Preview

INTERNATIONAL LABOUR OFFICE

THE COST
OF MEDICAL CARE

•JíS.S

GENEVA
1959

L ;V? ili!* 195 5; ;

STUDIES AND REPORTS
New Series, No. 51

PRINTED BY " LA TRIBUNE DE GENÈVE ", GENEVA (SWITZERLAND)

CONTENTS
Page
INTRODUCTION

Purpose of the Inquiry
Scope of the Inquiry
Methods of Calculation Used
Plan of the Study
CHAPTER I. Persons Protected and Contingencies Covered
Persons Protected
General Remarks
Effects of Differences in Scope on Comparability
Agricultural Workers
Non-Manual Workers and Higher-Income Groups
Miners, Railwaymen and Seafarers
Dependants
Pensioners
Contingencies Covered
Employment Injury
Tuberculosis
Mental Diseases
.
Other Diseases
Maternity
CHAPTER II. Expenditure on Medical Benefits and Cost of Medical Care . .
Medical Practitioner Care Given outside Hospital Wards
General Practitioner Care
England and Wales
Netherlands
Denmark
New Zealand
Italy
General Remarks
Medical Practitioner Care, Including Care by Specialists
Federal Republic of Germany
France
Italy
Netherlands
Switzerland
Canada (Swift Current Region, Saskatchewan)
Belgium
Denmark
Norway
England and Wales
New Zealand
Mexico and Venezuela
United States
General Remarks
Pharmaceutical Preparations Supplied outside Hospital Wards . . . .
England and Wales
France

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THE COST OF MEDICAL CARE
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Federal Republic of Germany
Italy
Belgium
Netherlands
New Zealand
Switzerland
Denmark
Mexico and Venezuela
Norway
Canada
United States
General Remarks
f; Hospital Care
England and Wales
France
Canada
Belgium
Federal Republic of Germany
Italy
Netherlands
Norway
Denmark
New Zealand
Switzerland
Mexico
Venezuela
'
United States
General Remarks
(a) Cost of Hospital Care
(b) Cost of Hospital Care (Not Including Cost of Construction)
(c) Cost of Hospital Care Received under Sickness Insurance
Schemes
(d) Cost of Hospital Care Received under Sickness and Employment-Injury Insurance (France)
.
(e) Cost of Care in Mental Hospitals (Not Including Cost of Construction)
(f) Cost (Not Including Cost of Construction) of Hospitals Other
than Mental Hospitals
Dental Care
England and Wales
France
Federal Republic of Germany . .
Belgium
': :
\ .
Netherlands
New Zealand
Denmark
Norway
Italy
Mexico and Venezuela
United States
General Remarks
Residual Care
Total Cost of Medical Care of All Types
Cost of the Four Main Types of Care
Cost of Medical Care of Every Description
England and Wales
Belgium

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CONTENTS

_;V
Page

Canada
Denmark
France
Netherlands
New Zealand
Norway
United States
General Remarks
Conclusions
Cost of Medical Care of All Kinds
Cost of Different Types of Medical Care
CHAPTER III. Trends in Expenditure on Medical Care
General Practitioner and Specialist Care
General Practitioner Care
Denmark
England and Wales
Italy
Netherlands
New Zealand
Medical Practitioner Care, Including Care by Specialists
Belgium
Canada (Swift Current Region, Saskatchewan)
France
Federal Republic of Germany
Mexico
Norway
Switzerland
Venezuela
United States
General Remarks
Pharmaceutical Preparations
Belgium
Denmark
England and Wales.
France
Federal Republic of Germany
Italy
Mexico
Netherlands
New Zealand
Switzerland
Venezuela
United States
General Remarks
Hospital Care
Belgium
Canada (Saskatchewan)
Denmark
England and Wales
France
Federal Republic of Germany
Italy
Mexico
Netherlands
New Zealand
Norway
Switzerland

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. . . .
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. 105
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Ill
Ill
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• .

THE COST OF MEDICAL CARE
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Venezuela
United States
General Remarks
Dental Care
Belgium
Denmark
England and Wales
France
Federal Republic of Germany
Netherlands
New Zealand
United States
General Remarks
Total Expenditure on Medical Care of All Types
CHAPTER IV. The Incomes of Medical Practitioners
General Practitioners
Denmark
England and Wales
Italy
Netherlands
New Zealand
Belgium
Canada (Swift Current Region, Saskatchewan)
Chile
France
Federal Republic of Germany
Mexico
Switzerland
United States
General Remarks
Specialists
Italy
Netherlands
Belgium
Canada (Swift Current Region, Saskatchewan)
England and Wales
France
Mexico
New Zealand
Switzerland
United States
General Remarks
The Incomes of Medical Practitioners from All Sources
Canada (Swift Current Region, Saskatchewan)
England and Wales
France
Federal Republic of Germany
Italy
Netherlands
New Zealand
Switzerland
United States
General Remarks
Dentists
England and Wales
United States
General Remarks

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CONTENTS

VII
Page

CHAPTER V. Conclusions

Cost of Medical Care in Terms of the Average Income per Economically
Active Person
Trends in Expenditure of Social Security Schemes
APPENDIX

A. Explanations of Calculations
Belgium
Medical Practitioner Care
Pharmaceutical Supplies
Hospital Care
Incomes of Medical Practitioners
Canada
Medical Practitioner Care (Swift Current Region)
Hospital Care
Denmark
Medical Practitioner Care
Hospital Care
England and Wales
Hospital Care
France
Medical Practitioner Care
Pharmaceutical Supplies
Hospital Care
Incomes of Medical Practitioners
Federal Republic of Germany
Pharmaceutical Supplies
Hospital Care
Italy
Pharmaceutical Supplies
Hospital Care
Netherlands
Medical Practitioner Care
Hospital Care
Incomes of Medical Practitioners
New Zealand
Hospital Care
Dental Care
Norway
Hospital Care
Total Cost of Medical Care
Switzerland
Hospital Care
Incomes of Medical Practitioners
United States
Hospital Care
B. National Statistics
Belgium: Population, National Income, and Expenditure of Sickness
and Invalidity Insurance on Medical Benefits by Type of Care,
1950-55
Canada: Expenditure of Swift Current Region Medical Care Scheme and
of Saskatchewan Hospital Service Plan on Medical Benefits per
Person Protected, and Population and National Income of Canada,
1947-55

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186

Vili

THE COST OF MEDICAL CARE
Page

Chile: Expenditure of Workers' Sickness and Maternity Insurance
Scheme on Medical Benefits by Type of Care, and Population and
National Income, 1943-51
Denmark: Expenditure of Subsidised Voluntary Sickness Insurance
on Medical Benefits by Type of Care, and Population and National Income, 1938 and 1945-55
England and Wales: Expenditure of National Health Service, and
Cost of Care Received, by Type of Care, 1949-55; United Kingdom: Population, Gross National Product at Factor Cost and
National Income, 1949-55
France: Expenditure of Sickness Insurance Scheme for Non-Agricultural Employees on Medical Benefits by Type of Care, and Population and National Income, 1947-55
Federal Republic of Germany: Expenditure of General Sickness
Insurance Scheme on Medical Benefits per Insured Person by Type of
Care, and Population and National Income, 1937 and 1949-55. . .
Italy: Expenditure of General Sickness Insurance Scheme on Medical
Benefits by Type of Care, and Population and National Income,
1946-55
Mexico: Expenditure of Sickness and Maternity Insurance Scheme
on Medical Benefits by Type of Care, and Population and National
Income, 1950-53
Netherlands: Expenditure of Compulsory Medical Care Insurance
Scheme per Person Protected by Type of Care, and Population and
National Income, 1943 and 1945-55
New Zealand: Expenditure of the Social Security Fund on Medical
Benefits by Type of Care, Total Hospital Expenditure and Population and National Income, 1943 and 1945-55
Norway: Expenditure of Public Sickness Insurance Funds on Medical
Benefits by Type of Care per Insured Person, and Population and
National Income, 1939 and 1945-55
:
Switzerland: Expenditure of 555 Sickness Funds on Medical Benefits by
Type of Care, per Insured Person, and Population and National
Income, 1946-55
;;
Venezuela: Expenditure of Sickness and Maternity Insurance Scheme
on Medical Benefits by Type of Care, and Population and National
Income, 1946-53
United States: Private (and Voluntary Insurance) Expenditure oñ
Medical Care by Type of Care; Expenditure on Maintenance and
Construction of Hospitals; and Population and National Income,
1946-55
C. Comparative Tables
Table A. Number of Persons Protected (a) or Persons Insured (b) under
the Social Security Medical Care Schemes Covered, and Population of the United States
Table B. Total Expenditure per Person Protected on Medical Benefits
under 13 Social Security Services, and Private Expenditure on
Medical Care in the United States, in Terms of the Income per
Head and of the Reference Wage
Table C. Expenditure per Person Protected on Medical Practitioner
(or General Practitioner) Care under 13 Social Security Services,
and Private Expenditure on Such Care in the United States, in Terms
of the Income per Head and of the Reference Wage
Table D. Expenditure per Person Protected on Pharmaceutical Supplies under 11 Social Security Services, and Private Expenditure
on Such Supplies in the United States, in Terms of the Income per
Head and of the Reference Wage

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CONTENTS

IX
Page

Table E. Expenditure per Person Protected on Hospital Care under
13 Social Security Services, Private Expenditure on Such Care
in the United States, and Total Hospital Expenditure in New
Zealand and the United States, in Terms of the Income per Head and
of the Reference Wage
Table F. Expenditure per Person Protected on Dental Care under
Seven Social Security Services, and Private Expenditure on Such
Care in the United States, in Terms of the Income per Head and
of the Reference Wage
Table G. Expenditure per Person Protected on Care Not Included in
Tables B to F under 11 Social Security Services, and Private
Expenditure on Such Care in the United States, in Terms of the
Income per Head and of the Reference Wage
Table H. National Income per Head of the Population, and Wage of
Unskilled Labourer Employed in Manufacture of Machinery, per
Year, in National Currency
Table J. Proportion of Economically Active Persons in the Population

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LIST OF TABLES
Page

Table 1. Cost of General Practitioner Care per Person Protected . . . .
Table 2. Cost per Person Protected of Medical Practitioner Care Outside
Hospital Wards, Including Patient's Share
Table 3. Expenditure per Person Protected on Medical Practitioner Care
Given Outside Hospital Wards (Not Including Patient's Share)
Table 4. Cost per Person Protected of Pharmaceutical Benefits Supplied
Outside Hospital Wards (Including Patient's Share) . . . .
Table 5. Expenditure per Person Protected on Pharmaceutical Benefits
Supplied Outside Hospital Wards (Not Including Patient's
Share)
Table 6. Cost per Person Protected of Hospital Care, Including Public
and Private Expenditure
Table 7. Expenditure per Person Protected by Social Security Services on
Hospital Care in 13 Countries and Private Expenditure in the
United States
Table 8. Cost per Person Protected of Dental Care (Including Patient's
Share)
Table 9. Expenditure per Person Protected of Social Security Services on
Dental Care in Five Countries
Table 10. Estimated Average Cost of Medical Practitioner, Pharmaceutical,
Hospital and Dental Care per Person Protected as a Percentage
of the Average National Income per Economically Active
Person
Table 11. Average Cost of Medical Care as a Percentage of the Average
National Income per Economically Active Person
Table 12. Italy: Number of Items of Service Given by General Practitioners
under Sickness Insurance per Person Protected
Table 13. Netherlands: Expenditure on Medical Care, 1950-55
Table 14. Belgium: Consultations of and Visits by Medical Practitioners
per Person Protected, 1950-55
Table 15. Mexico: Expenditure per Person Protected on Dispensaries under
Sickness, Maternity, Employment Injury and Pension Insurance, 1950-55
Table 16. Mexico : Number of Consultations of and Visits by General Practitioners per Person Protected, 1950-55
Table 17. Expenditure on General Practitioner Care Outside Hospital Wards
as a Percentage of Total Expenditure on Medical Benefits
under Five Social Security Schemes
Table 18. Expenditure on Medical Practitioner Care as a Percentage of
Total Expenditure on Medical Benefits under Ten Social
Security Schemes and Private Expenditure on Medical Practitioner Care as a Percentage of Total Private Expenditure on
Medical Care in the United States, 1945-55
Table 19. Belgium: Number of Prescriptions per Person Protected by Type
of Preparation, 1950-55

21
31
34
43
44
59
63
67
68

70
76
83
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88
89
92

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THE COST OF MEDICAL CARE
Page

Table 20. Belgium: Percentage Distribution of Prescriptions by Type of
Preparation, 1950-55
Table 21. Belgium: Percentage Distribution of Proprietary Preparations by
Type, 1950-52
Table 22. Belgium: Number of Prescriptions per Consultation or Visit
by Type of Preparation, 1950-55
Table 23. Belgium: Percentage Distribution of Prescriptions per Consultation or Visit by Type of Preparation, 1950-55 . . . . . . .
Table 24. Belgium: Indices of the Volume of Pharmaceutical Benefits Supplied, 1950-55
Table 25. Belgium : Expenditure per Person Protected as Percentage of Income
per Head by Type of Preparation, 1950-55
Table 26. Belgium: Percentage Distribution of Expenditure by Type of
Preparation, 1950-55
Table 27. Belgium: Percentage Distribution of Expenditure on Proprietary
Preparations by Type of Preparation, 1950-55
Table 28. Belgium: Expenditure per Prescription by Type of Preparation as
Percentage of Income per Head, 1950-55
Table 29. Belgium : Indices of Volume of Pharmaceutical Benefits and of
Expenditure per Person Protected, 1950-55
Table 30. Denmark : Prevalence of Sickness Among Adult Members,
1945-55
Table 31. Denmark: Percentage Distribution of Expenditure by Type of
Preparation, 1946-55
Table 32. England and Wales: Average Cost per Prescription, 1949-54 .
Table 33. England and Wales: Composition of Payments to Pharmacists,
1950-54
Table 34. Italy: Average Number of Prescriptions per Person Protected by
Type of Medicine and Average Expenditure per Prescription,
1948-55
Table 35. Netherlands: Number of Deliveries per Person and Cost, 1946-53
Table 36. New Zealand: Numbers and Cost of Prescriptions issued in Relation to Population and Services Provided by Doctors under
the Social Security Scheme, 1942-55
Table 37. Expenditure on Pharmaceutical Supplies Provided Outside Hospital
Wards as a Percentage of Total Expenditure on Medical Benefits under Eleven Social Security Schemes and Private Expenditure on Pharmaceutical Supplies as a Percentage of Total
Private Expenditure on Medical Care in the United States,
Prior to 1945 and 1945-55
Table 38. Federal Republic of Germany: Number of Days of Hospitalisation of Members and Dependants per 100 Members, 1937 and
1950-55
Table 39. Mexico: Hospitalisation under Sickness, Maternity and Employment Injury Insurance, 1950-55
Table 40. Expenditure on Hospital Care as a Percentage of Total Expenditure
on Medical Benefits under Twelve Social Security Schemes, and
Private Expenditure on Hospital Care as a Percentage of Total
Private Expenditure on Medical Care in the United States,
Pre-War and 1945-55
Table 41. Belgium : Number of Consultations of Dentists, 1950-55 . . . .
Table 42. Belgium: Expenditure on Consultations of Dentists and on Dentures, 1950-55

95
95
96
96
96
97
97
97
97
98
99
99
.101
101
106
107
109

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119

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LIST OF TABLES

XIII
Page

Table 43. England and Wales : Courses of Dental Treatment (Including
Emergency Treatment), 1950-55
Table 44. Federal Republic of Germany : Expenditure per Person Protected
on Dentures, 1950-55
Table 45. Expenditure on Dental Care as a Percentage of Total Expenditure
on Medical Benefits under Seven Social Security Schemes and
Private Expenditure on Dental Care as a Percentage of Total
Private Expenditure on Medical Care in the United States . .
Table 46. Estimated Gross Income of General Practitioners from Persons
Protected by Social Security (and from Private and Voluntary
Insurance Practice in the United States) in Terms of Average
Income per Economically Active Person

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128

130

140

INTRODUCTION
PURPOSE OF THE INQUIRY

In 1953, in view of the widespread apprehension in social security
circles at the increase in the cost of medical care, the International
Latour Office decided to undertake a study of its cost under social security
schemes in a number of countries.
The difficulties of such an undertaking were fully realised. Statistics
of social security medical care services are not directly comparable.
Apart from the fact that they are in different currency units, there are
considerable differences in the range and extent of medical benefit
to which they relate, the population protected and the contingencies
covered. Moreover, the way in which different classes of cost are
grouped for statistical purposes cannot be understood without a detailed
examination of the practices followed within the different schemes
which are often incomprehensible to outsiders. In view of the great
importance of medical costs to social security, however, the International
Labour Office—while fully aware of the many pitfalls, the possible
errors, the tentative nature of the estimates made and the provisional
nature of the results arrived at—has attempted to overcome these
difficulties in the present study.
With these difficulties in mind the authors of this study set out to
achieve the following aims:
Firstly, to examine the range and extent of the benefits provided in order
to ascertain to what extent, if any, differences in the expenditure so
measured are due to differences in the range of benefits, in the definition of the types of care, in the classification of basic data or other
factors.
Secondly, to make the statistics more comparable by expressing the
expenditure of the different social security schemes in terms of
national income per head of the population, income per economically
active person, and a reference wage.
Thirdly, to estimate the " real " cost of the medical care received by the
persons protected under the social security schemes covered by
adding to the expenditure of the social security scheme that part of
the cost (if any) borne by the public authorities and that borne by
the patient himself.

