Voir page 758 le resume en francais. En la pagina 759 figura un resumen en espanol.
In most respects the problems faced by health systems in countries of the Organisation for Economic Co-operation and Development (OECD) are less severe than those in other countries. The 29 Member Countries of the OECD are industrialized countries with high or middle per capita incomes. On average their populations enjoy a relatively high health status. Their economies, for the most part, support adequate or more than adequate levels of health expenditure. Moreover, most OECD countries have organized the financing of their health care systems in such a way that the healthy support the sick, the young support the old, and the rich support the poor.
On the demand side of health systems, people who reach old age tend to become sick as they become older. A high proportion of total health expenditure in OECD countries is devoted to patients who are within two years of death. Affluence can encourage unhealthy habits and pose threats to health, not least via side-effects on the environment. Some groups in OECD countries, for instance the unemployed and the poor, tend to be excluded from the general health advances enjoyed by the majority or do not benefit to the same extent. Meanwhile, among the majority, rising standards of living, a growing cascade of new medical technologies and increasing consumerism raise expectations about what can and should be clone to improve health protection and alleviate the remaining burden of disease.
On the supply side, economic growth and technological changes tend to raise the relative cost of protecting public health and of supplying populations with personal medical care and the latest medical advances. Mainly for reasons of equity the governments of most OECD countries have become heavily involved in the regulation, financing and sometimes the provision of medical care. Consequently, the problem of reconciling rising demand and increasing costs falls mainly in the public sector. It follows that most, if not all, OECD governments carry heavy, responsibilities for achieving, or continuing to achieve, good performance (1) in their health systems.
Achievements of OECD health systems
Over the past 35 years the average life expectancy at birth in the Member Countries of the OECD has increased by about eight years for women and seven years for men. Fig. 1 shows trends in average life expectancy for men and women in 13 OECD countries during the period 1960-96. The increase was largely attributable to a halving in years of life lost before the age of 70. In recent years the threat of an AIDS epidemic, which might have interrupted or reversed some of the gains in life expectancy, has been contained.
[Figure 1 ILLUSTRATION OMITTED]
There has been much debate about whether improved life expectancy has been offset by increasing morbidity, particularly among the elderly. Evidence from household surveys in some OECD countries indicates that the contrary is true. Morbidity, in the form of severe disability, seems to have been declining for some years in the majority of OECD countries for which data are available, at least in the :younger age groups among the elderly (2).
The gains in health status are not solely attributable to improvements in health care and public health. Increasing educational status and rising standards of living over several generations may have been more important. Nevertheless, multiple regression analysis of the determinants of premature mortality suggests that, in addition to such factors, increases in numbers of physicians per capita, admissions to hospital and real expenditure on pharmaceuticals have all been associated significantly with falling premature mortality (3, 4).
There is only limited evidence as to whether health systems in OECD countries achieve the goal of being responsive to the legitimate expectations of their populations. …