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Integration vs separation in the provision of health care: 24 OECD countries compared

  • Federico Toth (a1)


This article proposes a classification of the different national health care systems based on the way the network of health care providers is organised. To this end, we present two rivalling models: on the one hand, the integrated model and, on the other, the separated model. These two models are defined based on five dimensions: (1) integration of insurer and provider; (2) integration of primary and secondary care; (3) presence of gatekeeping mechanisms; (4) patient’s freedom of choice; and (5) solo or group practice of general practitioners. Each of these dimensions is applied to the health care systems of 24 OECD countries. If we combine the five dimensions, we can arrange the 24 national cases along a continuum that has the integrated model and the separated model at the two opposite poles. Portugal, Spain, New Zealand, the UK, Denmark, Ireland and Israel are to be considered highly integrated, while Italy, Norway, Australia, Greece and Sweden have moderately integrated provision systems. At the opposite end, Austria, Belgium, France, Germany, the Republic of Korea, Japan, Switzerland and Turkey have highly separated provision systems. Canada, The Netherlands and the United States can be categorised as moderately separated.


Corresponding author

*Correspondence to: Federico Toth, Dipartimento di Scienze Politiche e Sociali, Strada Maggiore, 45, Bologna 40125, Italy. Email:


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Amelung, V, Stein, V, Goodwin, N, Balicer, R, Nolte, E and Suter, E (eds) (2017) Handbook Integrated Care. Cham: Springer.
Bazzoli, GJ, Shortell, SM, Dubbs, N, Chan, C and Kralovec, P (1999) A taxonomy of health networks and systems: bringing order out of chaos. Health Services Research 33(6): 16831717.
Blank, RH, Burau, V and Kuhlmann, E (2018) Comparative Health Policy. Basingstoke: Palgrave-Macmillan.
Böhm, K, Schmid, A, Götze, R, Landwehr, C and Rothgang, H (2013) Five types of OECD healthcare systems: empirical results of a deductive classification. Health Policy 113(3): 258269.
Burns, L and Pauly, M (2002) Integrated delivery networks: a detour on the road to integrated health care? Health Affairs 21(4): 128143.
Calnan, M, Hutten, J and Tiljak, H (2006) ‘The challenge of coordination: the role of primary care professionals in promoting integration across the interface’ in R Saltman, A Rico and W Boerma (eds) Primary Care in the Driver’s Seat? Organizational Reform in European Primary Care. Maidenhead: Open University Press, 85104.
Conrad, D and Shortell, S (1996) Integrated health systems: promise and performance. Frontiers of Health Services Management 13(1): 340.
Damiani, G, Silvestrini, G, Federico, B, Cosentino, M, Marvulli, M, Tirabassi, F and Ricciardi, W (2013) A systematic review on the effectiveness of group versus single-handed practice. Health Policy 113(1-2): 180187.
De Pietro, C, Camenzind, P, Sturny, I, Crivelli, L, Edwards-Garavoglia, S, Spranger, A, Wittenbecher, F and Quentin, W (2015) Switzerland: health system review. Health Systems in Transition 17(4): 1288.
Delnoij, D, Van Merode, G, Paulus, A and Groenewegen, P (2000) Does general practitioner gatekeeping curb health care expenditure? Journal of Health Services Research & Policy 5(1): 2226.
Delnoij, D, Klazinga, N and Glasgow, K (2002) Integrated care in an international perspective. International Journal of Integrated Care 2(1): 14.
European Commission (2017) State of Health in the EU: Companion Report 2017. Luxembourg: Publications Office of the European Union.
Evans, J, Baker, R, Berta, W and Barnsley, J (2013) The evolution of integrated health care strategies. Advances in Health Care Management 15: 125161.
Field, MG (1973) The concept of the ‘health system’ at the macrosociological level. Social Science & Medicine 7(10): 763785.
Fierlbeck, K (2011) Health Care in Canada. Toronto: University of Toronto Press.
Frenk, J and Donabedian, A (1987) State intervention in medical care: types, trends and variables. Health Policy and Planning 2(1): 1731.
Gillies, R, Shortell, S, Anderson, D, Mitchell, J and Morgan, K (1993) Conceptualizing and measuring integration: findings from the health systems integration study. Hospital & Health Services Administration 38(4): 467486.
Goodwin, N, Stein, V and Amelung, V (2017) ‘What is integrated care?’ in V Amelung, V Stein, N Goodwin, R Balicer, E Nolte and E Suter (eds), Handbook Integrated Care. Cham: Springer, 323.
Kodner, D (2009) All together now: a conceptual exploration of integrated care. Healthcare Quarterly 13: 615.
Kodner, D and Spreeuwenberg, C (2002) Integrated care: meaning, logic, applications, and implications – a discussion paper. International Journal of Integrated Care 2(14): 16.
Kringos, D, Boerma, W, Hutchinson, A and Saltman, R (2015) Building Primary Care in a Changing Europe. Copenhagen: WHO Regional Office for Europe.