THE COST OF MEDICAL CARE

Fourthly, to attempt to estimate the approximate aggregate cost of
all medical care and of each individual type of care in terms of
cost per head of the population in each of the countries studied and
to compare the results with the estimated cost of the care received
by the persons protected under the social security schemes covered
by the study and with the expenditure of these schemes.
Fifthly, to compare the cost of the medical care received by the persons
protected under the social security schemes covered and the expenditure of the schemes with private expenditure on medical care and
total hospital expenditure in the United States.
Sixthly, to examine the trend of social security expenditure in terms of
national income and of reference wages to ascertain whether (and,
if so, to what extent) the general apprehension at the rising cost of
medical care is justified.
SCOPE OF THE INQUIRY

The present study is based on an analysis (in most cases covering
periods ending in 1955) of the expenditure on medical benefits of the
following selected social security medical care services:
the Belgian general compulsory sickness and invalidity insurance scheme
for employees;
in Canada (Saskatchewan), the medical practitioner service for the
residents of the Swift Current region and the hospital insurance
scheme for residents of the whole province;
the Chilean general social insurance scheme for manual workers and
independent workers of small means as it existed prior to 1953;
the Danish voluntary subsidised sickness insurance scheme for residents
of small means ;
in England and Wales, the National Health Service;
the French compulsory general social insurance scheme for non-agricultural employees;
in the Federal Republic of Germany, the general sickness insurance
scheme for employees;
the Italian compulsory general sickness insurance scheme for employees
and certain groups of independent workers;
the Mexican compulsory sickness insurance scheme for employees;
the Netherlands compulsory medical care insurance scheme for employees
of small means;
the New Zealand social security medical care service for the whole
population;

INTRODUCTION

the Norwegian compulsory and voluntary sickness insurance scheme,
mainly for employees of modest means, as it existed prior to 2 July
1956;
the Swiss subsidised voluntary or compulsory medical care insurance
funds for residents which regularly report their medical care expenditure;
the Venezuelan general compulsory sickness insurance scheme for
industrial employees.
For the United States, estimated private expenditure on medical
care and contributions to voluntary insurance schemes, and the expenditure of all hospitals in the country, are given.
The data on expenditure under the above social security services and
in the United States are derived from official sources unless otherwise
stated.
METHODS OF CALCULATION USED

For the purpose of the present study the expenditure1 on medical
benefits of each of the social security medical care services considered
has been divided by the total number of persons protected by it, i.e.
all persons entitled to medical benefit, either as insured persons or
(where these groups are entitled to medical benefit) as dependants or
pensioners. In the cases of England and Wales and New Zealand the
total population is assumed to be protected.
The figures given for the United States show private expenditure on
medical care and on voluntary medical care insurance per head of the
population ; the same applies to the estimates of hospital expenditure.
The expenditure per person protected (or, where applicable, the cost
per head of the population) is expressed in terms of—
(i) the average annual income per head of the population of the country
concerned (referred to as the income per head);
(ii) an annual reference wage; and
(iii) the national income per economically active person.
The first two of these are used for observing the trends of expenditure
or cost within a given country, while the third is used for purposes of
international comparison. In all three the use of national currency
units is thus obviated. Moreover, fluctuations in average expenditure or
cost which run parallel to fluctuations in the income per head, the reference wage or the national income per economically active person (as
1
Unless otherwise stated the word " expenditure " is used to denote the sums
spent by social security services, and " cost " to denote such expenditure plus payments
by the patient and contributions from the public authorities (if any).

THE COST OF MEDICAL CARE

the case may be) are not recorded, whether they are due to inflation or
deflation, to changes in productivity or in wage levels or to other factors.
Any fluctuations recorded are consequently due either to changes in the
amount of medical care received or to changes in the prices of items of
medical care that exceed changes in the general price level.
The third of the measures used to express the average expenditure
or cost per person protected, although in some cases defective, has the
advantage of relating the cost per head to the income of the breadwinner
only, whatever the average number of persons dependent on one breadwinner. It might be likened to the income of the average family.
The fundamental factors taken into consideration are thus the
national income, the total population, the reference wage and the economically active population.
The figures of national income at factor cost used in the present
study are the estimates published by the Statistical Office of the United
Nations 1, and the income per head is obtained by dividing such income
in the year under review by the total population of the country concerned 2 in the same year.3 For England and Wales the national income
figure estimate used is that of the gross national product at factor cost
of the United Kingdom.4
As a rule the national income estimates are those available at the
time when, the calculations in respect of a particular country were first
made. Subsequent revisions of estimates for the period covered have
not as a rule been taken into account unless they differed from the earlier
ones to an appreciable degree. For recent years new series may thus
have been used without revising the estimates for earlier years. The same
applies to population estimates.
The reference wage chosen for the purposes of the present study is,
as a rule, the annual wage of an unskilled labourer in the manufacture of
machinery other than electrical machinery. It is computed on the basis of
the hourly rates of wages of adult wage earners for normal hours of work
published by the International Labour Office in its Year Book of Labour
Statistics and the Statistical Supplement of the International Labour
1
United Nations : Statistics of National Income and Expenditure, Statistical
Papers, Series H, Nos. 4 to 10 (New York, 1953-57), and Monthly Bulletin of Statistics
(New York).
2
The population estimates for Venezuela do not include the Indian jungle population, estimated at 56,700 in 1950.
3
The population figures are taken from United Nations : Monthly Bulletin of
Statistics, loc. cit., from November 1954 onwards.
4
Since January 1957 the national income at factor cost is also given for the United
Kingdom ih Series H <see note 1 on this page). It has not, however, been possible to
revise calculations at this stage. The difference between the gross national product asused in this study and the national income at factor cost.in 1953 was about 100 to 91..

INTRODUCTION

Review. The annual wage is obtained by multiplying the weekly wage
by 52. Where data on normal hours of work are not published regularly,
hours of work are estimated on the basis of general information. For
France the working week is assumed to be 40 hours, i.e. the statutory
working week. In the case of Venezuela the wage for 1951 and the
following years is that of the unskilled labourer in the iron and steel
industry, as the publication of statistics on wages of workers engaged in
the manufacture of machinery was discontinued that year.
For Denmark only figures of average earnings are available; these
are higher than rates of wages for normal hours of work.
As regards Switzerland the average earnings of unskilled workers
in the metal and machinery industry, as published since 1951 in La Vie
Economique1 and in the Year Book of Labour Statistics (table 18), are
taken as the reference wage. In the years prior to 1951 the earnings of
unskilled workers were not given separately, and for those years they
have been estimated by applying to the figures for the average earnings
of unskilled and semi-skilled workers taken together the same minus
differential as existed between the earnings of unskilled workers alone
and those of unskilled and semi-skilled workers taken together in
October 1951, the ratio being 92.25 : 100. For 1953 the official estimate
is given. The hours of work are assumed to be 2,400 a year (a figure
somewhat below the actual hours worked) in order to take account of the
fact that earnings and not wage rates are taken for the purposes of
calculating the reference wage.
The figures showing the proportion of the population which is
economically active are derived from the Year Book of Labour Statistics,
1953, or subsequent issues, as they appeared, but revised estimates
appearing subsequently have not been taken into account.
Unfortunately the definition of the " economically active population " is not always uniform, although steady progress is being made in
this respect. For France the proportion of 44.8 per cent, calculated for
1954 on a new and more accurate basis has been used throughout.
PLAN OF THE STUDY

In Chapter I the range of persons protected and the contingencies
covered by the social security medical care services included in the study
are analysed and the possible effects of differences of scope on the*
comparability of the expenditure on medical benefit are briefly discussed.
1
Published monthly by the Swiss Federal Department of Public Economy,
Berne.

THE COST OF MEDICAL CARE

In Chapter II expenditure on medical benefits under the schemes is
discussed in relation to the range of benefits and an attempt is made to
estimate the cost of the medical care received by the persons protected
as distinct from the expenditure of the service on such care. The cost of
medical care to the whole country is also estimated wherever possible.
In Chapter III the trends in expenditure on medical care under
the social security schemes covered during the period under review are
discussed and an attempt is made to gauge the proportion of the total
expenditure accounted for by each of the different types of care.
In Chapter IV some inferences are drawn from the material available
regarding the incomes of medical and dental practitioners derived from
social security and other sources.
Chapter V sums up the conclusions.
The appendix contains—(a) explanations of the methods of calculating some of the percentages given for the different countries;
•(b) tables of statistics concerning individual countries; and (c) tables
of comparative statistics (lettered A to J).

CHAPTER I
PERSONS PROTECTED AND CONTINGENCIES COVERED
The expenditure of the various social security services covered by
the present study on medical benefits may differ for reasons not connected with divergencies in the nature and extent of the benefits provided,
in the cost of the elements of care or in the state of health of the persons
protected. The most important factors impairing comparability are
differences in scope, or rather in the composition of the protected population, as well as differences in the contingencies covered by the services.
These are examined in this chapter.
PERSONS PROTECTED

General Remarks
The range of persons protected by the social security services under
review is described beginning with the schemes which have the greatest
coverage.
In England and Wales and in New Zealand the benefits of the social
security services are available to the whole population.
In Canada the Saskatchewan hospital service covers from 92 to 94
per cent, of the province's population; under the medical practitioner
service in the Swift Current region of Saskatchewan some 96 per cent.
of the residents are protected.
In Denmark and Norway the services cover about 80 per cent, of
the population.
The official statistics for Denmark give medical expenditure per
" member ". This term embraces residents whose income does not
exceed a prescribed limit (whether employees, independent workers or
others) and also housewives, but does not include children under 15 years
of age of insured persons; these are entitled to medical benefits under
their parents' insurance. The number of such children protected represents about 40 per cent, of the number of members * ; accordingly, in
1
The number of children has been estimated on the basis of the population data
for 1951 by relating the number of persons under 15 years of age to the number of
persons aged 15 to 65. This estimate has been officially confirmed.

THE COST OF MEDICAL CARE

order to arrive at the expenditure per person protected, the expenditure
per member as published in the official statistics has been divided by 1.40.
The statistics for Norway relate to compulsorily and voluntarily
insured persons belonging to public sickness funds and to their dependants. 1 Up to 1953 the majority of insured persons were employees
whose incomes did not exceed a prescribed limit, the insured representing
about 97 per cent, of all employees. The income limit was abolished in
1953. Unemployed persons in receipt of benefit were automatically
covered, but pensioners only if voluntarily insured. Seafarers engaged
in foreign trade and railwaymen were not insured by the general funds
and are consequently not covered by this study. The number of dependants has been estimated on the basis of data available for the years
1947-52, when the number of persons insured in all funds (including
approved private funds) represented about 53 per cent, of the estimated
total number of persons protected. The rates of expenditure per insured
person as published in the official reports have accordingly been divided
by 1.89 for the years prior to 1953; the divisors used for the figures
for 1953, 1954 and 1955 were 1.934, 1.936 and 1.938, respectively.2 It
should be noted that medical care insurance was extended to the whole
population in 1956.
In the Federal Republic of Germany the total number of persons
protected for whom statistics are given represents about 60 per cent, of
the population. The statistics include industrial and agricultural employees
and other persons compulsorily or voluntarily insured against sickness
under the general scheme, as well as their dependants, but not pensioners.
Non-manual employees are insured if their incomes do not exceed a
prescribed limit. The number of dependants has been officially estimated
qn the basis of the 1950 census; their ratio to the number of persons
insured has been estimated at 0.80, 0.80, 0.77, 0.76 and 0.77 in the
years 1951 to 1955 respectively; for 1937, 1949 and 1950 it is assumed
to have been 0.80. Accordingly the rates of expenditure per insured
person published in the official reports have been divided by 1.80, 1.77
ajid L76, as the case may be, in order to arrive at the approximate
expenditure per person protected.
,.. The statistics for the Netherlands cover about 50 per cent, of the
population; they relate to all persons who are compulsorily insured
with the funds administering medical care insurance, which is separate
from the cash benefit scheme, as well as their dependants. The category
1
The data required are available only for persons insured with public funds over
the whole period covered. Approved private funds and railwaymen's funds account
for 2 to 3 per cent, of the total number of insured persons.
2
Estimates of the National Insurance Institution prepared in 1958.

PERSONS PROTECTED AND CONTINGENCIES COVERED

" compulsorily insured persons " includes all employees within an income
limit, all unemployed persons and, since 1951, all other persons receiving
social security benefits and their dependants. 1 Seafarers have special
protection abroad, but since 1951 are covered by the general scheme
when they return to their home country. Miners are not included in the
general statistics; railwaymen have been included since 1953. Dependants
are considered as being indirectly insured.2
The statistics for Belgium also cover some 50 per cent, of the popular
tion. They include all employees other than public servants and seafarers,
as well as invalidity pensioners, and the dependants of these persons. 3
In Switzerland the number of persons insured with the 555 sickness
funds publishing detailed data represents about 45 per cent, of the population; the total number insured for medical care, however, reached
60 per cent, in 1953. They include dependants, since these are insured
in their own right.
In France the persons protected (i.e. those covered by the general
social security scheme for non-agricultural employees) represent some
40 per cent, of the population. The number of insured contributors in
1955 is given as 8.85 million; corresponding figures for the years prior to
1953 have been supplied to the I.L.O. by the competent authorities
together with statistics of the numbers of dependants and pensioners.4
The total number of persons protected is now over 19 million. Mineworkers, railwaymen and seafarers are not covered by the general
scheme; agricultural employees are covered by a separate scheme.
The Italian statistics included in the tables cover some 30 per cent, of
the population; they relate to the members of the National Sickness
Insurance Institution and their dependants and include industrial,
commercial and agricultural employees and their families as well as
share-farmers. However, share-farmers, day-labourers in domestic
service and some other categories of workers are not entitled to pharmaceutical benefits (to which, in 1955, about 12 million out of the
17 million persons protected were entitled). Expenditure on pharmaceutical supplies has nevertheless been related to the total number of
1
In 1957 compulsory insurance for pensioners was replaced by voluntary subsidised insurance.
?
In addition to about 5.5 million persons compulsorily insured or protected, to
which the present survey relates, some 2 million are protected by voluntary insurance;
in fact, therefore, about 75 per cent, of the population is protected.
3
In order to render the statistics more easily comparable, the data given in the
official reports have been regrouped under the items shown in tables C to F of the
appendix in the manner described in Chapter II (see below, p. 17).
• 4 The estimates made by the National Federation of Social Security Institutions
give totals considerably higher than the official figures.

