Health system models-an overview

Health Models And Health System Models
Dr. Ahmed-Refat AG Refat (Nov. 2012) www.SlideShare.net/AhmedRefat

Dr. Ahmed-Refat AG Refat
Taibah University – Nov. 2012
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Contents
Section One : Health Models
 Positive Vs Negative
 Preventive Vs Curative
 Biomedical Vs social
Section Two: Health Care systems
 Private vs Public
 Beveridge, Bismark,Private and Out-of-pocket models
 Tired vs Diffuse Care Model
 Outpatient Care and Hospitals
Global Health Care Systems
 UK – Canada, France, Germany, Japan & USA.

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Health Models
• Positive Health Model
State • Negative Health Model

• Biomedical Health Model
Determinants • Social Health Model

• Preventive Health Model
Care • Curative Health Model

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Health Models
(I)
The positive and negative models
of health

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1- The positive model of health
One of the best known of the positive definitions of health is that
of the World Health Organization. In defining health as:
"a state of complete physical, mental and social well-
being and not merely the absence of disease
or infirmity"
the World Health Organization has sought to broaden our view
of the nature of health status and therefore the responsibilities
of those who contribute in different ways to health care.

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Merits of The WHO definition of Health
 Recognizes the various aspects of health (physical,
mental and emotional)
 Draws attention to the fact that health affects every
sphere of life (work, rest and play)
 Incorporates a subjective element – how we feel about
our state of health.

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Limitations of the WHO' definition
 Too idealistic, in the sense that it conceptualizes good
health in such a way that it is unattainable – no one would
ever describe himself or herself as being in ‘a state of
complete physical, mental and social well-being’
 All-embracing and undifferentiated, since it seems to
imply that every positive aspect of life is an element of good
health
 Too generalized, with too little account being taken of the
 differences between individuals.
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Health in terms of the capacity
The Ottawa Charter defined health as a resource for doing

things—a capacity, not a state of well-being. According
to this definition, health must be clearly differentiated from
health status, because health has a dynamic potential for
increasing or at least maintaining whatever health status
(place on the spectrum) a person has. Health in this sense is a
means of moving toward the positive end of the health
status spectrum.

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Probably more than achieving some degree of health status,
people want health as a resource for doing the things they want
to do. That view of health characterizes the new era of health.
The goal is longevity with good function, and the challenge
to health professionals is not only preventing disease and
overcoming it when it occurs but also helping people to
achieve that goal.

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The new concept advanced in the Ottawa Charter—that health
is not a state of well-being but a resource for living—can be
measured in its physical (e.g., body mass index [BMI]), mental
(e.g., cognition), and social health dimensions (e.g., network of
friends and relatives). It also can be measured in terms of
health-related practices (e.g., exercise), because there is
evidence that, as a category of personal characteristics, health-
related practices are important resources for living that carry
great influence for future health
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2- The negative model of health
The negative model is based on the idea that health is the polar
opposite of disease. On the basis of this model, people are
deemed to be healthy if no trace of disease can be found,
regardless of how they feel or behave.

Conversely, if disease is detected, they are considered to be
unhealthy to varying degrees, regardless of whether or not they
regard themselves as unhealthy.

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Thus, unlike positive definitions of health, negative definitions
allow no room for subjectivity. They are essentially objective in
the sense that the presence or absence of disease is
established by scientific investigation.

With the advance of technology for the purposes of screening
and diagnosis, the detection of disease – and therefore the
assessment of health status from the point of view of the
negative model – becomes more sophisticated and relies less
and less on patient reporting.

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Which model predominates??
Which model predominates will be determined by a number of factors,
including:
 . the distribution of power between the various stakeholders, with
academics and some health care practitioners favoring positive
definitions and doctors favoring negative definitions
 . the stage of development of a health care system, with less
developed, simpler systems tending towards positive definitions and
more developed, complex systems tending towards negative
definitions
 . the particular circumstances of an individual case, with positive
definitions more likely to prevail in community settings and negative
definitions more likely to prevail in hospital settings.

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Health Models
(II)
The Biomedical and Social Models
of Health
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1- The biomedical model of health
There is a close affinity between the biomedical model and the
negative model of health. The basic idea is that the human
body is a machine made up of a number of parts/organs . As
such, any malfunction (such as disease) is an ‘engineering’
problem which is capable of being tackled by technical means.

The model has its origins in germ theory, which is particularly
associated with the pioneering work of Pasteur and Koch in the

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nineteenth century. This, in turn, gave rise to the doctrine of
specific aetiology: for every disease there is a single and
observable cause that can be isolated.