Kroneman, M, Maarse, H and van der Zee, J (2006) Direct access in primary care and patient satisfaction. Health Policy 76(1): 7279.
Kroneman, M, Boerma, W, van den Berg, M, Groenewegen, P, de Jong, J and van Ginneken, E (2016) The Netherlands: health system review. Health Systems in Transition 18: 1239.
Lee, SL, Chun, CB, Lee, YG and Seo, NK (2008) The National Health Insurance system as one type of new typology: the case of South Korea and Taiwan. Health Policy 85(1): 105113.
Marchildon, G (2013) Canada: health system review. Health Systems in Transition 15(1): 1179.
McDaid, D, Wiley, M, Maresso, A and Mossialos, E (2009) Ireland: health system review. Health Systems in Transition 11(4): 1268.
Mossialos, E, Dixon, A, Figueras, J and Kutzin, J (2002) Funding Health Care: Options for Europe. Buckingham: Open University Press.
Mossialos, E, Osborn, R, Sarnak, D and Wenzl, M (2016) International Profiles of Health Care Systems. New York: The Commonwealth Fund.
OECD (1987) Financing and Delivering Health Care: A Comparative Analysis of OECD Countries. Paris: Organisation for Economic Cooperation and Development.
OECD (2004) Proposal for a Taxonomy of Health Insurance. Paris: Organisation for Economic Cooperation and Development.
OECD (2016) Health Systems Characteristics Survey. Paris: Organisation for Economic Cooperation and Development.
Reibling, N and Wendt, C (2012) Gatekeeping and provider choice in OECD healthcare systems. Current Sociology 60(4): 489505.
Rico, A, Saltman, R and Boerma, W (2003) Organizational restructuring in European health systems: the role of primary care. Social Policy & Administration 37(6): 592608.
Robinson, J and Casalino, L (1996) Vertical integration and organizational networks in health care. Health Affairs 15(1): 722.
Roemer, M (1960) Health departments and medical care – a world scanning. American Journal of Public Health 50(2): 154160.
Rosen, B, Waitzberg, R and Merkur, S (2015) Israel: health system review. Health Systems in Transition 17(6): 1212.
Rothgang, H, Cacace, M, Frisina, L, Grimmeisen, S, Schmid, A and Wendt, C (2010) The State and Healthcare: Comparing OECD Countries. Basingstoke: Palgrave Macmillan.
Rothgang, H, Cacace, M, Grimmeisen, S and Wendt, C (2005) The changing role of the state in healthcare systems. European Review 13(S1): 187212.
Sagan, A, et al. (2011) Poland: health system review. Health Systems in Transition 13(8): 1193.
Saltman, R and Figueras, J (1998) Analyzing the evidence on European health care reforms. Health Affairs 17(2): 85108.
Saltman, R, Rico, A and Boerma, W (eds) (2006) Primary Care in the Driver’s Seat? Organizational Reform in European Primary Care. Maidenhead: Open University Press.
Shortell, SM, Gillies, RR and Anderson, DA (1994) The new world of managed care: creating organized delivery systems. Health Affairs 13(5): 4664.
Shortell, SM, Gillies, RR, Anderson, DA, Erickson, KM and Mitchell, JB (2000) Remaking Healthcare in America: The Evolution of Organized Delivery Systems. San Francisco: Jossey-Bass.
Starfield, B (1998) Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford University Press.
Starfield, B, Shi, L and Macinko, J (2005) Contribution of primary care to health systems and health. The Milbank Quarterly 83(3): 472502.
Suter, E, Oelke, N, Adair, C, Waddell, C, Armitage, G and Heubner, LA (2007) Health Systems Integration. Definitions, Processes and Impact: A Research Synthesis. Edmonton: Alberta Health Services.
Terris, M (1978) The three world systems of medical care: trends and prospect. American Journal of Public Health 68(11): 11251131.
Thaldorf, C and Liberman, A (2007) Integration of health care organizations. The Health Care Manager 26(2): 116127.
Toth, F (2010) Healthcare policies over the last 20 years: reforms and counter-reforms. Health Policy 95(1): 8289.
Toth, F (2016) Classification of healthcare systems: can we go further? Health Policy 120(5): 535543.
Valentijn, PP, Schepman, SM, Opheij, W and Bruijnzeels, MA (2013) Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care 13: e010.
Victoor, A, Delnoij, D, Friele, R and Rademakers, J (2012) Determinants of patient choice of healthcare providers: a scoping review. BMC Health Services Research 12(1): 272.
Weber, M (1922) Wirtschaft und Gesellschaft. Tübingen: Mohr.
Wendt, C (2009) Mapping European healthcare systems: a comparative analysis of financing, service provision and access to healthcare. Journal of European Social Policy 19(5): 432445.
Wendt, C, Frisina, L and Rothgang, H (2009) Healthcare system types: a conceptual framework for comparison. Social Policy & Administration 43(1): 7090.
WHO (2008) The World Health Report 2008. Primary Health Care – Now More Than Ever. Geneva: World Health Organization.


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Integration vs separation in the provision of health care: 24 OECD countries compared

  • Federico Toth (a1)


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