Health Politics in Europe: A Handbook is a major contribution to an enduring quest to compare Europe's disparate health systems in order to not only understand them but also to improve them (Marmor, Freeman, and Okma 2005; Sturdy, Freeman, and Smith-Merry 2013). In this task, the handbook offers readers an authoritative account of the historical and current political-institutional trajectories of 36 health systems in Europe.
Such an expansive task comes with a health warning: this book is a tome. At more than 1,000 pages, it can neither be thrown into a bag to read on a train journey nor comfortably held to read in an armchair. It is a book that requires a desk. In the preface, the editors, all leading lights of contemporary European health policy analysis, reflect on the experience of compiling the handbook during the “horrifying stress test” (v) of our health systems that has been the COVID-19 pandemic. I read the book in a week of COVID-19 testing, waiting for results, and caring for a child home from school with COVID-19. Instead of the solid desk the handbook warranted, it sat on a kitchen table among the familiar detritus of pandemic home-working life. The editors explain, convincingly, that they decided against an “eleventh-hour revision” (v) to accommodate COVID-19 updates, and given the rich country descriptions within, it is clear why: there must be reasons in most years to hold publication while the ramifications of a surprise election result or path-breaking reform become apparent in one or other of the systems outlined here. And indeed, there is much here that will still be true once this pandemic passes, even if the scale of the shock to these systems seems presently daunting.
The weighty (in all senses of the word) size of this book reflects its ambitions. The culmination of a large-scale NORFACE Welfare State Futures Programme coordinated at Humboldt University of Berlin, it proposes a coherent framework to understand contemporary health politics in Europe and then presents a political-institutional analysis of the health systems of 36 European countries, grouped into seven regional sections, and each section with an extended regional outlook overview chapter. As if the European Union membership was not a big enough task, the handbook covers candidate and “potential candidate” countries as well as non-EU countries Norway, Switzerland, and the United Kingdom (the latter a member state when the research project began).
Three overview chapters introduce the topic and approach of the handbook. First, Ellen Immergut zooms out to discuss the book's political-institutional approach and describes the political shocks that she argues have shaped European health systems (specifically: state formation, industrialization, World War II and its aftermath, the fall of Communism, and finally the New Public Management model). A familiar account of path dependency is offered, along with a more specific discussion of health politics veto points with examples from different systems. The organizing idea of health politics as bifurcated between “partisan” and “valence” issues is outlined. In chapter 2, Schneider, Roots, and Rathman review the indicators and measurements that one might use to compare the performance or effectiveness of diverse health systems. Reflecting on the difficulties and drawbacks of various options, they propose access to health care as a key measure for analysts keen to identify which policy measures might best improve health outcomes and reduce health inequalities, and they outline a conceptualization of access that includes physical accessibility, financial affordability, and acceptability of care. In the final introductory chapter, Barlacu and Roesco provide a valuable overview of the parallel (or, as they put it, “disarticulated”) literatures on public normative commitment to health care, public opinion on personal experiences of health care, and finally the political salience of health care issues in different countries. They review the large-scale European social surveys from which we might derive these measures, and they propose an integrated analysis of the “three S's”—solidarity, satisfaction, and salience—calling for more attention to their interrelations and their consequences for health policy. The preliminary materials also offer a bonus “How to Use This Handbook” section, with a helpful overview of the companion data sets available online.
One of the marketing points offered for the handbook is its “systematic structure,” and indeed, a great deal of the text's value comes from how it squeezes complex national histories into a fairly rigid template. For each health system, the chapter comprises a historical overview, an assessment of contemporary functioning, and a political narrative of developments since 1989 (chosen to mark the fall of the Iron Curtain). The 36 countries are organized into seven regions: Ireland and the UK; the Nordic countries; Southern Europe; the Baltic countries; Continental Europe; Central Eastern Europe; and Southern Eastern Europe. Comparisons among them, although grounded in robust quantitative data, are hamstrung by the underlying quality and comparability of the administrative data sources, and by ongoing discrepancies in measures such as preventable and treatable disease. The handbook itself resulted from a classical health systems comparison project, and at times it feels reminiscent of what Vindrola-Padros and Whiteford (2021: 361) characterize as a pre-2000 approach: “strict attention to purported and assumed ‘scientific’ objectivity, close data scrutiny, reliable measurement.” At times the editors appear frustrated with the complexity of the task and the incommensurability of the phenomena they pursue: “The trouble is that healthcare systems are composed of multiple institutions that do not have homogenous effects. Moreover these systems change over time” (Immergut 2021: 29). I imagined a frustrated photographer confronting an unruly group of subjects: “Won't you all just stay still while I get one good photograph?”