THE COST OF MEDICAL CARE

persons protected, except for the computation of adjusted rates.1
Dependants of casual agricultural labourers and of domestic servants are
not entitled to medical care and are not included in the tables. In 1955
just under 50 per cent, of the persons protected were dependants entitled
to medical care. Pensioners have been covered since 1 November 1955.
In Chile about 18 per cent, of the population was covered by the
medical care service of the Workers' Insurance Institution when the
statistics for this study were compiled. The persons insured included
agricultural and industrial manual employees as well as independent
workers of limited means. Dependent wives were entitled only to
maternity medical care and children under 2 years of age to pediatric
care; they were not, however, included in the statistics of persons protected. The numbers of insured persons in the years 1950 and 1951
are known; for previous years they are assumed to be the same as in
1950. In 1953 a revised insurance scheme for manual workers and a
national health service were introduced.
In Venezuela only industrial employees with limited means and their
dependants are covered, and even then only in certain industrial districts.
Approximately 5 per cent, of the population is protected. The total
number of persons protected in 1953 was 303,846, of whom 182,020
were dependants.2 These figures, however, are only very approximate
and are probably too high.
In Mexico the insurance scheme, during the period under review,
covered industrial workers in selected areas and their dependants. The
number of persons protected has steadily increased with the inclusion
of new areas; in 1953 it was almost 1,300,000, or 4.6 per cent, of the
population; in 1954 this percentage had risen to 4.8. However, these
data which were supplied by the Mexican Social Security Institute
must be considered as estimates only.
To sum up, the expenditure per person protected expressed in terms
of income per head and reference wages, shown in tables B to G in the
appendix, relates to the whole population for England and Wales and
New Zealand; over 90 per cent, of the population under the hospital
scheme of Saskatchewan (Canada); 80 per cent, for Denmark and
Norway; 60 per cent, for the Federal Republic of Germany; 50 per cent.
for Belgium and the Netherlands; 45 per cent, for Switzerland; over 40
per cent, for France; 30 per cent, for Italy; 18 per cent, for Chile; over
5 per cent, for Venezuela and less than 5 per cent, for Mexico.
1

See below, p. 174.
The information on the number of persons protected is derived from a report
prepared by an actuarial expert and relates to the second half of the year, since the
data on expenditure relate to the financial year beginning 1 July.
8

PERSONS PROTECTED AND CONTINGENCIES COVERED

Agricultural workers are excluded from the figures for France,
Mexico and Venezuela.
Non-manual employees are excluded from those for Chile.
Miners are excluded from those for France and the Netherlands.
Railwaymen and seafarers are excluded from those for France and
Norway.
Dependants are practically excluded from those for Chile.
Pensioners are wholly or partly excluded from the figures for the
Federal Republic of Germany, Italy (up to November 1955), Mexico,
Norway and Venezuela.
For the United States the expenditure figures relate to the whole
population.
Effects of Differences in Scope on Comparability
The probable effect of these differences in scope of protection on
the comparability of the data on the expenditure on medical care is
briefly discussed below.
Agricultural Workers.
Such statistics as are available show expenditure per head on medical
benefits to be lower for agricultural than for non-agricultural workers.
In Germany, for instance, before the Second World War the number of
cases of sickness entailing incapacity for work and the number of cases
not entailing such incapacity per insured person were both consistently
lower in rural funds than in local funds.1 From 1949 to 1952 the total
expenditure per insured person, including sickness benefit in cash, was
also much lower for the rural funds than for the other funds.
In France the average number of consultations and visits in 1953
per insured person, including those of dependants, was 3.35 under
agricultural insurance 2, and 5.09 under non-agricultural insurance.3
The exclusion of agricultural workers might therefore affect comparability so far as the percentages for France, Mexico and Venezuela
are concerned, making them comparatively higher than those obtained
for the other countries.
1
Cf. Laura E. BODMER: " Morbidity Trends and Trade Cycles ", in International
Labour Review (Geneva, I.L.O.), Vol. XLIII, No. 5, May 1941, p. 533.
2
Ministère de l'Agriculture: Rapport sur l'application en agriculture de la législation relative aux assurances sociales : Statistiques du 1" janvier au 31 décembre 1953
(Paris, Imprimerie des Journaux officiels, 1955).
s
Information supplied by the French Government.

THE COST OF MEDICAL CARE

Non-Manual Workers and Higher-Income Groups.
There is some evidence that non-manual workers spend more on
medical care than manual workers, although the incidence of employment injury among them is lower. This higher expenditure would
appear to be at least partly due to the fact that their incomes are higher.
According to statistics, collected in an inquiry covering the year 1935-36
on the medical care expenditure of families in the United States who were
not on relief, such expenditure per person varied from $6 for the group
with a family income of less than $500 to $120 for the group with
$10,000 or more, rising continuously with average income between these
two extremes.1 A recent Canadian survey confirms this correlation.
Under the French general scheme for non-agricultural employees
total expenditure on medical care for men in January 1949 in a sample
of the insured population varied in a ratio of 100 for the lowest wage
class (earning less than Frs. 12,000 per month) to 196 for the highest
(earning more than Frs. 100,000 per month). For medical practitioner
care outside hospitals the variation was 100 to 394; for specialist
care (including that in private clinics) 100 to 383; for dental care 100
to 400; for pharmaceutical products 100 to 258; but for hospital care
in public hospitals 100 to 26.2 Non-manual workers are not included in
the Chilean statistics ; as such workers are liable to give rise to higher
expenditure than others on medical care, even under social security
systems, their exclusion would tend to make an estimate of costs err on
the low side. More generally, the income limits obtaining under the
Danish, Netherlands and Norwegian schemes and for non-manual
employees under the German scheme would also make for a comparative
understatement. The effect, however, is not likely to be great, as relatively
few people are thus excluded.
Miners, Railwaymen and Seafarers.
The morbidity of these groups of workers is usually high. In Norway,
for instance, where comparable data are available for recent years,
expenditure on medical benefits per insured person in 1955 was 316.06
crowns for seafarers and 301.76 crowns for railwaymen, compared with
165.34 crowns for the insured persons covered by the present survey.
If the figures for seafarers, railwaymen and approved private funds are
1
Federal Security Agency, Social Security Board, Bureau of Research and
Statistics : Medical Care and Costs in Relation to Family Income O^ureau Memorandum',
No. 51), p. 72.
* Cour des Comptes : La sécurité sociale, Années 1950-51. Rapport au Président
de la République, suivi des réponses des administrations {Journal officiel de la République française, Annexe administrative, 18 Mar. 1952, p. 171).

PERSONS PROTECTED AND CONTINGENCIES COVERED

added to those for the general scheme the annual expenditure per
insured person works out at 171.15 crowns, or about 3 per cent, more
than if these groups are excluded.
For miners, expenditure in Belgium was Frs. 821.98 per person
protected in 1954, compared with Frs. 782.99 for all persons protected.
The exclusion of miners in France and the Netherlands and seafarers
and railwaymen in France and Norway from the statistics covered by
the present survey consequently tends to lower average costs for these
countries.
Dependants.
Expenditure per head appears to have been somewhat lower for
dependants than for economically active persons, at least at the beginning
of the period under review. Thus Belgian statistics show that expenditure
per head in 1949 was lower for dependants than for insured contributors
other than pensioners. The position, however, was reversed in the course
of the period 1949 to 1954; during that period the annual expenditure
on dependants rose from Frs. 526.28 to Frs. 769.01 per dependant, while
that in respect of insured contributors rose from Frs. 702.20 to Frs. 725.63
per insured contributor.
In France expenditure on medical benefits in respect of short-term
illness in 1954 was Frs. 7,797 per head for insured contributors and
Frs. 7,723 per head for dependants and pensioners (for whom no separate
figures are available). The average number of visits and consultations
recorded by the central fund for the Paris area ranged for insured
contributors from 2.56 per insured contributor in 1950 to 2,44 in 1953,
while for dependants and pensioners it ranged from 1.67 to 2.15 per
insured contributor. Whereas the number of items of service for contributors themselves declined, that for dependants and pensioners increased. It should be noted that the number of non-contributors was
106 per cent, of the number of contributors in 1950 and 109 per cent, in
1953 (an increase of 2.8 per cent.). Nevertheless, the number of items of
service per contributor increased by 28.9 per cent, for non-contributors
while it fell by 4.3 per cent, for the contributors themselves.
A similar tendency is apparent in the Federal Republic of Germany.
No separate figures exist showing the expenditure on medical practitioner
care for insured persons and dependants; as regards other types of care,
expenditure on pharmaceutical benefits and dentures rose from DM 14.74
per insured person in 1950 to DM 21.15 in 1955 (an increase of 43 per
cent.) for insured persons, while the amount spent on dependants rose
by 56 per cent., from DM 7.47 to DM 11.66 per insured person. The
expenditure on hospital care per insured person rose from DM 12.69

THE COST OF MEDICAL CARE

in 1949 to DM 20. 07 in 1955 (58 per cent.) for insured persons, and from
DM 7.05 to DM 12.92 (83 per cent.) for dependants. 1 Hospital benefit
is one which the funds are not required by law to provide for dependants,
but is granted in respect of about 80 per cent, of membership.
The exclusion of dependants from the statistics for Chile may be
expected to increase the average costs shown in the tables, particularly
in view of the fact that the cost of maternity medical benefit for dependants is included in the expenditure figures and that this type of benefit
is usually more costly for dependants than for insured persons. However,
as shown above, the difference between the cost of providing care for
economically active persons and of that for dependants appears to be
diminishing steadily.
Pensioners.
The medical needs of old persons are generally above the average,
owing to the greater severity of the illnesses they contract. 2
Expenditure on medical care for invalidity pensioners is obviously
much higher than that for other persons protected. Under the Belgian
scheme, for instance, expenditure per head in 1954 was Frs. 4,100 for
invalids as compared with Frs. 726 for economically active insured
persons.3 The number of invalids, however, was less than 2.3 per cent.
of the number of economically active insured persons and less than
1 per cent, of the total number of persons protected.
The inclusion of pensioners among the persons protected will lead
to overstatement of costs but is unlikely to have any appreciable effect
on comparability.
CONTINGENCIES COVERED

The expenditure shown in tables B to G of the appendix is that
in respect of medical benefits; but some services do not give coverage
against all conditions requiring medical care.
All morbid conditions, irrespective of cause, are covered by the health
services of England and Wales and New Zealand, except that in New
Zealand a small amount is paid towards the cost of medical care in
case of employment injury by the employer or the insurer under workmen's compensation legislation.
'Bundesministerium für Arbeit: Die soziale Krankenversicherung im Jahre 1955
(Bonn), p. A63.
2

See Laura E. BODMER, op. cit.

Ministère du Travail et de la Prévoyance sociale: Rapport général de l'année
sociale 1954 (Part IV) (Brussels), p. 114.

PERSONS PROTECTED AND CONTINGENCIES COVERED

Employment injury is only partly covered by the services included in
the study for Denmark1, Germany (Federal Republic)2 and Venezuela,
and not at all by the remaining services.
Tuberculosis is wholly or largely excluded from the scope of the
sickness insurance schemes of the Federal Republic of Germany 3 and
of Italy and that of the Saskatchewan hospital service.
Mental disease among the persons protected is excluded from coverage
by the sickness insurance schemes of Italy (as regards hospital care)
and by the hospital service of Saskatchewan, and is only partly covered by
the sickness insurance schemes of Belgium, the Netherlands and Norway.
Expenditure on maternity care is not included in the statistics used
¡ n the present study for Norway and Switzerland, although the contingency is covered by the schemes concerned.
Employment Injury
The inclusion of employment injury incurred by the persons protected
evidently increases the frequency of morbidity and therefore also medical
expenditure. This increase will be particularly marked where the scheme
covers employees only.
In France, for instance, where the scope of employment injury
insurance is roughly the same as that of sickness insurance (except,
of course, for dependants), expenditure on medical benefit in respect
of employment injury, if related to the number of persons protected by
the sickness insurance branch of the general scheme (including dependants
and pensioners) amounted to 0.21 per cent, of the income per head in
1953. Expenditure under the sickness insurance scheme in the same
year amounted to 3.72 per cent.; the inclusion of employment injury
expenditure would thus give a total of 3.93 per cent.—a difference of
about 6 per cent.
For the Netherlands the total expenditure per man-year on medical
care under the employment injury insurance scheme for non-agricultural
employees has been multiplied by the number of employees compulsorily
insured under the medical care insurance scheme. The total expenditure
thus arrived at has been divided by the total number of persons protected
1
In Denmark sickness insurance provides medical care in case of employment
injury to the extent of its obligations, but employment injury insurance provides the
medical care required in excess of these obligations.
2
In the Federal Republic of Germany sickness insurance generally provides
medical care in case of employment injury for up to 42 days. However, the employment
injury insurance institution may take over the case at any time, which it often does,
particularly when special treatment is required.
s
In the Federal Republic of Germany invalidity insurance schemes bear most
of the cost of care and treatment for tuberculosis and some other long-term diseases.

THE COST OF MEDICAL CARE

by the medical care scheme. The estimated cost for 1951 is then 0.10
per cent, of the income per head, as compared with 2.03 per cent, for
other medical care. The total expenditure, if that of employment injury
insurance had been included, would then have been 2.13 per cent, of
the income per head—about 5 per cent, higher.
The exclusion of employment injury in the statistics of some of the
services covered by the study will therefore affect comparability. Some
account is taken of this factor in the course of the discussion of the
relative cost of medical care in Chapter II.
Tuberculosis
It is obvious that the exclusion of tuberculosis from the contingencies
covered by a service will appreciably affect comparability. So far as
possible adjustments are made for such an exclusion in Chapter II.
Mental Diseases
While mental diseases are specifically excluded from coverage under
some of the services surveyed, they are only partly covered under other
schemes that provide hospital care for limited periods only or do not
deal with incurable cases. Reference to these restrictions will be made
in Chapter II.
Other Diseases
The exclusion of cancer from coverage, as is done under the
Saskatchewan hospital service scheme, must inevitably have an appreciable effect, especially on the figures for hospital expenditure. Allowance
is made for such an exclusion in Chapter II.
Maternity
Medical expenditure per person protected in case of maternity is
comparatively low for employees and its exclusion has only a slight
effect on comparability. Such expenditure is, however, greater for
dependent wives than for insured women and is of some importance
for a national health service such as that of England and Wales.
To conclude, it may be stated that coverage in regard to contingencies
differs considerably from one service to the other. As far as possible
account will be taken of this factor in Chapter II.

CHAPTER II
EXPENDITURE ON MEDICAL BENEFITS AND COST OF
MEDICAL CARE
It may be assumed, for the purposes of this study, that the differences
in the relative expenditure on medical benefits under the social security
services covered by the present study are largely if not wholly due to
differences in the nature and extent of the benefits provided.
In this chapter an attempt is made, first, to define more closely the
nature of the various items of expenditure entered into by each scheme ;
secondly, to attempt to estimate the actual cost of the medical care
received by the persons protected by adding to the total expenditure of
the scheme the additional expenditure (if any) of the patient or of the
public authorities for the care received under the service, wherever
this is known; and, finally, to estimate the aggregate cost to the nation
concerned of all the medical care received by the population. An analysis
is also given of private expenditure on medical care in the United States.
In order to distinguish more accurately between the different types
of care, expenditure on medical benefits has been analysed, as far as
possible, under the following five heads :
(a)

(b)

(c)

(d)

(e)

medical practitioner care outside hospital wards, i.e. treatment by
medical practitioners (whether general practitioners or specialists)
of out-patients and of patients receiving domiciliary care but not
the treatment of hospitalised patients ;
pharmaceutical supplies prescribed for persons not hospitalised,
including proprietary and non-proprietary medicines as well as
minor appliances such as dressings, bandages, etc. ;
hospital care, including maintenance (board and food), nursing,
treatment by medical practitioners (whether surgical or other),
dental care, pharmaceutical supplies and all auxiliary services given
to hospitalised patients in medical establishments of any type;
dental care, including treatment by dental practitioners (referred
to as conservative care) and the supply of prostheses, for persons
protected who are not hospitalised; and
other medical care for persons, not hospitalised, including such
items as the supply of eye-glasses and non-dental prostheses., care

THE COST OF MEDICAL CARE

outside hospital wards given by members of professions allied
to the medical profession (such as nurses, chiropodists, masseurs
and physiotherapists), ambulance services, etc.
It is hoped that this subdivision will make it possible to single out
the main elements of service on the prices of which, in terms of national
income or reference wages, the cost depends.
In order to adjust the basic material with a view to arriving at the
real cost of the care received by the persons protected as distinct from the
cost to social security schemes, an estimate has been made of those
cost elements which are not included in the percentages shown in tables
B to G in the appendix. They consist chiefly of the following:
(a) that part of the cost of the care received under the social security
service which is borne directly by the patient or his breadwinner (referred
to as cost-sharing), provided it is paid to the doctor, pharmacist, dentist
or hospital or other supplier and not to the social security service; and
(b) that part of the cost of the care received which is paid by public
authorities and not included in the expenditure of the scheme.
All sources of information available—both official and unofficial—
have been drawn upon, and numerous estimates have been used for which
no claim of finality can be made.
For the purpose of comparing the estimated cost of medical care
in particular countries and in selected years (generally 1951 and 1953)
the cost is expressed in terms of the national income per economically
active person. This has been done by multiplying the adjusted percentages of the income per head arrived at by the proportion of economically active persons in the population (shown in table J of the appendix).
Where this proportion is not known for the year for which the cost is
computed the corresponding figure for the year closest to the year under
study is taken for this purpose.1
Medical Practitioner Care Given outside Hospital Wards
All the services covered provide both general and specialist care,
although not always to the same extent. However, expenditure on general
practitioner care is separately recorded by only five of the 14 schemes
studied. Since general practitioner care is both the most fundamental
type of care and as the information available thereon is the most homogeneous it will be examined first here.
1
Detailed explanations of the methods used to calculate the percentages given
will be found in the appendix.

