Comparative studies serve as a valuable but idiosyncratic mirror that can be held up to a particular country's health system. Valuable in that they reflect back what is happening elsewhere. Idiosyncratic in that the reflection is distorted by differences of national context and culture embedded in existing organizational and institutional arrangements, masquerading as structural fact.

This essential tension between reflection and distortion – between useful as against less useful information, between transferrable as against less transferrable strategies and approaches – sits at the heart of the comparative enterprise. The interesting question, as always, is what information is reflection, and what is distortion and who decides. A further question is whether and/or how this balance differs among different countries, and/or shifts over time.

Comparative studies make it possible to identify strategies and/or activities that are similar across a group of countries. For example, over the last 10 years or so, there has been an increasing trend among Western European countries to reverse previous forms of decentralized administration in favor of strengthening state control – even when that state control is used to re-structure health care institutions on a more independent market-oriented manner (e.g. Norway). More centralized state control over funding can be seen in countries like Denmark, Germany, Netherlands, and, to a lesser degree, in countries still committed to decentralization such as Italy and Sweden. More centralized control over provider institutions, particularly hospitals, can be found in Norway, Denmark, Ireland and (to a lesser degree) Estonia. This trend toward re-centralization is not universal – few trends are. Certainly the new government in the United Kingdom is moving in a different direction, and countries like Spain and Finland remain highly decentralized in policy as well as practice. However, it is worth noting that some policymakers in both the latter two governments are struggling to find ways to re-centralize that might be compatible with the existing national context and culture – not an easy effort.

A second structural trend that appears to be strengthening is the softening and sometimes the melting of boundaries between health system categories that previously were firmly set either within or between different national health systems.

One such softening of boundaries within health systems concerns the public as against private provision of services, a boundary which is shrinking if not beginning to disappear for some forms of care in a number of countries (Norway and Denmark for elective hospital services, in Sweden for primary care, in Estonia and Czech Republic for inpatient hospital services, also in England for certain elective hospital procedures) – and shrinking, it should be said, rather quietly with little ideological dispute (except perhaps in England due to its own cultural and political idiosyncrasies).

A similar melting of boundaries, in this case between countries, can be seen in the long-held distinction between social health insurance (SHI) and tax-funding of different national systems. Countries like Israel and now Germany have both substituted nationally collected taxes (Israel) or payments (Germany) for employer/employee contributions traditionally made directly to sickness funds. Other Western European countries have replaced a portion of SHI-based health care funding with national tax revenues (the Netherlands for children; France with a wealth tax). This sense that the boundary between SHI and tax-funded countries is wilting is reinforced by new hybrid models that a number of Central European countries have adopted, in which there is only one (Estonia, Macedonia, Hungary) or a limited number (Czech Republic) of social health insurance funds which, rather than being private not-for-profit in the traditional German or Dutch fashion, are direct arms of the national government. In addition, most of these Central European SHI funds receive a substantial portion of their revenues directly from national tax revenues – again a difference from the traditional Western European SHI models.

A third, less visible but more controversial melting of traditional boundaries – here within health systems again – involves subtle but ongoing efforts to shift the balance between collective and individual responsibility, not so much for financing care (although that is a small but growing part of the debate) but more for co-producing and managing various types of chronic and continuing care. This incipient process of beginning to melt what have been rather rigid internal borders reflects a combination of trends: patient preference to have more choice and control over how and from whom they receive certain services, shortages of publicly funded health professionals, the emerging limits of collective financing in terms of increased labor costs (SHI systems), increased taxes (tax-based systems) and the impact of globalized economic development, as well as the ongoing financial crisis of the state across large parts of the European Union. As the Norwegian State Secretary for Health told an Observatory seminar in October 2009: “The current way we finance and deliver health care services is not sustainable.” And this from Norway, which has no financial crisis but rather a sovereign investment fund of oil revenues worth some $400 billion, set aside to pay future Norwegian welfare costs.

Beyond these similarities that comparative observation can discern, there also are strong elements of existing health system practice that comparative studies lack the tools to penetrate. Note that, in several places in the above description of similarities between systems, I felt constrained to refer to the ‘national context and culture’ of specific systems to explain why they did not conform as expected to the broader trend. This is a type of catch-all phrase for the inability of comparative studies to go beyond a certain general analytic level, and reflects the reality that much of what differs between European health systems embodies national history, politics and especially culture.

This last category is a conceptual and practical problem. Most cultural anthropologists deny that there is any such thing as national cultural norms and values that could influence public policy. Moreover, culture is a famously elusive concept, differing between parts of countries (think Lille and Nice), indeed between parts of the same city (e.g. London or Paris).

Yet, cultural and social norms represent perhaps the key to understanding why health system structures exist as they do, why they differ among different countries especially in Europe with its long history of different cultures and regions, and why existing institutions are so difficult to change. As Geert Hofstede, one of the few anthropologists to address these issues, noted in Culture's Consequences (1980):

This is an area where comparative studies will need to borrow and/or develop a much more robust framework if it is to successfully explain many of the key distinctions that one still finds across health systems.