Applied Health Economics and Health Policy

, Volume 11, Issue 6, pp 639–652 | Cite as

Preferences on Policy Options for Ensuring the Financial Sustainability of Health Care Services in the Future: Results of a Stakeholder Survey

  • David TordrupEmail author
  • Aris Angelis
  • Panos Kanavos
Original Research Article



Universal access to health care in most western European countries has been a given for many decades; however, macroeconomic developments and increased pressure on health care budgets could mean the status quo cannot be maintained. As populations age, a declining proportion of economically active citizens are being required to support a larger burden of health and social care, while increasing availability of novel technologies for extending and improving life continues to push health care costs upwards. With health expenditure continuing to rise as a proportion of national income, concerns are raised about the current and future financial sustainability of Organisation for Economic Co-Operation and Development (OECD) health care systems. Against this backdrop, a discussion about options to fund health care in the future, including whether to raise additional health care finance (and the ways to do so), reallocate resources and/or ration services becomes very pertinent.


This study elicits preferences among a group of key stakeholders (payers, providers, government, academia and health-related industry) on the issue of health care financial sustainability and the future funding of health care services, with a view to understanding the different degrees of acceptability between policy interventions and future funding options as well as their feasibility.

Study Design and Participants

We invited 842 individuals from academia, other research organisations (eg. think tanks), national health services, providers, health insurance organisations, government representatives and health-related industry and related advisory stakeholders to participate in an online survey collecting preferences on a variety of revenue-generating mechanisms and cost/demand reducing policies. Respondents represented the 28 EU member states as well as Norway, Iceland, Switzerland, Australia, Russian Federation, Canada and New Zealand.


We received 494 responses to our survey from all stakeholder groups. Across all groups, the highest preference was for policies to modify lifestyle and implement more extensive screening within risk groups for high burden illnesses. There was a broad consensus not to reallocate resources from social security/education. Between stakeholders, there were differences of opinion between industry/advisory and a range of other groups, with industry being generally more in favour of market-based interventions and an increased role for the private sector in health care financing/delivery. Conversely, stakeholders from academia, government, national health services and insurance were relatively more in favour of more restrictive purchasing of new and expensive technologies, and (to varying extent) of higher income/corporate taxes. Taxes on cigarettes/alcohol were by far considered the most politically feasible option.


According to this study, policy options that are broadly acceptable across stakeholder groups with different inherent interests exist but are limited to lifestyle modification, screening interventions and excise taxes on harmful products. Representatives from the private sector tend to view solutions rooted in the private sector as both effective and politically feasible options, while stakeholders from academia and the public sector seem to place more emphasis on solutions that do not disproportionately impact certain population groups.


Gross Domestic Product National Health Service Stakeholder Group Policy Option User Charge 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We are grateful to the anonymous reviewers and editors for their valuable comments and insights. We also thank the participants of the “Recent trends and future challenges in the EU pharmaceutical P&R policies” session chaired by Anastasia Ventouri at the European Health Economics Conference, Zurich, July 2013, for useful feedback and comments.

Authors contributions

Panos Kanavos conceptualised and initiated the study. David Tordrup, Aris Angelis and Panos Kanavos designed the questionnaire. David Tordrup administered the questionnaire and analysed the data. David Tordrup created illustrations and wrote the paper, with input from Panos Kanavos. Panos Kanavos is the guarantor for the overall content.

Sources of funding and conflicts of interest

There are no sources of funding for this project. All authors declare that there are no conflicts of interest.


  1. 1.
    Olshansky SJ, Rudberg MA, Carnes BA, Cassel CK, Brody JA. Trading off longer life for worsening health: the expansion of morbidity hypothesis. J Aging Health. 1991;3(2):194–216.Google Scholar
  2. 2.
    Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980;303(3):130–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Lafortune G, Balestat G. Trends in severe disability among elderly people: assessing the evidence in 12 OECD countries and the future implications: OECD Publishing. 2007 Mar.Google Scholar
  4. 4.
    Meier V, Werding M. Ageing and the welfare state: securing sustainability. Oxford Rev Econ Policy. 2010;26(4):655–73.CrossRefGoogle Scholar
  5. 5.
    Weisbrod B. The health care quadrilemma: an essay on technological change, insurance, quality of care, and cost containment. J Econ Lit. 1991;29(2):523–52.Google Scholar
  6. 6.
    Hartwig J. What drives health care expenditure? Baumol’s model of ‘unbalanced growth’ revisited. J Health Econ. 2008;27(3):603–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Abel-Smith B. An international study of health expenditure and its relevance for health planning. Public Health Papers. 1967;32:1–127.PubMedGoogle Scholar
  8. 8.
    Gerdtham U-G, Søgaard J, Andersson F, Jönsson B. An econometric analysis of health care expenditure: a cross-section study of the OECD countries. J Health Econ. 1992;11(1):63–84.PubMedCrossRefGoogle Scholar
  9. 9.
    Parkin D, McGuire A, Yule B. Aggregate health care expenditures and national income: is health care a luxury good? J Health Econ. 1987;6(2):109–27.PubMedCrossRefGoogle Scholar
  10. 10.
    Baltagi BH, Moscone F. Health care expenditure and income in the OECD reconsidered: evidence from panel data. Econ Model. 2010;27(4):804–11.CrossRefGoogle Scholar
  11. 11.
    Appleby J. Rises in healthcare spending: where will it end? BMJ. 2012;345:e7127.Google Scholar
  12. 12.
    EC. Flash Eurobarometer 356. Public opinion in EU regions. European Commission; 2012 [cited 18 December 2012]; Available from:
  13. 13.
    Angelis A, Tordrup D, Kanavos P. Is the funding of socialised medical insurance sustainable over the long term? An analysis of 10 OECD countries. J Soc Policy. 2013; Submitted for consideration.Google Scholar
  14. 14.
    Mann H, Whitney D. On a test of whether one of two random variables is stochastically larger than the other. Ann Math Stat. 1947;18(1):50–60.CrossRefGoogle Scholar
  15. 15.
    Yach D. HCGCHKJ. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004;291(21):2616–22.Google Scholar
  16. 16.
    Dixon J. Social determinants of health. Health Promot Int. 2000;15(1):87–9.Google Scholar
  17. 17.
    Steinbrook R. Saying no isn’t NICE : the travails of Britain’s National Institute for Health and Clinical Excellence. N Engl J Med. 2008;359(19):1977–81.PubMedCrossRefGoogle Scholar
  18. 18.
    Thomson S, Mossialos E. Choice of public or private health insurance: learning from the experience of Germany and the Netherlands. J Eur Soc Policy. 2006;16(4):315–27.CrossRefGoogle Scholar
  19. 19.
    Creese AL. User charges for health care: a review of recent experience. Health Policy Plann. 1991;6(4):309–19.CrossRefGoogle Scholar
  20. 20.
    OECD. OECD.StatExtracts. Organisation for Economic Co-Operation and Development; 2012 [cited 2012 November]. Available from:
  21. 21.
    IMF. World economic outlook October 2012. International Monetary Fund; 2012 [cited 2012 November]. Available from:
  22. 22.
    World Bank Data. World Bank; 2012 [cited 2012 November]. Available from:

Copyright information

© Springer International Publishing Switzerland 2013

Authors and Affiliations

  1. 1.LSE HealthLondon School of Economics and Political ScienceLondonUK

Personalised recommendations