.
Against this, however, must be set a number of weaknesses:-
 Not everyone exposed to a causative agent will give in to
the disease.
 There appear to be many different causative agents
rather than a single one.

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2-The Social Model of Health
The social model can be seen, in part, as a reaction to the
limitations of the biomedical model. This model is closely linked
with positive definitions of health. In the social model the health
of individuals and communities is seen as the result of complex
and interacting social, economic, environmental and personal
factors.

A person’s optimum state of health is equivalent to the state of
the set of conditions which fulfill or enable a person to work to
fulfill his or her realistic chosen and biological potentials.

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Because of the range of its determinants, the potential for
allocating responsibility for ill-health is much greater. In the
case of biomedicine it has been easier to regard ill-health as an
‘act of God’ and therefore nobody’s fault.

By contrast, the social model gives rise to many possibilities for
apportioning blame and has resulted, on the one hand, in
‘victim blaming’ and, on the other, in pointing the finger at
deficiencies in public policy and the behavior of business and
industry.

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People are influenced and constrained by the social, economic
and physical environment in which they live and the
organizational setting within which they work.

Thus the failure of governments to provide adequate housing
may result in individual behaviour which is damaging to health
and can also lead directly to an increase in respiratory disease.

In short, the social model sees health primarily as an issue for –
and the responsibility of – society as a whole. Among other
things, this means a collective responsibility for ensuring that
individuals have every opportunity to adopt healthy lifestyles.

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By now it should be clear that the positive and
social models of health are more likely to lead to
an approach to health care in which top priority is
given to prevention.

Likewise, application of the principles of the
negative and biomedical models will result in a
curative approach.

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Health Models
(III)
The Preventive and Curative
Models of Health

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A- The Preventive Model of Health Care
Advocates of the preventive model:
. Give pride of place to measures designed to reduce the
incidence and prevalence of ill-health – for example,
promotional campaigns, ensuring that people have access to
the prerequisites for health (adequate housing, satisfactory diet,
etc.), screening, and vaccination and immunization

. Argue for what has come to be called ‘healthy public policy’
which means, in effect, making ‘healthy choices the easier
choices’ – for example, ensuring that healthy food is cheaper

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than unhealthy, and creating environments in which it is difficult
to smoke.

. Emphasize the importance of mobilizing a wide range of
agencies such as academic institutions, voluntary organizations
and local authorities, and tapping as many different sources of
expertise as possible, both professional and lay

. See community settings, such as the home, schools and
leisure centres, as the most significant locations for the
provision of health care

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. Stress the need for more epidemiological research, to
enhance our understanding of the links between disease
patterns and social factors in health and health care.

There are a number of drawbacks, however.

First, preventive strategies are more difficult to justify because
of the long-term nature of the outcomes and uncertainty
regarding their effectiveness.

For example, the effect of anti-smoking campaigns in primary schools
will not be felt for several years, during which time many other factors
will play a part in influencing people’s smoking behavior
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Second,
the collaboration necessary when several professional groups
and agencies are involved in planning and implementing a
preventive programme is extremely difficult to sustain in
practice and can easily lead to a dilution of responsibility.

Last,
prevention often raises people’s expectations to such an extent
that some will inevitably be disappointed. This is the case with
people who, despite their healthy lifestyle, getting heart
disease.

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B-The curative model of health care

Those who pledge the curative model take as their starting
point the insights provided by the biomedical model and
concentrate on measures designed to cure disease.
They:
. Give pride of place to what are called, in the colourful
language sometimes used in this context, ‘magic bullets’
(wonder drugs, heroic surgery, and other techniques)
. Focus on the treatment of individuals

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. Legitimize the central and dominant role played by clinicians
in the health care process
. Regard hospitals as the principal delivery point for health care
Services . place particular emphasis on research into the
biological causes of ill-health and methods for tackling the
malfunctions referred to earlier.

The overwhelming argument in favour of this approach is that
many diseases and conditions can be successfully treated
through the application of science and technology. Moreover, in
so doing, it has made a significant contribution to improving the
health status and well-being of many people.

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None the less, it is not without its drawbacks.
For many conditions, particularly those which are currently
major causes of morbidity, such as lung cancer, cures have
remained vague.
In addition, treatment is often very costly in financial terms and
carries with it risks, /‘iatrogenesis’ –
At the same time, the curative approach has made only a
limited contribution to improving the health status of the
population as a whole.
This is reflected, in part, in the increasing demand for health
services.