EXPENDITURE AND COST

The expenditure in each of the schemes studied on medical practitioner
care or on general practitioner care only (as the case may be) per
person protected in terms of the income per head and of the reference
wage is shown in table C of the appendix.
Private and insurance expenditure on medical practitioner care in
the United States is also shown by way of comparison.
GENERAL PRACTITIONER CARE

In the five countries for which the expenditure of the social security
scheme on general practitioner care is shown in table C (namely Denmark,
England and Wales, Italy, the Netherlands and New Zealand) the
expenditure per person protected ranged from 0.35 to 0.53 per cent.
of the income per head in 1953 and from 0.32 to 0.45 per cent, in 1951.
In terms of the reference wage the range was 0.21 to 0.38 per cent.
in 1953 and 0.16 to 0.37 per cent in 1951. These figures include payments
for maternity care given by general practitioners in England and Wales,
but not, so far as can be ascertained, in other countries.
England and Wales.
In England and Wales (and also in the Netherlands) the medical care
service provides full general practitioner care without limit of duration and
without the patient's having to contribute to the cost. The person protected
registers with a general practitioner of his choice who attends him as and
when he needs care. He can change his " family doctor " at any time, however.
A fixed sum (the so-called capitation fee) is paid to the practitioner by the
scheme for each such person irrespective of the number and nature of the
services rendered. The figures given include payment for maternity care
given by general practitioners, which in 1953-54 accounted for 4.70 per cent.
of the total expenditure on general practitioner care. On the other hand,
this expenditure relates to the whole population of England and Wales, of
whom it is estimated that about 3 per cent, are not registered with a general
practitioner under the National Health Service. Thus, while the inclusion
of the cost of maternity care would raise the percentage for England and Wales
as compared with that for the Netherlands, the inclusion of the total population among the persons protected rather than only the population registered
would make for an understatement of the English percentages.
The expenditure of the National Health Service of England and Wales on
general practitioner care—and, as the patient makes no contribution, the
actual cost of its provision—was 0.40 per cent, of the income per head and
0.38 per cent, of the reference wage in 1953
; the corresponding figures for
1951 were 0.38 per cent, and 0.37 per cent.1
1

It is estimated that the aggregate income of general practitioners from private
practice amounts to approximately £2 million per year. Added to the amount of
£51,719,000 spent by the National Health Service on general practitioner care in
1953-54, this would raise the cost per head of the population from 0.40 to 0.42 per
cent, of the income per head. See Memorandum on the Supplementary Estimates
for the Additional Sums To Be Provided for the Remuneration of General Medical
Practitioners in the National Health Service. Cmd. 8599 (London, H.M. Stationery
Office, 1957).

THE COST OF MEDICAL CARE

Netherlands.
The expenditure of the medical care services in the Netherlands (where
likewise the patient pays nothing) on general practitioner care was 0.35 per
cent, of the income per head and 0.26 per cent, of the reference wage in 1953 ;
the percentages for 1951 were 0.33 and 0.24. The patient may change his
doctor twice a year.
Denmark.
In Denmark the patient does not contribute to the cost of general practitioner care, but this is granted only for 420 days in any three consecutive
calendar years. No assessment can be made of the effect of this factor. The
capitation-fee system is used in cities and towns (where the general practitioner can be changed once a year only), while a system of payment for
services rendered, with free choice of doctor, obtains in the countryside.
Thus in 1953 the cost of medical care under the Danish scheme amounted
to 0.41 per cent, and 0.21 per cent, respectively of the income per head and the
reference wage; the corresponding percentages for 1951 were 0.31 and 0.16.
New Zealand.
The social security health service in New Zealand pays 7s. 6d. for each
visit or consultation \ or roughly 70 per cent, of the cost of the general
practitioner care, which is estimated at 10s. 6d. per visit or consultation.
Higher fees are paid for Sunday, holiday and night services. As a rule the
fee is paid to the doctor, the patient paying the remainder of the cost. There
is free choice of doctor except in isolated areas, where doctors are employed
by the State on a salaried basis. No limit is placed on the duration of care.
The expenditure shown in table C, however, includes some payments for specialist care, since the social security fund pays the same fees for consultations
of specialists established in private practice as it pays for those of general
practitioners. Otherwise specialist care is available free of charge in hospital
out-patient departments. 2
In 1953-54 the outlay on medical care of the New Zealand social security
scheme and the estimated share of the cost borne by the patient added
together came to 0.60 per cent, of the income per head and 0.42 per cent, of
the reference wage. The corresponding percentages for 1951-52 were 0.63
and 0.48.
The expenditure of the scheme alone in 1953-54 worked out at 0.43 per
cent, of the income per head and 0.30 per cent, of the reference wage; for
1951-52 the corresponding percentages were 0.45 and 0.34 respectively.
Italy.
In Italy the general sickness insurance scheme provides general practitioner
care without any charge to the patient up to a maximum of 180 days in any
one calendar year. In practice this restriction applies only to hospital care
and to sickness benefit in cash. 3 Care is given by practitioners established in
private practice, who during the period under review were paid by the scheme,
sometimes on a capitation-fee basis, but more often according to services
rendered. The patient may choose his doctor from among those who have
entered into an agreement with the institution. The expenditure of the Italian
1

For any consultation an additional fee is payable for every complete 15 minutes
after the first half-hour.
2
See below, p. 55
3
See below, p. 50,

EXPENDITURE AND COST

scheme was 0.53 per cent, of the income per head in 1953 and 0.45 per cent in
1951. N o reference wage is available for either of these years; but in 1952, for
which it is known, the expenditure was 0.29 per cent, of the reference wage.

General Remarks.
The five services for which the cost of general practitioner care is
separately recorded provide such care without any charge to the patient,
with the exception of the New Zealand social security health service,
under which the patient pays 30 per cent, or more of the total cost.
There is a limit of duration for general practitioner care in Denmark.
In order to arrive at the total cost of general practitioner care in the
five countries concerned, the New Zealand expenditure figures have been
adjusted to include estimated cost-sharing by the patient.
The cost in terms of the income per head, the reference wage and the
average income per economically active person in 1951 and 1953 is
shown in table 1.
TABLE 1. COST OF GENERAL PRACTITIONER CARE
PER PERSON PROTECTED
Cost as a percentage of—
Country

Denmark
. . . .
England and Wales
Italy
Netherlands . . .
New Zealand :
Cost
Expenditure . .

Income per head

Reference wage

Average income
per economically
active person

1951

1953

1951

1953

1951

1953

0.31
0.38
0.45
0.33

0.41
0.40
0.53
0.35

0.16
0.21
0.37
0.38
0.29
0.24
0.26

0.15
0.18
0.19
0.13

0.20
0.18
0.23
0.14

0.63
0.45

0.60
0.43

0.48
0.34

0.24
0.77

0.23
0.16

0.42
0.30

1952.

The average cost in the five services expressed in terms of the income
per economically active person, which is used for purposes of international
comparison, was 0.18 per cent, in 1951. Incidentally, this is also the
median percentage and corresponds to the cost of general practitioner
care under the National Health Service of England and Wales. F o r
1953 the average a n d the median were 0.20 per cent. The cost in 1953
was somewhat higher than in 1951 in three of the five countries.
The cost under the Netherlands medical care service in 1951 a n d 1953
was considerably lower than that in the other countries. However, a n
increase in the capitation fee brought the percentage u p to 0.19 in 1955.

THE COST OF MEDICAL CARE

The expenditure of the New Zealand social security scheme alone
(i.e. excluding the patient's share) expressed in terms of average income
per economically active person was similar to that under the National
Health Service in England and Wales in 1951-52 but lower in 1953-54.
The English percentage includes the cost of some maternity care, but the
New Zealand figure includes some expenditure on specialist care.
The average expenditure of the social security services in the five
countries (in New Zealand the cost exclusive of the patient's share)
was 0.16 per cent, of the average income per economically active person
in 1951, the median percentage being 0.17. In 1953 both the average and
the median percentages were 0.18.
The estimates for other countries in Chapter III also show the cost
of general practitioner care per person protected to be of the order of
0,20 per cent, of the average income per economically active person.
MEDICAL PRACTITIONER CARE, INCLUDING CARE BY SPECIALISTS

Data on the expenditure on care given by medical practitioners,
including both general practitioners and specialists, are available for
the majority of social security services covered by the present study.
The scale of this expenditure is shown in table C of the appendix. However, the National Health Service in England and Wales and the social
security medical care service in New Zealand only give separate figures of
expenditure on general practitioner care. The figures given in table C
for Mexico and Venezuela relate to expenditure on the remuneration
of all staff employed by the insurance institution and engaged in the
provision of medical or auxiliary care, including medical practitioners
and auxiliary staff, as no more detailed information is available. No
comparable data could be obtained for Chile.
The expenditure shown in table C is in general that incurred for care
given outside hospital wards. However, it was not possible in all cases
to isolate this expenditure, and some of the percentages shown include
elements of hospital costs, as will be explained.
The expenditure on medical practitioner care per person protected
ranged from 0.36 to 0.99 per cent, of the income per head and from
0.24 to 0.70 per cent, of the reference wage in 1953. The corresponding
figures for 1951 were 0.38 to 0.87 per cent, of the income per head and
0.19 to 0.59 per cent, of the reference wage.
Federal Republic of Germany.
The general sickness insurance scheme in the Federal Republic of Germany
provides practically full medical practitioner care, both general and specialist,
and its expenditure represents the real cost of the service, with the exception

EXPENDITURE AND COST

that the full cost of treatment of employment injuries is not shown. It is the
scheme in which the cost of medical practitioner care is highest.
Under this scheme, general practitioners and specialist care outside hospital wards is given mainly at or from the doctor's private surgery. There is
no limit of duration. During the military occupation of Germany in the years
following 1945 the patient paid a proportion of the cost (which varied according
to the zone), but this is no longer the case. The patient's contribution to the
cost (if any) was paid to the sickness fund by the insured person when obtaining
a sickness form ; it is therefore included in the figures in table C.
The patient can change his doctor for each case of treatment. Sickness
forms are generally valid for a period of three months in respect of treatment
by the same doctor. Most of the sickness funds pay capitation fees which
vary with the total earnings of insured persons on the basis of which contributions and benefits are computed, and are fixed by taking into account the
volume of medical care provided in the period of reference. The amount
is paid in a lump sum to the insurance practitioners' associations, which
in turn share it out among the individual practitioners according to the
number of items of service rendered.
Thus the cost of medical practitioner care in 1953 amounted to 1.02 per
cent, of the income per head and 0.73 per cent, of the reference wage. The
corresponding percentages for 1951 were 0.90 and 0.60.
Next in order of magnitude comes the expenditure of a group including, if the years 1952 or 1953 are taken for the purpose of comparison,
the sickness insurance services of the Swift Current region of Saskatchewan (Canada), France, Italy, the Netherlands and Switzerland. The
order within the group is somewhat different according to whether expenditure is expressed in terms of the income per head or the reference wage.
France.
In France the persons protected by the general insurance scheme for nonagricultural employees have free access both to general practitioners and to
specialists established in private practice, but the system followed is one of
repayment to the insured person of part of the costs borne by him. Some
specialist treatment is given at hospital out-patient departments ; expenditure
under this head is included in table E.1 The expenditure shown in table C,
on the other hand, includes payments for surgical and other specialist treatment in private clinics or nursing homes, as well as expenditure on care given
by allied professions.
Until 1955 medical benefit under the French scheme was limited to 26 weeks
per case for ordinary illness and to 156 weeks for illness requiring prolonged
care, provided there was a prospect of recovery. The time limit of 156 weeks
could be further extended if the working capacity of the beneficiary could
thereby be maintained or in case of retraining. In 1955 these time limits were
abolished. An insured person under the French scheme is reimbursed 80 per
cent, of the fees in the official insurance tariff in case of ordinary illness and
100 per cent, in case of long-term or serious illness.
If the percentages shown in table C are tentatively adjusted in order to
exclude expenditure on care given by allied professions and to allow for
cost-sharing by the patient (estimated at 25 per cent, for short-term illness
and 5 per cent, for long-term illness), and if expenditure on treatment in case of
1

About one consultation per head of the population is given per year in hospital
out-patient departments.

THE COST OF MEDICAL CARE

employment injury is added, a total cost per person protected by the scheme
of 0.96 per cent, of the income per head and 0.89 per cent, of the reference
wage is arrived at for 1953, as compared with expenditure by the sickness and
employment injury insurance schemes of 0.75 per cent, of the income per
head and 0.70 per cent, of the reference wage. The corresponding percentages
for 1951 are 0.86 and 0.76 for costs and 0.67 and 0.60 for expenditure.
To estimate the real cost of medical care account must also be taken of
the aggregate incomes of doctors.
The total gross income of medical practitioners in France has been
estimated by the National Institute of Statistics and Economic Research at
Frs. 90,000 million for 1952, representing 0.87 per cent, of the national income
or, per head of the population, 0.82 per cent, of the reference wage.1 The
corresponding estimates for 1951 are Frs. 73,128 million (or 0.80 per cent.
of the national income per head and 0.71 per cent, of the reference wage).
These figures include medical fees for treatment in private hospitals and
those medical fees earned in public hospitals which are liable to income tax.
If the cost per person protected of medical treatment in public hospitals under
the sickness insurance scheme (0.09 per cent, of the income per head) is deducted
from the gross aggregate income of medical practitioners, their earnings for the
provision of care outside public hospitals work out at 0.78 per cent, of the
income per head of the population in 1952 or 0.73 per cent, of the reference wage.
If the same deduction is made from the 1951 figures it appears that the
cost of providing care outside public hospitals was 0.71 per cent, of the income
per head (the cost of the care received under sickness insurance was 0.78 per
cent.) and 0.63 per cent, of the reference wage (0.70 per cent, under sickness
insurance). 2
Italy.
Under the Italian general sickness insurance scheme general practitioner
care, as already stated, is given by private practitioners. Specialist care,
however, is given at the polyclinics of the sickness insurance institution.
Some specialist care is also given outside the clinics by private practitioners.
Like general practitioner care, it is granted without limit of time. 3 The patient
does not contribute to the cost of either type of care. While general practitioners are paid fees for services rendered or capitation fees, specialists
working at the polyclinics are paid by the hour of work at the clinic on the basis
of the average number of consultations they are able to give in the course of
an hour.
The expenditure of the Italian insurance scheme as shown in table C thus
represents expenditure on general practitioner and specialist care given
outside hospitals. The figures do not include treatment for employment
injury or for tuberculosis, these being covered by special schemes. It does,
however, include expenditure on dental care given at the polyclinics.
The expenditure of the Italian scheme per person protected was 0.89 per
cent, of the income per head in 1953 and 0.81 per cent, in 1951. The reference
wage for those years is not known. In 1954 expenditure amounted to 0.94
per cent, of the income per head and 0.57 per cent, of the reference wage.
1
Comité national de productivité, Institut national de la statistique et des études
économiques: Rapport sur les dépenses de santé, Centre de recherches et de documentation sur la consommation, Study No. 4 (Paris, 1954, mimeographed), p. 9.
2
For a detailed explanation of the calculations on which the above estimates
are based see p. 167.
3
The law provides for a maximum duration of 180 days per year, but this
limitation does not apply to treatment of persons not hospitalised and not receiving
cash benefit.

