, Number 2, Pages 337–353, 2014

We studied health regulation and control as they have a special function in pro-market policy speech. The Rockefeller Foundation, for instance, says that regulation and control can tame inequity admittedly attached to care commoditization. The Foundation even  admits that without regulation and control, privatization of services cannot produce equity in access to care. See G.Lagomarsino, S Nachuk, S Singh Kundra. Public stewardship of private providers in mixed health systems. Synthesis from the Rockefeller Foundation. Results for Development Institute. . Washington DC, 2009.


Here are theoretical and empirical reasons to believe that although needed, regulation and control can only achieve limited impact on improving access to and quality of care when it is commoditized.  


Shuftan C, JP Unger. The Rockefeller Foundation’s “Public Stewardship of Private Providers in Mixed Health Systems”: A Point-by-Point Critique: Social Medicine, Vol 6, No 2 (2011): 128-136


Empirical observations in China, India and Vietnam show how and why (maternal) care regulation and control are destined to be ineffective in LMICs – e.g. because of weak governance, medical secrecy and conflicts of interest related to physicians’ dual employment.


Jean-Pierre Unger, Patrick Van Dessel, Casper van der Veer, Sarah Shelmerdine (2012) Maternal health regulations in Vietnam, India and China. A comparison across case studies and countries. Deliverable 5.1. HESVIC project ‘Health system stewardship and regulation in Vietnam, India and China’. Institute of Tropical Medicine, Antwerp. A project financed by the European Commission. 154 pages,


While the international policy substituted public health programs to individual care delivery in LMICs public services, it drastically restricted access to care, provoking thereby suffering, avoidable mortality, political instability and international migrations (that Europeans and Americans seem to fear so much).

Unger, JP., Morales, I. & De Paepe, P. Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market.BMC Health Serv Res 20,1072 (2020).

Note that this article also gives tips on methodologies in health policy. The analysis of international health policies is based on the evaluation of national healthcare policies. The research of national health policies is based on the study of health care delivery and management, and disease control. Our policy research was inductive in essence.

Other aspects of international health policies, in particular regarding disease control programmes, are discussed in the 'Development Cooperation' section.