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Models of Health Care System

According to According to
Delivery Funding
Methods Methods

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Health System
According to Funding Types
All healthcare systems occupy a distinct place on the “public
versus private” continuum in terms of the financing and delivery of
healthcare . Although distinctions blur, most systems tend to
predominantly hold a (a) “national health service model,” (b)
“entrepreneurial model,” or (c) “mandated insurance model.”

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A• Under a national health service (e.g. the United Kingdom
and Spain), universal coverage is publicly financed through
taxation. Healthcare delivery occurs via mostly public
mechanisms; hospitals are publicly owned, and medical
services are primarily delivered by government-salaried
physicians .

B• In an entrepreneurial model of healthcare (e.g. the United
States), people voluntarily purchase employment-based or individual
insurance, and the healthcare delivery mechanisms (providers and
healthcare facilities) exist largely in the private sector. Financing can

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come from both private and public sources . Consumerist-
commercial-capitalist
C• Between these two extremes lies the mandated insurance
model, in which compulsory universal coverage is publicly
financed and health care is delivered by both public and private
entities . Within this category, systems can be further classified as
following a national health insurance/single-payer model (e.g.
Sweden) or a multi-payer health insurance model that relies on
sickness funds to provide universal health coverage (e.g. Germany
and France) .

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Another Classification

Health Systems Based on
the Sources of Funding

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Based on the source of their funding, three main models of
national healthcare systems can be distinguished:

1. the Beveridge model,
2. the Bismarck model
3. the Private Insurance model

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1-The Beveridge Model
"Public Model" - “Socialized Medicine Model”

The Beveridge "public" model was inspired by the William Beveridge
Report for social insurance presented in the English Parliament in 1942.

Funding is based mainly on taxation and is characterized by a centrally
organized National Health Service where the services are provided by
mainly public health providers (hospitals, community GPs, specialists and
public health services).

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In this model, healthcare budgets compete with other spending priorities.
The countries using this model, beside United Kingdom, are Ireland, Sweden,
Norway, Finland, Denmark, Spain, Portugal, Italy, Greece, Canada and
Australia.
Characteristics:
 Healthcare is provided and financed by the government,
through tax payments
 There are no medical bills
 Medical treatment is a public service
 Providers can be government employees
 Lows costs b/c the government controls costs as the sole
payer

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2-The Bismarck Model
"Mixed Model" - “Sickness Funds”

The Bismarck „mixed” model was inspired by the 1883 Germany
Social Legislation and National Health Insurance Plan for workers
introduced by Otto von Bismark, the Chancellor of Germany. Funds
are provided mainly by premium-financed social/mandatory insurance
and, beside Germany, is found in countries such as France,
Switzerland, Japan, Central and South East European (CSEE)

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countries and Former Soviet Union (FSU) countries. Also Japan has
a premium-based mandatory insurance funds system. This model
results in a mix of private and public providers, and allows more
flexible spending on healthcare.
Characteristics:
 Providers and payers are private
 Private insurance plans – financed jointly by employers and
employees through payroll deduction
 The plans cover everyone and do not make a profit
 Tight regulation of medical services and fees (cost control)

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3-The Private Insurance Model

The „private” insurance model is also known as the model of
„independent customer”. Funding of the system is based on
premiums, paid into private insurance companies, and in its pure form
actually exists only in the USA.
In this system, the funding is predominantly private, with the
exception of social care through Medicare and Medicaid. The great
majority of providers in this model belong to the private sector.

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4-(!) Out-of-Pocket Model
There is also a 4 th type of health system ( No System !!!!) called
" the out-of-pocket-model!!!

Only the developed, industrialized countries -- perhaps 40 of
the world's 200 countries -- have established health care systems.
Most of the nations on the planet are too poor and too disorganized to
provide any kind of mass medical care. The basic rule in such
countries is that the rich get medical care; the poor stay sick or die.

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In rural regions of Africa, India, China and South America, hundreds
of millions of people go their whole lives without ever seeing a doctor.
They may have access, though, to a village healer using home-
brewed remedies that may or not be effective against disease.

Characteristics:
 Only the rich get medical care; the poor stay sick or die
 Most medical care is paid for by the patient, out-of-pocket
 No insurance or government plan

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What is the best System?
All models of health care systems are imperfect and there is
no a odel which is the best and broadly accepted and
recommended. There are big differences among countries in
relation to the goals, structure, organization, finance and the
other characteristics of the health care systems.
These differences are influenced by history, traditions,
socio-cultural, economic, political and other factors. But,
regardless of all present differences, there are same common
characteristics, typical for all organized health care systems

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Health Care Delivery System
There is no perfect healthcare delivery system for a country.