The answer to this unruliness is a reversion to narrative, i.e., descriptive expertise within the handbook's individual chapters, albeit heavily templated to provide the systematic approach that the handbook promotes. While chapter sections on “contemporary functioning” report the quantitative indicators introduced in chapter 2, and each chapter contains helpful tables listing key legislation and veto points, the bulk of each country chapter relies heavily on authoritative “common sense” narratives of how health systems are and what makes a difference to their institutional trajectories. Sources, whether primary or secondary, are kept to a minimum within these descriptions. This is a style of health systems analysis that will be familiar to readers from the work of World Health Organization Observatories and resources such as the Commonwealth Fund's Country Profiles. It's an approach that Sturdy, Freeman, and Smith-Merry (2013: 534) identified in their research on the World Health Organization's European work around mental health:
Rigorous international comparison proved impossible, as did the technocratic aim of setting universal standards of provision. . . . Successes have been achieved through the production and mobilisation of a very different kind of knowledge: not standardised and comparative, but case-based and holistic, and rooted in personal experience of the peculiarities of local mental health systems of a kind that proved difficult to reduce to the standardised categories necessary for technocratic policy making.
The combination of painstaking, “elusive” (Sturdy, Freeman, and Smith-Merry 2013: 550) quantitative comparison with holistic, case-based expert narratives is therefore a well-established modality of knowledge generation and dissemination within European health systems. Across these 36 health systems the sheer range and eclecticism of institutional contexts makes more grounded qualitative analysis (such as that offered by Greener 2021; Tuohy 1999, 2018) impracticable. And so the country chapters provide richly described expert overviews, with relatively few references to verifying evidence beyond the author's knowledge. The pedigree of the authors as country experts is undeniable; I do not doubt that should references have been deemed necessary, they could have been found. What is striking is the underlying faith in expert knowledge of a system, which sits oddly alongside the commitment to assembling and analyzing robust and comparable quantitative indicators and measurements.
As a reader I found myself wondering about the untold stories within these expert-led health system portraits. For example, we have seen in the work of scholars such as Michener (2018) how much can be left out of the common sense, big-picture narratives that spring up around our health systems. In the UK, recent work by Bhambra and colleagues has prompted a necessary reappraisal of the self-reinforcing “origin stories” of the British NHS: asserting that imperial exploitation, and not a simple upsurge of social solidarity, should be seen as the fertile ground from which the NHS sprang (Bhambra 2022; Millar 2022). The handbook contains chapters on health systems that have much less historiography than Britain's NHS (Gorsky 2008), and chapters on some of the Eastern European health systems, in particular, have but a handful of references. This, then, is an act of faith on the part of the reader in expert narratives of “what happened, and why it mattered” in the political-institutional trajectory of each health system.
The handbook has no concluding chapter, nor a coda to the substantive opening chapters. After the last chapter—a fascinating portrait of the Kosovan health system—ends, the next page is the beginning of the book's index. While the transition feels abrupt, and this reader wished for a comparative summary to round things off, this choice underlines the handbook's primary role as a reference work. Indeed, when COVID-19 finally leaves this household and the book makes its way from kitchen table to the office where it belongs, it will provide an enduring source of information about the range of health systems present in this continent. The introductory chapters, to a great extent, offer the conclusion one might expect to close the handbook, although overall the book downplays its comparative potential in favor of encyclopedic function. In her introductory chapter, Immergut celebrates the gains in “fundamental health security” made across Europe, and she emphasizes that effective politics matters by contrasting the successes of countries such as Slovenia and Estonia with the relative stalemates of others such as Latvia, Bulgaria, and Portugal (Immergut 2021). As Rudolf Klein wrote in this journal some years ago: “The experience of other countries is largely valuable insofar as it prompts such a process of critical introspection by enlarging our sense of what is possible and adding to our repertoire of possible policy tools. . . . The experience of other countries stimulates the policy imagination” (Klein 1997: 1270). In its thorough chronicling of the diversity of health systems in contemporary Europe, this book offers readers just such an expansion of possibility.