EXPENDITURE AND COST

Netherlands.
In the Netherlands, under the compulsory medical care insurance scheme
for employees, the patient receives general practitioner care from the doctor
with whom he is registered. He is referred to the specialist by his general
practitioner. The specialist receives a specified sum per month for each patient
referred to him, irrespective of the number of consultations or visits rendered.
He can himself propose a prolongation of the treatment. There is no limit
of duration, and the patient does not pay a share of the cost.
However, the expenditure figures for 1949 and the succeeding years,
shown in table C, include about 70 per cent, of the expenditure on specialist
treatment given in hospital, which is not included in the hospital fees but paid
directly to the specialists concerned. 1 If the expenditure shown in table C is
adjusted to exclude these payments the resulting percentages, in terms of the
income per head and the reference wage, are 0.57 and 0.42 for 1953 and 0.53
and 0.37 for 1951 respectively.
According to an inquiry into national expenditure on medical care in
1953 2, the amount paid to medical practitioners not employed by hospitals
was 139 million florins, representing 0.72 per cent, of the national income
or, per head, 0.54 per cent, of the reference wage. These percentages are
almost the same as those shown in table C. It is not clear whether this is a
coincidence or whether the national expenditure includes fees paid to specialists for the care of hospitalised patients for which remuneration is not
included in the hospital fees.3
Switzerland.
In Switzerland the funds carrying subsidised compulsory or voluntary
medical care insurance pay for care by medical practitioners established in
private practice, whether they are general practitioners or specialists, for at
least 180 days in any period of 360 consecutive days (or for 270 days if the
patient bears part of the cost). Most of the funds, however, pay for longer
periods. Approximately 45 per cent, of all insured persons receive benefit
without limit of duration; some 52 per cent, receive benefit for 360 days in
any period of 540 consecutive days.4 Usually the number of days of benefit
received is calculated on the basis of one day for every Frs. 3 of expenditure
the patient incurs. The patient has direct access not only to the general practitioner but also to the specialist, although it is preferred that he should only
visit the latter on the advice of a general practitioner. Expenditure on employment injury and maternity cases is not included in the statistics used in the
present study.
As a rule the patient pays part of the cost of treatment (at least 10 per
cent, but not more than 25 per cent.). Most of the funds pay the doctor
directly, then collect the patient's share from him. Since the patient's share
is thus paid to the fund and not to the doctor, it is included in the receipts
of the funds and also included in the expenditure shown in table C. The share
of the cost borne by the patient averages 17 per cent.
Thus the Swiss funds spend approximately 83 per cent, of the amounts
shown in table C on medical benefit. In terms of the income per head and the
1

See below, p. 52.
Centraal Bureau voor de Statistiek : Kosten en financiering van de gezondheidszorg in Nederland in 1953 (Zeist, De Haan, 1957), p. 23.
3
For a detailed explanation of the calculations on which the above estimates
are based see p. 175.
4
International Social Security Association, 13th General Meeting (London,
May 1958): Sickness Insurance (Annex to Report II). National Monographs (Replies
to the Questionnaire of the I.S.S.A.) (Geneva, 1958, mimeographed).
2

THE COST OF MEDICAL CARE

reference wage the expenditure would then be 0.68 per cent, and 0.51 per cent.
respectively in 1953, as compared to 0.65 per cent, and 0.48 per cent, in 1951.
The real cost of the benefits provided (that is, the aggregate of the cost to the
funds and to the patient) was 0.82 per cent, of the income per head and 0.61
per cent, of the reference wage in 1953; the corresponding percentages for
1951 were 0.78 and 0.58. No adjustments can be made to allow for the exclusion of the cost of medical benefits provided in case of employment injury,
since the sickness insurance schemes do not cover employees only or even
all employees. Similarly, the persons insured for maternity care are not
necessarily insured for sickness.
Canada (Swift Current Region,

Saskatchewan).

The Swift Current scheme of Saskatchewan provides comprehensive care
by medical practitioners, both general and specialist, established in private
practice, including in-patient treatment by such practitioners as well as outpatient hospital care. 1 There is no limit to the duration of the care provided,
and until 1953 the entire cost was borne by the scheme. Since 10 August 1953,
however, a utilisation fee of 1 dollar for each surgery visit has been payable. A
fee for home visits was introduced seven months earlier. Payment is made by
the scheme direct to the practitioners on the basis of agreed fees, which are
lower than those charged to private patients; in 1953 the basic fees paid by
the service were 75 per cent, of the normal fees.
As cost-sharing was introduced in 1953, the real cost of medical practitioner care has been estimated for 1952, for which complete figures are available.
In 1952 the population of the Swift Current region (some 50,000) was
served by 33 physicians practising in the region, of Whom two were full specialists. Three specialists visited the region at regular intervals. Part of the cost
of emergency and specialist services provided outside the region are also paid
for by the scheme. The expenditure shown in table C is the cost per head of
practitioner services in the region, including the cost of treatment in hospital
wards but not that of out-patient treatment at hospitals and of care by
physicians outside the region.
If the figures on expenditure for 1952 are adjusted to exclude that on
treatment of hospitalised patients and to include that on hospital out-patient
care and on care outside the region other than that given to hospitalised
patients, the total works out at 0.57 per cent, of the income per head (instead
of 0.76 per cent.) and 0.29 per cent, of the reference wage (instead of 0.39 per
cent.). For 1951 the corresponding percentages are 0.53 and 0.28.2
The next group of services in order of relative magnitude of expenditure includes Belgium, Denmark and Norway.
Belgium.
Under the Belgian sickness and invalidity insurance scheme the beneficiary
also has direct access to general practitioners and specialists in private practice.
There is no limit on the duration of treatment so long as the patient or his
breadwinner is insured. The qualifying period is 13 to 26 weeks of insurance,
according to age on entry into insurance, and 60 or 120 days of work respectively performed during these periods at the beginning of each benefit period.
The system followed is that under which part of the patient's expenses are
reimbursed. The patient himself has to pay up to one-quarter of the official
1

See below, p. 48.
For a detailed explanation of the calculations on which the above estimates
are based see p. 162.
2

EXPENDITURE AND COST

schedule of medical fees on the basis of which the insurance scheme reimburses
the insured person, depending on the item of service. In fact, however,
during the period under review, the fees charged by the doctor often exceeded
those in the insurance schedule.
The expenditure shown in table C does not include that on special therapies, as separate figures for out-patient and in-patient treatment under this
head are not available. If the Belgian expenditure figures for 1953 are adjusted
to include the part of the cost borne by the patient (estimated at about 50 per
cent.) and the cost of certain special types of treatment, the approximate total
cost of this type of care in 1953 was 0.83 per cent, of the income per head
and 0.70 per cent, of the reference wage.1 However, the accounts for 1953
were closed at an earlier date than previously, so that the 1953 figures, by
comparison with previous years, are somewhat understated. 2
Denmark.
Under the Danish subsidised voluntary insurance scheme care by specialists
is a supplementary and not a statutory benefit. It is provided by the majority
of funds, at least in the cities. Like general practitioner care, it is limited
to 420 days in three consecutive calendar years, except that there is no limit
of duration in the case of children. The patient pays no part of the cost.
He is referred to the specialist by his general practitioner for treatment at
the private surgery of the doctor or at a hospital out-patient department. The
insurance fund pays either a capitation fee or fees for items of service. The
percentages in table C represent expenditure on medical practitioner care
outside hospitals and relate to all persons protected by the scheme, whether
or not they are entitled to specialist care.
In order to arrive at the total expenditure of the service on medical practitioner care, expenditure on out-patient care in public hospitals (0.03 per cent.
of the income per head and 0.02 per cent, of the reference wage in 1953) has
been added to the figures given in table C. This brings the percentages of
expenditure in terms of income per head and of the reference wage from
0.48 and 0.24 to 0.51 and 0.26 respectively. The corresponding percentages
for 1951 were 0.40 and 0.21, expenditure on out-patient care representing
0.03 per cent, of the income per head and 0.02 per cent, of the reference wage.3
These figures, however, do not include the private expenditure of the
persons protected on specialist care. Some allowance should also be made
for the fact that not all persons protected are entitled to a contribution towards
the cost of specialist care from the insurance fund.
The above results may be compared with those obtained by the aid of an
inquiry into national expenditure on health recently undertaken by the
Government. 4 Expenditure on medical practitioner care outside hospitals by
all health insurance funds, by public authorities and by insurance companies,
but exclusive of other private expenditure, amounted to 103,839,000 crowns,
or 0.48 per cent, of the national income, in 1952-53, and to 122,653,000 crowns
(0.55 per cent, of the national income or, per head of the population, 0.28 per
cent, of the reference wage) in 1953-54.
1

An interesting attempt to evaluate the participation of insurance in the cost
to a number of families of medical care will be found in " Les réformes à apporter
au régime de l'assurance obligatoire contre la maladie et l'invalidité ", in Le Progrès
social (Liège, Association belge pour le progrès social), 41st Year, 3rd series, No. 3,
Mar. 1953, pp. 15 ff.
2
For details of the calculations on which these estimates are based see p. 159.
3
For details of the calculations on which these estimates are based see p. 164.
4
Communication from the adviser in social sciences to the Danish Ministry of
Labour and Social Affairs.

THE COST OF MEDICAL CARE

Norway.
Under the Norwegian sickness insurance scheme both general practitioner
and specialist care are provided as a rule from the doctor's private surgery
without limit of duration so long as insurance continues. The patient is normally referred to the specialist by his general practitioner. Payment is either
made by the insurance scheme directly to the doctor or by reimbursement to
the patient of part of his expenses on the basis of the sickness insurance tariff.
Where the fund pays the doctor, the patient also pays his share of the cost
directly to the doctor.
It is estimated that on the average the patient then pays between onequarter and one-third of the cost. If it is assumed that the figure is 30 per
cent, an adjustment on this basis would bring the cost in 1951 from 0.35 to
0.50 per cent, of the income per head and from 0.28 to 0.40 per cent, of
the reference wage. If mileage fees are added, the total is 0.53 per cent, of
the former and 0.43 per cent, of the latter; corresponding percentages for
the expenditure of the funds are 0.38 and 0.31. For 1953 the percentage in
terms of income per head is 0.67.
A recent estimate of the cost of health services in Norway in 1955-56 puts
the aggregate income of doctors in private practice at 110 million crowns. 1
There is no indication of what this item comprises, but it may be roughly
assumed to represent the cost of medical practitioner care. In terms of the
national income of 19,507 million crowns, this cost was 0.56 per cent, or, per
head of the population, 0.24 per cent, of the average income per economically
active person. Transportation for medical purposes cost 35 million crowns,
but doctors' mileage fees were not separately recorded.
The cost of mileage fees in 1951 was 2.86 crowns per member of the scheme,
or an estimated 1.52 crowns per person protected. The latter figure, representing 0.03 per cent, of the income per head or 0.025 per cent, of the reference
wage, is added to the adjusted percentages of 0.50 per cent, and 0.40 per cent.
making totals of 0.53 per cent, and 0.43 per cent., respectively.
England and Wales.
In England and Wales the National Health Service provides all specialist care
given at or from hospitals without limit of duration. Specialists are employed by
the hospital administration on a full-time or part-time salaried basis. Care
outside hospital wards is available at the hospital out-patient departments,
where the patient is usually sent by his general practitioner. Domiciliary
visiting of specialists may be arranged for by the general practitioner.
The cost of all specialist care is included in the figures in table E. It is
estimated that out-patient care represents one-tenth of the total cost of hospital
care. 2 The total cost of medical practitioner care in 1953-54 was thus made
1
Karl EVANG (Director-General of Health Services): Health Services in Norway,
English version by Dorothy Burton Skardal (Oslo, Norwegian Joint Committee
on International Social Policy, 1957), p. 150.
2
See below, p. 46. Part of this amount is for auxiliary services and not for
treatment by specialists or other doctors and part, of course, for general expenses.
However, doctors' salaries for treatment given in hospital, including both in- and
out-patient care, accounted for 0.21 per cent, of the income per head in 1953-54,
or rather more than one tenth of the cost of the hospital service, which was 2.04 per
cent, of that income. If half of this amount is assumed to be for out-patient treatment and doubled to allow for the general expenses connected with such treatment,
the cost of out-patient treatment by specialists would still be approximately 0.20 per
cent, of the income per head. Pending more detailed accounts of the cost of outpatient care, it is accordingly assumed, for the time being, that the cost of specialist
care for out-patients, including the general expenses connected therewith, is onetenth of the total cost of hospital care.

EXPENDITURE AND COST

up of 0.40 per cent, of the income per head for general practitioner care and
0.20 per cent, for specialist care given at or from hospital out-patient departments, making 0.60 per cent, in all. Expressed in terms of the reference wage
the corresponding percentages would be 0.38, 0.19 and 0.57 respectively.
In 1951-52 the cost was 0.60 per cent, of the income per head or 0.59 per cent.
of the reference wage.
New Zealand.
In New Zealand the social security fund pays 7s. 6d. per visit or consultation (the same amount as is paid for general practitioner care) towards
the cost of care given by specialists outside hospitals. The patient pays the
remainder of the fee charged by the specialist. The expenditure shown in
table C, therefore, includes some expenditure on care given by specialists at
their private surgeries. Otherwise, specialist care is as a rule provided free of
charge and without limit of duration at hospital out-patient departments.
X-ray diagnostic, laboratory diagnostic and physiotherapy services are the
subject of separate benefits (see table G).
If an adjustment is made to include the estimated cost of out-patient care
at hospitals, and if allowance is made for cost-sharing as regards general
practitioner care, the cost of medical practitioner care in 1953-54 was 0.74 per
cent, of the income per head and 0.52 per cent, of the reference wage. The
corresponding percentages for 1951-52 were 0.75 and 0.57. On the other hand,
the expenditure of the social security fund was 0.57 per cent, of the income per
head and 0.40 per cent, of the reference wage in 1953-54, and 0.57 per cent.
and 0.43 per cent, respectively in 1951-52. It is assumed that the fund pays the
full cost of out-patient care at hospitals, the cost of which is estimated 1 at
0.12 per cent, of the income per head and 0.09 per cent, of the reference wage
in 1951-52, the corresponding percentages for 1953-54 being 0.14 and 0.10
per cent.
Mexico and Venezuela.
The expenditure shown for Mexico in table C appears to relate to the
remuneration of all medical and dental practitioners employed by the institute
administering sickness insurance, and also to the wages and salaries of auxiliary
workers engaged in providing medical services, at the Institute's dispensaries.
It includes all the expenses of the scheme's dispensaries. The figures given
for Venezuela in table C appear to include all remuneration of medical and
auxiliary staff except surgery and obstetrical staff and the medical staff of the
Institute's hospitals. In both countries the insurance scheme grants medical
care, normally at dispensaries, for a period not exceeding 39 weeks in Mexico
(52 since 1957) and 26 weeks, which may in certain circumstances be extended
to 52 weeks, in Venezuela. In practice, however, there would appear to be no
limit of duration in Mexico so long as the patient is not incapacitated for
work. In Mexico domiciliary visiting was usually done from the central
office by a special medical staff, the salaries of which appear to be included in
table C. More recently, domiciUary visiting was made the responsibility of
the family doctor at the dispensary.
Expenditure in Mexico in terms of the income per head was 3.12 per cent.
in 1953 and 3.23 per cent, in 1951. No reference wage figures are available
for these years. In Venezuela expenditure represented 2.85 per cent, of the
income per head in 1953-54. For 1951 the income per head is not available;
in terms of the reference wage, the expenditure was 1.21 per cent.
1

See bslow, p. 55.