Some models seem to work better than others but each has its own
advantages and drawbacks.

Broadly, healthcare delivery models could be classified under
tiered system or diffuse system.

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a- The Tiered System
The tiered system is made up of regionalized systems of healthcare
delivery divided into Primary care, Secondary care and Tertiary
care. Such a pyramidal system is more common in UK and in HMOs
(Health Maintenance Organizations) in US.

a- Primary care
Refers to the activities concerned with prevention and treatment of
common medical problems in outpatient setting. Care is delivered by
primary care practitioners (PCPs) in the US or general practitioners

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(GPs) in the UK. A PCP could be responsible for 2000-3000 patients
and is responsible for managing patient’s overall care.
b- Secondary care
Concerns with treatment of disorders requiring specialist
opinion or hospitalization. The patients are usually referred from
Primary care and the physicians are affiliated to a hospital or a
group practice.
c- Tertiary care
Provides medical and/or surgical management of complex
disorders in an inpatient setting and usually requiring
collaboration between multiple specialties. These are super-
specialized standalone hospitals or specialty departments in a
multi-specialty hospital.

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Self Care ( Nonprofessional care ):
Self care is nonprofessional care. It is performed within the
family, and the population group counts from one to 10 persons.

Self-care implies largely unorganized health activities and health-
related decision-making carried out by individuals, families,
neighbors, friends and workmates. These include the maintenance of
health, prevention of disease, self-diagnosis, self-treatment, including
self-medication, and self-applied follow- up care and social support to
the sick and weak members of the family after contact with the health
services

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b- Diffuse System
In the diffuse system there is no such division. In this system patients
can directly approach specialists without consulting GPs or PCPs
first. The boundaries between GPs, internists, family practitioners and
pediatricians are blurred. Many internal medicine specialists provide
primary care, many family practitioners provide secondary care.
The diffuse system is the relatively more common in United States. It
is a diamond type of system with most hospitals providing a mix of
multi-specialty secondary and tertiary services. The stress is on
getting the latest technology and advanced clinical care closer to
home.

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Outpatient Care

Outpatient care is very important part of the health care system
representing the first contact of the consumer with the
professional health care and the first step of a continuous
health care.
Such kind of services and institutions might be a part of the
hospital, community health center or certain polyclinic

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and dispensaries In-patient care and institutions

In-patient/hospital care means admission into hospital or other
stationary health organization, including diagnosis, treatment
and rehabilitation, with in-patient care and treatment of the most
severely ill patients who cannot be treated in ambulatory-
polyclinic institutions or at home.

Hospitals are institutions whose primary function is to provide
diagnostic and therapeutic medical, nursing, and other

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professional services for patients in need of care for medical
conditions. Hospitals have at least six beds, an organized staff
of physicians, and continuing nursing services under the
direction of registered nurses. The WHO considers an
establishment a hospital if it is permanently staffed by at least
one physician, can offer in-patient
accommodation, and can provide active medical and nursing
care .

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Classification of hospitals
Hospitals are classified in several ways: length of stay, type of
service, and type of control or ownership, as well as size of the
hospital
Length of stay is divided into acute care (short term) and
chronic care (long term). Acute care (of short duration or
episodic) is a synonym for short term. Chronic care (or long
duration) is a synonym for long term hospitals.

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Types of service denote whether the hospital is „general” or
„special”.

A third classification divides hospitals by type of control or

ownership: for profit (investor owned), or not for profit,
governmental (federal, state, local, or hospital authority),
religious or voluntary organizations.

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International
Health Care Systems

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GREAT BRITAIN
 Insured :100% of population insured
 Spending:7.5% of GDP
 Funding
—Single payer system funded by general revenues
(National Health System); operates on huge deficit
 Private Insurance
—10% of Britons have private health insurance
—Similar to coverage by NHS, but gives patients access to
higher quality of care and reduce waiting times
 Physician Compensations
—Most providers are government employees

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 Physician Choice
—Patients have very little provider choice
 Copayment/Deductibles
—No deductibles
—Almost no copayments (prescription drugs)
 Waiting Times
—Huge problem
 Benefits Covered
—Offers comprehensive coverage
—Terminally ill patients may be denied treatment