THE COST OF MEDICAL CARE

United States.
The expenditure and cost of the medical practitioner care provided under
the social security medical services selected for the purpose of the present
study may be compared with the estimated private expenditure on physicians'
services in the United States. The percentages shown in table C include the
expenditure of voluntary or private insurance schemes. The total expenditure
is estimated officially on the basis of the average gross income of medical
practitioners, obtained by sampling; to the results obtained the salaries of
doctors employed by pre-payment medical care plans are added.
The expenditure shown in table C includes payments to private practitioners for treatment in hospital. A 40 per cent, reduction has been made to
exclude such payments in the same way as for the estimates made in the
section on hospital care.1 This adjustment brings the cost for 1953 down
from 0.94 to 0.56 per cent, of the income per head and from 0.56 to 0.34 per
cent, of the reference wage. The corresponding percentages for 1951 would
be 0.55 and 0.34 instead of 0.92 and 0.57.
General Remarks.
The cost, per person protected, of medical practitioner care outside
hospital wards in the countries studied as estimated in this section in
terms of income per head, reference wages and the average income per
economically active person is shown in summarised form in table 2 below.
The cost per person protected in terms of the average income per
economically active person in four of the countries, Canada (Swift
Current region), Denmark, the Netherlands and Norway, and private
expenditure in the United States were very similar, ranging from 0.20
to 0.22 per cent, in 1951 and from 0.22 to 0.25 per cent, in 1953 or
1952. In these countries the patient is, as a rule, treated by a general
practitioner acting as a " family " doctor and referred by him to specialists established in private practice. The Danish insurance scheme does
not provide specialist care for all persons protected, and no estimate
is available on private expenditure by persons protected on this item.
The average cost per person protected in 1951 under these four
sickness insurance schemes and in the United States was 0.21 per cent.
of the average income per economically active person. For 1953 (1952
for Canada) the average was 0.24 per cent.
A second group is formed by the social security medical care services
of Belgium, England and Wales, France, the Federal Republic of
Germany, Italy, New Zealand and Switzerland; in these countries
the cost per person protected ranged from 0.28 to 0.42 per cent, of the
average income per economically active person in 1951 and from 0.28
to 0.50 per cent, in 1953.
The English and French percentages include the cost of care given
in case of employment injury, part of which is also included in the
1

See below, p. 57.

EXPENDITURE AND COST

TABLE 2. COST PER PERSON PROTECTED OF MEDICAL PRACTITIONER
CARE OUTSIDE HOSPITAL WARDS, INCLUDING PATIENT'S SHARE
Cost as a percentage of —

Country

Income per head

1951

1953

Reference wage

1951

1953

Income
per economically
active person
1951

Canada (Swift Current scheme,
0.22 '
0.20
0.53
0.57 ' 0.28
0.29
Saskatchewan)
Denmark :
0.40
0.51
0.26
0.20
0.25
0.21
Sickness insurance * . . . .
0.27
0.48 ' 0.55
0.28
0.24 :
Whole country
Netherlands :
0.57
0.37
0.42
0.21
0.23
0.53
Sickness insurance
. . . .
0.29
0.72
0.54
Whole country
0.23
0.67
0.43
0.28
0.53
Norway:
0.56
0.24
Sickness insurance
. . . .
0.56
0.22
0.22
0.55
0.34
0.34
3
Whole country
0.60
0.28
0.60
0.59
0.57
0.28
United States
0.74
0.28
0.75
0.57
0.52
0.29
England and Wales
0.39
0.87
0.70
0.81
0.35
New Zealand
0.78
France :
Sickness insurance
. . . . (0.86) (0.96) (0.76) (0.89) (0.39) (0.43)
0.78 ' 0.63
0.35 >
0.71
0.73 ' 0.32
(Sickness and employment
0.89
0.35
0.39
0.81
injury insurance)
. . . .
0.82
0.35
0.37
0.78
0.61
0.58
Whole country
0.83
0.34
0.70
Italy
1.02
0.50
0.42
0.90
0.60
0.73
Switzerland
3.12
1.01
1.05
3.23
2.85
0.97
Belgium
1.21
Germany (Fed. Rep.) 2 . . .
4
Mexico
1
1952. *5 Including part of cost of employment injury. In Denmark the patient's share in the
Venezuela
cost
of specialist care is not included for sickness insurance.
* 1955-56. * Including all salaries
and wages paid to persons engaged in providing medical care under sickness insurance at dispensaries.
* Including all salaries and wages except for surgery and obstetrics.

New Zealand figures. The latter do not include private expenditure
on care by specialists outside hospitals. However, for France, estimates
made of the cost of medical practitioner care for the whole population
give lower figures than those for the insured population only, the
percentages being 0.32 in 1951 and 0.35 in 1952. In the Federal Republic
of Germany part of the cost of employment injury insurance is
included in that of the sickness insurance scheme. For Italy the cost
does not include the cost of care in case of employment injury or
tuberculosis.
The average for this second group (not including Belgium) in 1951
was 0.35 per cent, and the median was also 0.35 per cent. The average in
1953 for the same six countries was 0.38 per cent. In 1953 the average
for all seven countries was 0.36 per cent, and the median 0.37 per cent.

THE COST OF MEDICAL CARE

The common characteristic of the English, the Italian and the New
Zealand medical care services is the provision of free specialist care
at out-patient clinics, to which the patient is normally referred by his
general practitioner.
The Belgian system, on the other hand, is similar to the French one
in that it reimburses part of the expenses incurred by the patient, who
consults a doctor of his choice (general practitioner or specialist),
although the family doctor system appears to be widespread. The cost
per person protected in Belgium in 1953 was 0.34 per cent, of the income
per economically active person. However, this figure falls short of
reality owing to earlier closing of accounts and temporary restrictions.
Nevertheless the 1954 figure is slightly lower.
In Switzerland the cost corresponded to the average in 1951 and to
the median in 1953.
The cost in the Federal Republic of Germany was the highest in both
years, rising from 0.42 per cent, per economically active person in 1951
to 0.50 per cent, in 1953. The system is one in which the patient has
direct access both to general practitioners and to specialists established
in private practice. He does not need to be referred to the specialist
by a general practitioner.
The differences between the cost of medical practitioner care in the two
groups is probably due to some extent to differences in methods of recording expenditure which could not be allowed for, but may also be partly
accounted for by differences in the practice of specialties. As will be
seen in Chapter IV, the income per person protected of general
practitioners in 1952 or 1953 was commonly around 0.20 to 0.25 per
cent, of the average income per economically active person. This figure
is not far short of the actual cost of medical practitioner care (including
that given by specialists outside hospitals) in the countries where it is
lowest.
In fact, under the Danish sickness insurance scheme, as shown
above, specialist care is not available to all persons protected and private
expenditure could not be estimated. For the Netherlands both the cost
of general practitioner care and of medical practitioner care under
sickness insurance was low in 1953, possibly owing to the deflationary
policy followed after the war. However, by 1955 the cost of general
practitioner care per person protected had risen to 0.19 per cent, of the
average income per economically active person. Moreover, national
expenditure on medical practitioner care had also risen (0.29 per cent.).
In the Swift Current region of Saskatchewan (Canada) the vast majority
of physicians are general practitioners. In the Federal Republic of
Germany, on the other hand, the cost of specialist care appears to be

EXPENDITURE AND COST

high, since the cost of general practitioner care is estimated to have
been not more than 0.25 per cent.
The over-all average percentage for the countries studied here (other
than Mexico and Venezuela) was 0.28 in 1951 or 1952; the median
percentage was 0.28 (11 countries) if the cost of medical practitioner
services for the whole country is taken for Denmark and France. For
1953 the average was 0.31 per cent, with medians of 0.28 and 0.29 per
cent, if the estimates for the whole country are taken for Denmark,
France, the Netherlands and Norway.
In Mexico the expenditure per person protected of the insurance
scheme on all salaries and wages of doctors, dentists, nurses and other
workers assisting in the provision of medical care at dispensaries was
1.01 per cent, of the average income per economically active person in
1953 and 1.05 per cent, in 1951. The corresponding percentage for
Venezuela (excluding the salaries and wages of surgeons and obstetricians) was 0.97 in 1953; data for 1951 are not available since the income
per head was not known to any degree of accuracy.
The expenditure per person protected of the social security services
on medical practitioner care given outside hospital wards (i.e. not
including the patient's share) in the countries concerned is shown in
table 3. The countries are placed in order according to their expenditure in terms of average income per economically active person
in 1951.
It will be seen that the group with the lowest costs has been joined
by Belgium and New Zealand, the range being 0.16 to 0.22 per cent.
in 1951 and 0.20 to 0.25 per cent, in 1953.
In England and Wales, France and Switzerland the expenditure was
somewhat higher, ranging from 0.27 to 0.31 (in the cases of France and
Switzerland employment injury insurance was not, however, included).
For Italy and the Federal Republic of Germany the percentages were
0.35 and 0.42 in 1951 and 0.39 and 0.50 in 1953.
In terms of the average income per economically active person the
average expenditure per person protected of the social security services
in all the countries other than Mexico and Venezuela was 0.26 per cent.
(with a median of 0.22 per cent.) in 1951 and the average cost 0.28 per
cent. By 1953, however, expenditure had risen to 0.28 per cent, and the
cost to 0.31 per cent; the median expenditure was 0.25. On the average
the patient's share was about 7 or 8 per cent, of the cost.
Very tentatively it might be inferred that both cost and expenditure were highest where the persons protected had direct access to
specialists.

THE COST OF MEDICAL CARE
TABLE 3. EXPENDITURE PER PERSON PROTECTED ON MEDICAL
PRACTITIONER CARE GIVEN OUTSIDE HOSPITAL WARDS
(NOT INCLUDING PATIENT'S SHARE)
Expenditure as a percentage ofCountry

Norway
Canada (Swift Current region)
Denmark 2
Netherlands
Belgium
New Zealand
England and Wales
France:
Sickness insurance
. . . .
(Sickness and employment injury insurance)
Switzerland
Italy
Germany (Fed. Rep.) s
. . .
Mexico 3
4
Venezuela
1

Income per head

Reference wage

1951

1953

1951

0.38
0.53
0.40
0.53
0.52
0.57
0.60

0.48
0.57 '
0.51
0.57
0.49
0.57
0.60
0.67

0.31
0.28
0.21
0.37
0.43
0.43
0.59

0.60
(0.67)
0.65
0.81
0.90
3.23

(0.75)
0.68
0.89
1.02
3.12
2.85

0.53

(0.60)
0.48
0.60
1.21

1953

0.29 '
0.26
0.42
0.42
0.40
0.57
0.62

Average income
per economically
active person
1951

1953

0.16
0.20
0.20
0.21
0.21
0.22
0.28

0.20
0.22 !
0.25
0.23
0.20
0.22
0.28

0.27

0.30

(0.70) (0.30)
0.51
0.30
0.51 ' 0.35
0.73
0.42
1.05

(0.34)
0.31
0.39
0.50
1.01
0.97

1952. ' Including part of cost of employment injury care. * Including all salaries and wages
paid under sickness insurance to medical and auxiliary staff at dispensaries, plus expenses. 4 Including
all salaries and wages of medical and auxiliary staff other than surgeons and obstetricians.

Pharmaceutical Preparations Supplied outside Hospital Wards
All the schemes covered by the present study, except those in Canada
and Norway\ provided during the period under review at least some
drugs, preparations and appliances, although the extent of their contribution towards the cost of these items varied greatly. No comparable
breakdown of the statistics is available for Chile.
In this section an attempt is made to estimate the total cost of the
pharmaceutical supplies received by persons protected outside hospital
wards (i.e. the cost of drugs, preparations and minor appliances, such as
dressings and bandages, prescribed for persons protected by the service
who are not in-patients of hospitals, but not including major appliances,
more particularly eye-glasses and artificial limbs) as distinct from the
expenditure of the social security schemes on these supplies. However,
the comparability of the figures is affected not only by differences in the
range of the benefits provided and the extent of cost-sharing but also
by differences in the methods used to record expenditure.
1

See below, p. 41.

EXPENDITURE AND COST

The expenditure on pharmaceutical benefits per person protected,
expressed in terms of the income per head and the reference wage in the
country concerned, is shown, for 13 of the 15 services under consideration,
in table D. Private and voluntary insurance expenditure on these items
in the United States is also given.
Expenditure on this item (the Latin American schemes apart) varied
from 0.12 per cent, to over 0.92 per cent, of the income per head in 1953;
the extremes in 1951 were 0.12 per cent, and 0.76 per cent. The range
of expenditure in terms of the reference- wage was equally wide,
varying from 0.06 per cent, to 0.78 per cent, in 1953 and from 0.06 per
cent, to 0.60 per cent, in 1951. In Mexico.and Venezuela expenditure
was much higher.
These differences, as will be shown below, are partly due to differences in the extent of the benefits provided, but not entirely so, for the
.most comprehensive schemes are not necessarily the most costly.
England and Wales.
The most comprehensive and liberal of the pharmaceutical benefit services
studied is that provided under the National Health Service of England and
Wales. The expenditure shown in table D is for drugs and preparations as well
as for appliances listed in a schedule, such as bandages, dressings, etc., but
not for prosthetic appliances or eye-glasses, the expenditure on which is shown
"in tables E and G respectively. Pharmaceutical benefits are those prescribed
for persons receiving general medical care or general dental care under the
scheme, but not those prescribed by' specialists at out-pátient departments of
hospitals. Pharmaceutical benefit is available without limit of time, and no
restrictions are placed on the prescribing of drugs and preparations except
that a check is kept on the average cost, investigations being made whenever
the cost of the prescriptions issued by a doctor is substantially above the
average for the area concerned. Prior to 1952 the patient made no contribution
to the cost, but in that year á charge of Is: per prescription form and charges
ranging from 5s. to 10s. for scheduled appliances were'introduced.
The expenditure of this service per person • protected was 0.31 per cent.
of the income per head and 0.29 per cent, of the reference wage in 1953-54.
In that year the total cost, including thé patient's share, was 0.36 per cent.
of the income per head and 0.34 1per cent, of the reference wage; the patient's
share of the cost was 14 per cent. For 1951-52 the corresponding percentages
were 0.41 and 0.40.
However, as already mentioned, the cost of pharmaceutical supplies
under the National"Health Service of England and Wales does not include
the cost of prescriptions given by specialists to oUt-patients under the hospital
and specialist service. Since the total expenditure on pharmaceutical benefits
of that branch of the service, including prescriptions for in-patients, is of the
order of £10 million as compared to some £46 million prescribed by general
practitioners or dentists, arid assuming that out-patient
care costs about onetenth of the total cost of hospital and specialist service2 and that pharmaceutical
supplies make up a similar proportion of both, it may be concluded that the
.-.:• : ! The expenditure was £39,826,000, the cost £46,226,000; the difference was
therefore £6,400,000, or 14 per cent, of the cost.
2
See bslow, p. 46.

THE COST OF MEDICAL CARE

cost of prescriptions given to out-patients by specialists amounted to £1 million,
or 2 per cent, of the total expenditure on pharmaceutical benefits. Its inclusion
or exclusion does not therefore appreciably affect the relative cost.
The National Health Service, although granting almost full coverage,
is not in the group of services included in table D which had a relatively
high expenditure on pharmaceutical benefits.
A m o n g the countries other than those in Latin America, the highest
expenditure occurred under the general sickness insurance schemes of
France, the Federal Republic of Germany a n d Italy.
France.
In France under the general sickness insurance scheme for non-agricultural
employees the person protected is refunded his expenditure, according to the
officiai drug tariff, on all non-proprietary drugs and preparations and for
proprietary preparations included in a special list. Up to 1955 benefit was
granted for a maximum period of 26 weeks in case of short-term illness and
156 weeks in case of long-term illness. These limits were abolished in 1955.
The expenditure under the French scheme per person protected was
0.92 per cent, of the income per head and 0.86 per cent, of the reference wage
in 1953. The corresponding percentages for 1951 were 0.74 and 0.66.
The expenditure shown in table D, however, includes expenditure on
optical and orthopaedic appliances, which constitutes about 7 per cent, of
the total. The expenditure of the insurance scheme per person protected on
drugs and preparations only in 1953 was 0.86 per cent, of the income per head
and 0.80 per cent, of the reference wage; the corresponding percentages for
1951 were 0.68 and 0.61.
The patient pays 20 per cent, of the cost of the drugs and preparations
received in case of short-term illness, which account for the bulk of the expenditure. An adjustment to take account of the patient's share brings the cost
to 1.06 per cent, of the income per head and 0.99 per cent, of the reference
wage in 1953 and 0.84 per cent, and 0.74 per cent, respectively in 1951.
If expenditure under employment injury insurance is added the cost per
head of drugs and preparations rises to 1.10 per cent, of the income per head
and 1.02 per cent, of the reference wage in 1953, and to 0.87 and 0.77 per cent.
respectively in 1951, per person protected under the general sickness insurance
scheme.1
These percentages do not include the cost to the patient of pharmaceutical
supplies for which the insurance scheme does not pay. They may be compared
with the national expenditure on pharmaceutical supplies in France as estimated by the National Institute of Statistics and Economic Research in the study
already referred to. 2 For 1952 it was estimated at Frs. 121,958 million,
representing 1.18 per cent, of the national income or, per head of the population,
1.11 per cent, of the reference wage. The total cost of pharmaceutical supplies
provided under the general sickness insurance scheme in that year accounted
for 0.96 per cent, of the income per head or 0.90 per cent, of the reference
wage per person protected, including cost-sharing. For 1951 national expenditure on pharmaceutical supplies was estimated at Frs. 97,632 million,
representing 1.07 per cent, of the national income or, per head of the population, 0.95 per cent, of the reference wage. It will be recalled that the estimated
1
For a detailed explanation of the calculations on which these estimates are
based see p. 168.
2
Rapport sur les dépenses de santé, op. cit., p. 10.