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CANADA
 Insured
—Single payer system – 100% insured
—Each province must make insurance:
 Universal (available to all)
 Comprehensive (covers all necessary hospital
visits)
 Portable (individuals remain covered when
moving to another province)
 Accessible (no financial barriers, such as
deductible or copayments)


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 Funding
—Federal government uses revenue to provide a block
grant to the provinces (finances 16% of healthcare)
—The remainder is funded by provincial taxes (personal
and corporate income taxes)
 Spending
—9% of GDP
—At one time all private insurance was prohibited;
changed in 2005
—Many private clinics now offer services on the black
market
 Physician Compensation

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—Physicians work in private practice
—Paid on a fee-for-service basis
—These fees are set by a centralized agency; makes
wages fairly low
—Referrals are required for all specialist services except
the ED
—Generally no copayments or deductibles
—Some provinces do charge insurance premiums
 Waiting Times
—Long waiting lists
—Many travel to the U.S. for healthcare

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FRANCE
• Insured
– About 99% of population covered
• Cost
rd
– 3 most expensive health care system
– 11% of GDP
• Funding
– 13.55% payroll tax (employers pay 12.8%, individuals
pay 0.75%)
– 5.25% general social contribution tax on income
– Taxes on tobacco, alcohol and pharmaceutical company
revenues

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• Private Insurance
– “more than 92% of French residents have
complementary private insurance”
– These funds are loosely regulated (less than U.S.); the
only requirement is renewability
– These benefits are not equally distributed (creates a two-
tiered system)
• Physician Compensation
– Providers paid by national health insurance system
based on a centrally planned fee schedule – fees are
based on an upfront treatment lump sum (similar to
DRGs in US)

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– However, doctors can charge whatever they want
– The patient or the private insurance makes up the
difference
– Medical school is free
– Legal system is fairly tort averse
• Physician Choice
– Fair amount of choice in the doctors they choose
• Copayment/Deductible
– 10% to 40% copayments
•

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• Waiting Times
– Very little waiting lists/times
• Technology
– Government does not reimburse new technologies very
generously
– Little incentive to make capital investments in medical
technology

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GERMANY
• Insured
– 99.6% of population – sickness funds
– Those with higher incomes can buy private insurance
– The federal gov. decides the global budget and which
procedures to include in the benefit package
• Funding
– Sickness funds are financed through a payroll tax (avg.
15% of income)
– The tax is split between the employer and employee
• Private insurance
–

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– 9% of Germans have supplemental insurance; covers
items not paid for by the sickness funds
– Only middle- and upper-class can opt out of sickness
funds
• Physician Compensation
– Reimbursement set through negotiation with the
sickness funds
– Providers have little negotiating power
– Very low compensation
– Significant reimbursement caps and budget restrictions
—Almost no copayments or deductibles

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 Technology
—Low technology compared to U.S.
 Waiting Times
—WHO reported that “waiting lists and explicit rationing
decisions are virtually unknown”
 Benefits Covered
—There is an extensive benefit package which even
includes sick pay (70% to 90% of pay) for up to 78
weeks

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JAPAN
 Insured
—Universal health insurance based around a mandatory,
employment-based insurance
—“The Employee Health Insurance Program” requires that
all companies with 700 or more employees to provide
workers with health insurance
—Small business workers join a government-run small
business national health insurance plan
—The self-employed and the retired are covered by
Citizens Insurance Program administered by municipal
governments

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
 Costs
—Not as high as U.S.; average household spends $2300
per year on out-of-pocket costs
—Japans have a healthy lifestyle – lower incidence of
disease
 Funding
—8.5% (large business) or an 8.2% (small business)
payroll tax
—Payroll taxes are split almost evenly between employer
and employee
—Those who are self-employed or retired must pay a self-
employment tax

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—Very rare for Japanese to use this; less than 1%
 JAPAN
 Physician Compensation
—Hospital physicians are salaried
—Non-hospital physicians are paid on a fee-for-service
basis
—Hospitals and clinics are privately owned but the
government sets the fee schedule
—No restrictions on physician or hospital choice
—No referral requirements

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—Copayments are 10% to 30%
—Capped at $677 per month for the average family
 Technology
—High levels of technology; comparable to U.S.
 Waiting Times
—Significant problem at the best hospitals b/c they cannot
charge higher prices
 Comparison of Global Healthcare by Rand Corporation
 UNIVERSAL LAWS OF HEALTHCARE SYSTEMS
 No matter how good the healthcare in a particular country
people will complain about it
 No matter how much money is spent on healthcare, the
doctors and hospitals will argue that it is not enough