EXPENDITURE AND COST

cost of pharmaceutical supplies provided under the sickness insurance scheme
accounted for 0.84 per cent, of the income per head and 0.74 per cent, of the
reference wage. The national estimates do not include direct purchases by
hospitals; similarly, figures for the cost of pharmaceutical products supplied
under sickness insurance is also exclusive of supplies to in-patients in hospital.
The difference between the estimated cost per head of medicines provided
under the sickness insurance scheme and that of medicines purchased in the
country as a whole may or may not be due to purchases of drugs not provided
by insurance. It would appear to contradict the prevalent belief that insurance
induces higher consumption.
Federal Republic of Germany.
Under the general sickness insurance scheme of the Federal Republic of
Germany drugs and preparations as well as minor appliances were statutory
benefits for insured persons during the period under review. Insured persons
usually paid a flat-rate contribution towards the cost. Major appliances and
artificial limbs were supplementary benefits for insured persons, except in
Lower Saxony, North Rhine Westphalia, Hamburg and Schleswig-Holstein
(the four Länder which formed the British occupation zone after the Second
World War) where they were statutory benefits up to a prescribed amount.
For dependants, on the other hand, drugs, preparations and minor appliances
were statutory benefits up to 50 per cent, of the cost except in the British
occupation zone, where dependants had the same rights as insured persons.
In the other zones the majority of funds paid more than 50 per cent, of the
cost for dependants; in 1955 one group of funds, with 6.68 million members
—or 73.8 per cent, of all members in the zones concerned—paid 70 to 80 per
cent, of the cost, while another group, with about a quarter of that number
of members, granted up to 70 per cent. Throughout the country major appliances, including eye-glasses and artificial limbs, were supplementary benefits
for dependants. The insured person paid D M 0.25 per prescription for himself;
and from 20 to 50 per cent, of the actual cost for his dependants, to the chemist
except in the Länder in the former British zone of occupation, where the insured
person paid D M 0.50 per prescription for himself and for his dependants.
It was not possible to estimate the patient's share of the cost.
The figures for expenditure under the scheme shown in table D includes
expenditure on major appliances and on artificial limbs. It also includes
expenditure on dental prostheses, which was not separately recorded prior
to 1951.
In 1953 the expenditure per person protected on drugs, preparations and
appliances only was 0.67 per cent, of the income per head (0.60 per cent, in
1951) or 0.48 per cent, of the reference wage (0.40 per cent, in 1951). These
percentages include expenditure on major appliances other than dental prostheses, particularly eye-glasses and artificial limbs, which are not included in
the figures for most of the other countries shown in table D. On the other
hand, they do not include the patient's share of the cost which is paid directly
to the pharmacist. 1
1
Total expenditure on medicines was reported to have been DM 30 per head of the
population in 1956, of which one-half was paid by the sickness funds. This represented
1.08 per cent, of the income per head (DM2,773), and 0.53 per cent, of the average
income per economically active person (Ärztliche Mitteilungen (Cologne), No. 1,
4 Jan. 1958, p. 13). Half of this (i.e. 0.54 per cent, of the income per head) would be
expenditure of the sickness insurance funds. However, this expenditure relates to
persons protected by sickness insurance only, which may account for the percentage
in table D being 0.83 for 1953.
For a detailed explanation of the calculations on which these estimates are based
see p. 173.

THE COST OF.MEDICAL CARE

Italy.
In Italy, as was mentioned earlier, under the general sickness insurance
scheme, pharmaceutical benefits are granted only to about two-thirds of the
persons protected. The statutory maximum benefit period is 180 days in any
one calendar year, but this limit applies only to hospital care and the payment
of cash benefit. The patient does not pay part of the cost, but the approval
of the insurance institute is required before certain categories of proprietary
medicines can be obtained.
Since 1950, moreover, general practitioners under contract with the
institution may prescribe drugs and preparations at the expense of the scheme
only for persons protected (whether members or dependants) who are
temporarily unable to attend to their usual activities or are suffering from
specified diseases. At the institution's polyclinics, on the other hand, drugs
and preparations prescribed are provided-free of charge.
If the percentages shown in table D are adjusted to take account of the
fact that pharmaceutical benefit is available only to about two-thirds of
the persons protected, the expenditure on such benefit was 0.95 per cent, of the
income per head in 1953, as compared to 0.82 per cent, in 1951. The reference
wage is not known for these years. 1
- - " N e x t in order of magnitude comes the expenditure of a group of
services (those of Belgium, the Netherlands, New Zealand and Switzerland) the pharmaceutical expenditure per person protected of which
ranges from 0.30 to 0.50 per cent, of the income per head.
Belgium.
In Belgium there is no limit of duration on the provision of pharmaceutical
benefits. However, cost-sharing is considerable. For non-proprietary prescriptions the sickness insurance scheme pays the pharmacist about 75 per cent.
of the cost of insurable items supplied by him; in practice the insured person's
participation is based on the average cost of prescriptions and represents a
fixed amount. Up to 1952 proprietary medicines were classified in two groups
—those deemed indispensable (for which 70 per cent, or more of the price was
paid by the scheme) and other medicines, included in a list, for which 50 per
cent, of the price was paid to the pharmacist up to a certain ceiling, which was
Frs. 20 at the end of April 1952. In May 1952 proprietary medicines other than
indispensable ones were taken off the list of pharmaceutical benefits. Subsequently the question of proprietary medicines not deemed indispensable was
re-examined by a subcommittee of the Sickness and Invalidity Insurance
Fund, and it was decided to include them in the list of approved medicines
if their price did not exceed what is known as the basic price (the price of
the corresponding non-proprietary medicine or of the cheapest proprietary
medicine of the-same composition) by more, than 50 per cent. Seventy-five per
cent, of the basic price of such medicines is paid by the scheme. At the beginning of 1955 the list included 1,500 such articles, as compared to some 20,000
before 1952.,
If account.is taken of cost-sharing by the patient (estimated at 27.3 per
cent, in 1953 and 40 per cent in 1-951) the. cost per person protected in 1953
works out at 0.57 per cent, of the income per head and the expenditure of the
scheme at 0.41 per cent, and 0.49 per cent, of the reference wage instead of
0.35 per cent. For 1951 the cost per person protected was 0.82 per cent, of
1
For a detailed explanation of the calculations on which these estimates are
based see p. 174.

EXPENDITURE AND COST

the income per head and 0.67 per cent, of the reference wage, while the expenditure of the scheme per person protected was 0.49 per cent, of the income per
head and 0.40 per cent, of the reference wage. 1
Netherlands.
In the Netherlands the medical care insurance service provides drugs,
preparations and dressings, subject to certain restrictions as to prescribing.
Such restrictions were first applied by the sickness funds individually. In
1949, however, a national medico-pharmaceutical committee was set up to
study ways and means of attaining some measure of uniformity in the control
of prescribing. It concluded that limits should be fixed for the quantities
ordered per prescription. It also proposed that certain simple " domestic "
drugs should be excluded from the statutory benefits; this was done by decree
of 1 February 1952. The committee established a list of all drugs and preparations that might be freely prescribed and a list of other drugs and preparations
for which the approval of the medical adviser or the medical and pharmaceutical committee of the sickness fund had to be obtained except in urgent cases.
Approval was not as a rule to be given for a proprietary medicine for which
a non-proprietary substitute of equal therapeutic value was available or for
a medicine which could be replaced by a cheaper one of equal efficacy. The
proposals of the committee were generally applied on a voluntary basis as
from 1 March 1952 and since the beginning of 1954 have been included in
the contracts between general practitioners and the sickness funds.
There is no limit of duration and no cost-sharing for pharmaceutical
benefits.
According to the inquiry into the total cost of health services in 1953
throughout the country, already referred t o 2 , 101.5 million florins, or 9.67
florins per head of the population (10,493,000), were spent on drugs and preparations. This expenditure represents 0.52 per cent, of the national income;
or, per head, 0.39 per cent, of the reference wage, while the expenditure of
the medical care service per person protected amounted to 0.35 per cent, of
the income per head and 0.26 per cent, of the reference wage. The service thus
paid about two-thirds of the full cost.
New Zealand.
In New Zealand, under the social security medical care service^ all official
drugs and preparations are included among benefits, but in some cases special
conditions or restrictions are imposed; for example, specified antibiotics are
available only when supplied by a hospital board. There are restrictions on
the provision of proprietary medicines at the expense of the social security
fund; some are provided, but only the cost of the corresponding official
preparation is payable. There are also limits on the quantities of drugs that
may be supplied at the expense of the service on any one medical prescription.
Bandages and dressings are not included among pharmaceutical benefits;
There is no limit on the duration of the benefit nor any cost-sharing other
than for those proprietary preparations referred to above. It is impossible to
estimate the additional cost to the patient of medicines for which part of the
cost only is paid by the social security fund or which are not included among
benefits.
In 1953-54 the expenditure of the New Zealand service per person protected
amounted to 0.40 per cent, of the income per head and 0.29 per cent, of the
1
For a detailed explanation of the calculations on which these estimates are
based see p. 160.
2
See p. 25.

THE COST OF MEDICAL CARE

reference wage. The corresponding percentages for 1951-52 were 0.39 and 0.30.
These figures include payments by the social security fund to institutions for
the provision of pharmaceutical supplies to out-patients, so far as these can
be ascertained.
Switzerland.
In Switzerland the subsidised sickness funds are required by law to pay
at least 75 per cent, of the cost of non-proprietary preparations; they may also
pay at least 75 per cent, of the cost of proprietary preparations included in a
list established by an expert committee by way of supplementary benefit.
Most funds provide these proprietary medicines. The time limits are the
same as those for medical treatment. The percentages shown in table D,
however, include the patient's share of the cost (about 17 per cent.), which is
paid to the fund and not to the chemist. If allowance is made for such costsharing the cost of pharmaceutical products to the insurance fund in 1953
works out at 0.28 per cent, (instead of 0.34 per cent.) of the income per head
and 0.22 per cent, (instead of 0.26 per cent.) of the reference wage. For 1951
the corresponding percentages are 0.27 per cent, of the income per head
(instead of 0.33 per cent.) and 0.20 per cent, of the reference wage (instead
of 0.24 per cent.).
Some countries, however, do not fall into any of the above groups.
Denmark.
In Denmark the expenditure on pharmaceutical benefits under the subsidised
voluntary insurance scheme is comparatively low. Three-quarters of the cost
of essential medicines is borne by the sickness funds, as the legislation in force
prior to 1 July 1951 provided that the funds might pay up to three-quarters
of the cost of specified important medicines as well as an allowance for other
medicines not exceeding two-thirds of the amount paid for the important
ones. Before that date the funds were required to pay only for vital medicines,
such as insulin for diabetics and liver preparations for persons suffering from
pernicious anaemia. In 1951 the funds' liability to pay for important medicines
was extended but their right to grant additional benefits was somewhat curtailed. The funds are now required to pay three-quarters of the cost of essential
medicines and of specified important medicines and, in cases of long and
serious illness, they may pay three-quarters of the cost of other specified
medicines, such as narcotics, sedatives, etc.
Pharmaceutical supplies are provided by chemists on prescription. The
patient pays his share of the cost at the time of purchase and the chemist
submits the prescription as documentary evidence when claiming the remainder
from the funds.
In 1952 (the first full year in which the new rules applied) the expenditure
per person protected incurred by the scheme was 0.11 per cent, of the income
per head. In 1953 it was 0.12 per cent, of that income and 0.06 per cent, of
the reference wage.
The recent inquiry into health expenditure, referred to earlier 1, shows
the total amount spent on drugs, including private expenditure (but not
including expenditure on eye-glasses, bandages and the like), to be
76,715,000 crowns in 1952-53 and 80,667,000 crowns in 1953-54. This
represents 0.35 per cent, of the national income in the first year and 0.36 per
cent, in the second year; in terms of the reference wage expenditure per head
of the population was 0.19 per cent, in 1953-54.
1

See above, p. 27.

EXPENDITURE AND COST

Mexico and Venezuela.
In Mexico and Venezuela the expenditure on pharmaceutical benefits
under the sickness insurance schemes for employees, shown in table D, includes
expenditure on in-patients in hospitals, so far as can be ascertained. The
Mexican figure comprises the salaries of chemists employed by the institute.
In Mexico benefit was granted for 39 weeks per disease and in Venezuela for
26 weeks, with a possibility of extension to 52 weeks. However, there appears
to be no limit of duration for out-patient care. Since 1 January 1957 the
Mexican scheme has granted benefit for 52 weeks per disease; this maximum
may be extended to 78 weeks for insured persons.
Expenditure under the Mexican sickness insurance scheme on all pharmaceutical supplies per person protected was 3.01 per cent, of the income per
head in 1953 as compared to 3.14 per cent, in 1951. The reference wage for
these years is not known.
For Venezuela expenditure per person protected was 1.29 per cent, of the
income per head in 1953-54; in 1952-53 it was 1.27 per cent of the income
per head and 0.58 per cent, of the reference wage. The national income was
not fully assessed prior to 1952; the reference wage is not known for 1953.
Expenditure in 1951-52 amounted to 0.58 per cent, of the reference wage.
Norway.
For Norway, where since October 1953 the scheme has reimbursed 75 per
cent, of the cost of essential and important drugs for specified diseases, the
recent estimate of the cost of Norwegian health services in 1955-56 already
referred to 1 gives the cost of all drugs, medicines, etc., consumed in the country
in that year as 150 million crowns. The composition of this amount is not
specified; but since hospitals supply drugs and other pharmaceutical products
to in-patients, it may be presumed to refer to pharmaceutical supplies outside
hospitals. It represents 0.77 per cent, of the national income or, per head of
the population, 0.33 per cent, of the average income per economically active
person.
Canada.
A survey of sickness in Canada 2 estimates the total expenditure on drugs
and appliances other than eye-glasses and dentures, for a population of
13,540,000 (excluding hospital and public expenditure on this item, but including medicines not prescribed), at 575,300,000 in the year beginning in the
autumn of 1950. This would make $5.56 per head. If related to the average
of the incomes per head for 1950 and 1951 (51,142) it represents 0.49 per
cent., and in terms of the average income per economically active person
0.19 per cent., per head.
United States.
In the United States the figures for private expenditure and some voluntary
insurance expenditure on pharmaceutical supplies cover drugs, preparations
and sundries, ophthalmic products and orthopaedic appliances. Some of this
expenditure may have been on supplies given in hospital.
In 1953 the expenditure on these pharmaceutical supplies per head of
population was 0.72 per cent, of the income per head and 0.43 per cent, of the
reference wage; the corresponding percentages for 1951 were 0.74 and 0.46.
1

Karl EVANG: Health Services in Norway, op. cit., p. 150.
Dominion Bureau of Statistics and Department of National Health and
Welfare: Canadian Sickness Survey, 1950-51. Special Compilation No. 1 : Family
Expenditures for Health Services (National Estimates) (Ottawa, May 1953), p. 5.
2

THE COST OF MEDICAL CARE

According to the statistics compiled by the American Medical Association,
which, although derived from the same, official source as those on which the
present study is based, differ slightly from the latter as a result of differences
in adjustments, the private expenditure on drugs, dressings and minor appliances'
purchased outside hospital but exclusive of artificial limbs, eye-glasses and
hearing aids, amounted to 51,615 million in 1953, representing 0.53 per cent.
of the national income or, per head of the population, 0.32 per cent, of the
reference wage. The correspondingfiguresfor 1951 were $1,516 million, or 0.55
per cent, of the national income and, per head, 0.34 per cent of the reference
wage.1
General Remarks.
The cost of pharmaceutical supplies varied considerably from scheme
to scheme and from country to country, both as regards the expenditure
of the service and the cost to the service and the patient.
However, the percentages, adjusted wherever possible to include
the patient's share and to eliminate the cost of items other than
drugs, preparations and minor appliances, differed from one another
considerably less than those shown in table D. The estimated cost of
pharmaceutical supplies provided under the social security services
covered, including the patient's share, and private or voluntary insurance expenditure in the United States, are shown in table 4.
In terms of the average income per economically active person the
cost, per person protected, of pharmaceutical supplies obtained by way
of benefit from social security schemes (excluding the Latin American
schemes) which supply practically all pharmaceutical products ranged
in 1951 from 0.15 per cent, in the Netherlands, New Zealand and Switzerland to 0.39 per cent, in France. By 1953 the range had widened, the
lowest figure being 0.14 per cent, and the highest 0.49 per cent.
There is a low-cost group comprising Denmark, England and WaleSj
the Netherlands, New Zealand and Switzerland. In New Zealand and
Switzerland, for which only social security data are given, there are
restrictions on the provision of proprietary medicines, but in England
and Wales there are none. On the other hand, in England and Wales
the cost of prescriptions issued by specialists for out-patients is not
included in table 4. The range is 0.15 to 0.19 in 1951 and 0.15 to 0.21
in 1953.
In 1951 (1952 in Denmark) and 1953 the average cost per person
protected in this group of countries was 0.17 per cent. The median
for 1953 was likewise 0.17 per cent.
1
Frank G. DICKINSON and James RAYMOND: The Economic Position of Medical
Care, 1929-1953, Bureau of Medical Economic Research, American Medical Association, Bulletin 99; and The Story in Charts of the Economic Position of Medical Care,
1929-1953, American Medical Association, Bulletin 99A (Chicago, 1955).