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 The last reform always failed
- Tsung-mei Cheng,
an American economist
 5 MYTHS ABOUT HEALTH CARE
AROUND THE WORLD
1. It’s all socialized medicine out there
 Many countries provide universal coverage
using private providers, hospitals and insurance
plans
2. Overseas, care is rationed through limited choices or long
lines – some truth.
3. Foreign health systems are inefficient, bloated
bureaucracies

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4. Cost control stifles innovation
 False. This pressure to control cost can
generate innovation
5. Health insurance companies have to be cruel
 Insurance plans in other countries accept all
applicants
 Cannot deny on the presence of a preexisting
condition
 Cannot cancel as long as you pay your
premium
 U.S. HEALTHCARE: COST DRIVERS
 Drugs and devices
 Defensive medicine

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 Demands
—Patient related
—Physician related---? Fee for service!
 Administrative costs
 Market driven healthcare
 COST MANAGEMENT
 Evidence based medicine
 Use of protocol and guidelines
 Reduction of administrative costs
 Managing demand
 Management of chronic diseases
 Promotion of healthier living
 Tort Reform

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U.S.A
In United States, the healthcare administration is largely
outside the governmental control. This leaves hospital
capacity regulation, residency seat allocation and
coordination of care in the hands of private entities.

The physician groups control the policy, occupational
standards and entry requirements for licensing. So their
professional interests and favor for technology and inpatient
capacity also led to expansion of hospital facilities.

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Over the last few decades, the healthcare has
increasingly been delivered at hospitals rather than physician
offices. With emerging consumer driven healthcare models
and advanced surgical techniques, there is a gradual shift
towards Ambulatory Clinics. This will introduce newer models
of healthcare delivery.

 The United States has a unique system of health
care delivery.
 The US health care delivery system is complex
and massive.
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 In contrast to the United States, most
developed countries have national health
insurance programs
 referred to as “universal access”
• provide routine and basic health care
• run by the government and financed
through general taxes.
 All Americans are not “entitled” to routine
and basic health care services.


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 187.4 million Americans have private health
insurance coverage,
 Health insurance can be bought from:
 1,000 health insurance companies
 70 BlueCross/BlueShield plans
 The managed care sector includes
approximately: 540 licensed health maintenance
organizations (HMOs) 925 preferred provider
organizations (PPOs)

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Vulnerable Populations
 Particularly the poor, uninsured, minorities
and immigrants
 live in disadvantaged communities and
receive care from “safety net” providers.
Vulnerable Populations
 Safety nets are not secure
 Provider type and availability vary
 Some individuals give up care and seek
hospital emergency services if nearby

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Characteristics Of The U.S. Health Care System
 No Central Governing Agency;
 Little Integration and Coordination
 Technology-Driven and Focuses on Acute
Care
 High on cost, Unequal in Access, and Average in
Outcomes
 Imperfect Market Conditions
 Government as Subsidiary to the Private Sector
 No Central Governing Agency;
 Little Integration and Coordination

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The US system is different from other
developed countries
 It is not centrally-controlled
• Central systems are less complex, less
costly
 Has different payment, insurance, and
delivery mechanisms
 Health care is financed both publicly and
privately
 Technology-Driven and Focuses on Acute Care

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What is good about USA system?
 US is responsible for more than 53% of Drug Research
Dollars
 Best Medical Education and Training in the World
 Eight of the top 10 medical Advances in the past 20 years was
developed in the US
 Nobel Prizes in Medicine have been awarded to more
Americans than to researchers in all other countries combined
 Eight of the 10 top-selling drugs are made in the US
 We have the highest breast, colon, and prostate cancer
survival rates in the world

84


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1. WHO. Measurement of Levels of Health. Geneva, Switzerland: WHO; 1957.
2. World Health Organization (WHO), European Regional Office. Ottawa Charter
for Health Promotion. Copenhagen, Denmark: WHO; 1986.
3. Lester Breslow, Health Measurement in the Third Era of Health. Am J Public
Health. January; 96(1): 17–19. 2006
4. Elizabeth A. www.ololcollege.edu
5. HEALTH SYSTEMS AND THEIR EVIDENCE BASED DEVELOPMENT. VESNA
BJEGOVI] AND DON^O DONEV(editor). Hans Jacobs Publishing Comany2004
6. Roger Ottewill and Ann Wall . Models of health and health care. Crwon
2004
7. Sibu Saha, HEALTHCARE MODELS ACROSS THE GLOBE
A COMPARATIVE ANALYSIS. Harvard University

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