EXPENDITURE AND COST
TABLE 4. COST PER PERSON PROTECTED O F PHARMACEUTICAL
BENEFITS SUPPLIED OUTSIDE HOSPITAL WARDS
(INCLUDING PATIENT'S SHARE)
Cost as a percentage of —
Country

New Zealand '
Switzerland
England and Wales
Denmark (whole country) . .
Netherlands (whole country) .
Belgium
Norway (whole country) . . .
Germany (Fed. Rep.)
. . . .
Italy
France:
Sickness insurance . . . .
(Sickness and employment injury insurance)
Whole country
Mexico 4
Venezuela*
United States 6

income per head

Reference wage

Average income
per economically
active person

1951

1953

1951

1953

1951

1953

0.39
0.33
0.41
0.35

0.30
0.24
0.40

0.15
0.15
0.19
0.17 2

0.67

0.29
0.26
0.34
0.19
0.39
0.49

0.60
0.82

0.40
0.34
0.36
0.36
0.52
0.57
0.77 3
0.67
0.95

0.40

0.48

0.28
0.35

0.15
0.15
0.17
0.18
0.21
0.23
0.33 a
0.33
0.42

0.84

1.06

0.74

0.99

0.38

0.47

(0.87)
1.07
3.14
1.27 2
0.74

(1.10)
1.18'
3.01
1.29
0.72

(0.77)
0.95

0.82

0.58
0.46

0.34

(1.02)
(0.39)
1.11 •• 0.48
!

0.43

1.02
0.43
0.30

(0.49)
0.53 2
0.98
0.44
0.29

1
Cost to service only.
* 1952. a 1955. * Including hospital supplies in Venezuela and pre
sumably in Mexico. . 6 Including orthopaedic.and optical appliances (private expenditure)..

The high-cost group includes Belgium, France, the Federal Republic
of Germany1, Italy and the United States. In this group the cost in
terms of income per economically active person ranged from a minimum
of 0.27 per cent, to 0.39 per cent, in 1951 and from 0.25 per cent, to 0.49
per cent, in 1953. The average cost per person protected was 0.33 per
cent, in 1951 and 0.35 per cent, in 1953.2 The medians were 0.34 and
0.33 per cent, in 1951 and 1953 respectively, the range having widened
in 1953.
All these countries except the United States are also in the highcost group for medical practitioner care.
However, if ophthalmic and orthopaedic appliances are excluded from
expenditure on pharmaceutical supplies in the United States, the percentage for 1951 becomes 0.22 per cent, and that for 1953, 0.21 per cent.;
these figures bring the United States into the low-cost group.
The over-all average in 1951 (1952 for Denmark), excluding the
Latin American schemes, was 0.27 per cent, and the median 0.28 per cent.
1
a

Not including patient's share.
Including sickness insurance only for France.

THE COST OF MEDICAL CARE

If the Canadian estimates for 1950-51 are included in the 1951 average,
the average becomes 0.26 per cent., with medians of 0.19 and 0.28 per
cent. For 1953 the average was again 0.27 per cent., but the median
had risen to 0.23 per cent. These averages include expenditure for the
whole population in Denmark, France, the Netherlands and Norway.
The expenditure per person protected on pharmaceutical benefits
by the schemes covered in the study is shown in table 5 in terms of the
three units.
The expenditure of the schemes per person protected, in terms of
the average income per economically active person, was low in Belgium,
England and Wales, the Netherlands, New Zealand and Switzerland,
ranging from 0.12 per cent, to 0.20 per cent, in 1951 and from 0.12 per
cent, to 0.17 per cent, in 1953. The average for this group was 0.15 per
cent, in 1951. For 1953 the average was only 0.14 per cent; expenditure
has fallen in three of thefiveservices.
Expenditure was uniformly high in France, the Federal Republic of
Germany and Italy. The average for these three countries was 0.31 per
cent, in 1951 and 0.38 per cent, in 1953, expenditure having risen in all
three services.
The over-all average (excluding Denmark, Mexico and Venezuela)
for 1951 was 0.22 per cent, and the medians were 0.19 and 0.20 per cent.
TABLE 5. EXPENDITURE PER PERSON PROTECTED ON
PHARMACEUTICAL BENEFITS SUPPLIED OUTSIDE HOSPITAL WARDS
(NOT INCLUDING PATIENT'S SHARE)
Expend •ture as a percentage of —

Country

Income per head

England and Wales
Netherlands
New Zealand
Belgium
Germany (Fed. Rep.) . . . .
France:
Sickness insurance
. . . .
(Sickness and employment
injury insurance)
. . . .
Italy 2
Mexico
Venezuela2
1

19S2.

'Including hospital supplies.

Average income
per economically
active person

1953

1951

1953

1951

1953

0.11 > 0.12
0.28
0.27
0.41
0.31
0.38
0.35
0.39
0.40
0.49
0.41
0:60
0.67

0.20
0.40
0.27
0.30
0.40
0.40

0.06
0.22
0.29
0.26
0.29
0.35
0.48

0.05 !
0.12
0.19
0.15
0.15
0.20
0.28

0.06
0.13
0.14
0.14
0.15
0.17
0.33

0.68

0.86

0.61

0.80

0.30

0.39

(0.71)
0.82
3.14
1.27 2

(0.90)
0.95
3.01
1.29

(0.64) (0.84)

(0.32)
0.35
1.02
0.43

(0.40)
0.42
0.98
0.44

1951

Denmark

Reference wage

0.58 2

—

EXPENDITURE AND COST

For 1953 the average was 0.23 per cent, but the medians had fallen to
0.15 and 0.17 per cent.; the increase in the average was due to rises in
expenditure in the high-cost countries (particularly in France, the Federal
Republic of Germany and Italy), while the expenditure of the schemes
in the other countries had remained stationary or fallen.
The over-all average of 0.22 per cent, for expenditure in 1951 (i.e.
the cost without the patient's share) compares to a cost of 0.27 per cent.
if the patient's share is included. The corresponding percentages for
1953 were 0.23 and 0.27.
Consequently the patient's share of the cost of pharmaceutical
supplies was, on the average, between 15 and 20 per cent, of the cost.
In Latin America the expenditure per person protected varied between
about 0.40 and 1 per cent, of the income per economically active
person; in Mexico the expenditure (presumably including hospital supplies) exceeded 1 per cent, of that income.
Hospital Care
Hospital care is defined as all care (including maintenance, nursing,
care by medical practitioners and members of allied professions, pharmaceutical supplies in hospital and all other auxiliary services) given
to in-patients in medical establishments of any kind.
The differences in the expenditure on medical care incurred by the
social security schemes covered by the present study are largely accounted
for by differences in hospital expenditure, as will be seen from table E.
It is clear that the majority of the schemes do not pay the full cost of
providing hospital care for the persons they protect, a greater or smaller
Share being borne by the taxpayers generally in the form of subsidies
to hospitals out of public funds (other than subsidies to the medical
care service itself), or by the persons protected out of their private
resources over and above their social security contributions.
Moreover, the items included under the heading " hospital expenditure " in table E differ from one scheme to another.
In this section these statements are amplified and an attempt is
made to adjust the figures given in table E so as to make them more
comparable.
England and Wales.
There is one scheme covered by the present survey for which the total cost
of providing hospital care for the persons protected, apart from the cost of care
received in private nursing homes or hospitals not owned by the scheme, is
shown in table E, namely that of England and Wales. The National Health
Service provides every type of hospital care, including care in mental institutions,

THE COST OF MEDICAL CARE

convalescent homes and other medical establishments without limit of duration.
The patient does not pay any of the cost except for care in so-called amenity
wards, but if hospitalised in a private ward he pays the full cost. Institutions of
a predominantly educational type for mentally deficient persons also belong
to the health service; the question whether such institutions should be classified
as hospitals or otherwise calls for closer examination, which cannot be undertaken in this context.
The figures in table E also include expenditure by the National Health
Service on specialist care given to out-patients, which is also provided entirely
by the hospital branch of the service.
On the basis of costing returns for hospitals and other estimates, as shown
below, the cost of providing out-patient care has been estimated at roughly
one-tenth of the total cost of the hospital and specialist service. The deduction
of this proportion from the total cost (2.04 per cent, of the income per head and
1.93 per cent, of the reference wage in 1953-54) gives the cost of hospital care
for in-patients (including payments by patients) in 1953-54, which was 1.84 per
cent, of the income per head and 1.74 per cent, of the reference wage. For
1951-52 the corresponding percentages were 2.01 and 1.93 (instead of 2.23 and
2.15) respectively.
The expenditure of the scheme (i.e. not including charges to patients) may
be estimated roughly by deducting the dilference between cost and expenditure
as shown in table E from the estimated cost of in-patient care, since most of the
charges made seem to be for in-patient care (e.g. accommodation in smaller
wards).
Thus calculated, the expenditure per person protected in 1953-54 was 1.81
per cent, of the income per head and 1.71 per cent, of the reference wage; the
corresponding percentages for 1951-52 were 1.98 and 1.91.
Capital outlay represented 0.07 per cent, of the income per head in 1953-54
and 0.10 per cent, in 1951-52. If this is excluded the expenditure per person
protected was 1.77 per cent, of the income per head and 1.67 per cent, of the
reference wage in 1953-54, the percentages for 1951-52 being 1.91 and 1.84
respectively. These figures include the cost of prostheses (other than dental
appliances), which accounted for approximately 3 per cent, of the total hospital
expenditure. 1
France.
During recent years the expenditure of the French general social security
scheme on hospital care has been approaching the level of expenditure in
England and Wales. It provides all types of hospital care. Up to 1955 it paid
80 per cent, of the cost of hospital care in general wards of public hospitals for
not more than 26 weeks per case and 100 per cent, for cases involving serious
operations and for long illness for up to 156 weeks per case. The time limit was
abolished in May 1955. There was a short qualifying period of employment.
Payments were made to the hospital. The figures in table E include payments
for maintenance expenditure in private clinics but not expenditure on surgical
and other specialist care in such clinics, which is included in table C. Expenditure on care in convalescent homes and sanatoria is included, as well as
that on occupational retraining, but not that on care at spas or in maternity
hospitals, which is included in the figures in table G.
If the share of the cost borne by the patient is added to the figures shown in
table E the totals for 1953 are 1.85 per cent, of the income per head (instead of
1.58 per cent.) and 1.73 per cent, of the reference wage (instead of 1.47 per cent.).
If the expenditure on hospital care for employment injury is added the per1
For a detailed explanation of the calculations on which these estimates are
based see p. 166.

EXPENDITURE AND COST

centages become 1.92 and 1.79 respectively. For 1951 the cost (excluding that
of employment injury) was 1.45 per cent, of the income per head and 1.29 per
cent, of the reference wage; if the cost of employment injury is included the
percentages are respectively 1.51 and 1.34. It should be recalled that these
figures do not include the cost of medical treatment in private institutions but
do include that of out-patient care in public hospitals. 1
According to the inquiry into expenditure on health services published in
1954 by the Research and Documentation Centre 2, the total expenditure of
hospitals in France (not including fees for medical treatment provided in
hospitals liable to the tax on professional incomes) was Frs. 171,038 million in
1952 and Frs. 120,956 million in 1951. This represents 1.66 per cent, of the
national income in 1952 and 1.32 per cent, in 1951 and, per head, 1.55 per cent.
of the reference wage in 1952 and 1.17 per cent, in 1951. To these figures,
however, must be added payments to medical practitioners which are not
included in public hospital receipts and fees paid for treatment in private
hospitals. The latter are, incidentally, not included in the cost of hospital
care provided under the sickness insurance scheme as estimated above. In
1952 doctors' fees paid by public hospitals under the sickness insurance
scheme (including, where appropriate, the proportion paid by the patients)
amounted to 0.09 per cent, of the income per head and a similar percentage of
the reference wage. If these figures are added to the estimated total expenditure
of hospitals the total cost for the whole country works out at 1.75 per cent, of
the income per head and 1.64 per cent, of the reference wage, while the expenditure, per person protected, of the sickness insurance scheme (including
the cost of treatment in spas) amounted to 1.71 per cent, of the income per
head and 1.60 per cent, of the reference wage.
If- 0.09 per cent, is added in the same way to the estimate of expenditure care given in public hospitals under the sickness insurance scheme
throughout the country the total per head of the population works out at 1.41
per cent, of the income per head, while the cost per person protected under the
sickness insurance scheme (including treatment given in spas) was 1.45 percent.
of the income per head. These percentages are equivalent, respectively, to 1.25
per cent, and 1.32 per cent, of the reference wage.
To the extent that these estimates are valid, it would appear that, generally
speaking, persons protected under sickness insurance received more hospital
care than the population as a whole and that insurance covers nearly all the
cost, only a relatively small direct contribution being required from the person
protected.
Canada.
The Saskatchewan hospital insurance scheme in Canada, which covers 93
to 94 per cent, of the population, imposes a qualifying period of six months of
residence in the province. The only persons not covered by the scheme are
those entitled'to complete hospital care under federal or provincial schemes for
special categories of persons, especially patients in mental hospitals and those
receiving care under the provisions of the legislation on tuberculosis sanatoria
and hospitals. For certain classes of persons receiving social assistance, contributions are paid to the hospital service by the provincial or municipal
governments. Indians not living in reserves are allowed to join the scheme on
a voluntary basis; since 1947 persons living in the Northern District, which
was originally excluded from the scope of the scheme, have been allowed to
join on. the same basis.
1

For a detailed explanation of the calculations on which these estimates are
based see p. 170.
2
Rapport sur les dépenses de santé, op. cit.

THE COST OF MEDICAL CARE

The service pays the cost of accommodation in public wards or an equivalent
amount towards the cost of accommodation in private or semi-private wards.
The benefits provided include board and lodging, general nursing, the use of
operating and delivery rooms, surgical dressings, X-ray, laboratory and other
diagnostic services, X-ray treatment, anaesthetics, physiotherapy and most drugs
in general use. Treatment by the medical staff of the hospital is included among
the benefits paid for, but not the services of doctors or special nurses who are
not employed by the hospital; these services, as well as out-patient treatment,
the extra charges for private and semi-private accommodation, blood transfusions, patent medicines and a few new and expensive drugs are not covered.
Apart from a small contribution which the service pays towards the cost of
tuberculosis sanatoria, it mainly provides care in general hospitals, since
tuberculosis and mental diseases are not covered. Employment injury is also
excluded. The scheme pays the participating hospitals for the services provided
by way of benefit.
The expenditure of the hospital service per person protected (not including
the cost of administration) was 1.53 per cent, of the income per head and 0.77
per cent, of the reference wage in 1953; the corresponding percentages for 1951
were 1.41 and 0.76. This expenditure is stated to cover over 90 per cent, of the
cost of in-patient care in general hospitals. However, the expenditure per
person protected shown in table E does not include payments by patients for
treatment given in hospital by private practitioners. The expenditure of
hospital patients on treatment by medical practitioners not on the staff of
hospitals has been estimated, on the basis of the experience of the medical care
service of the Swift Current region of Saskatchewan, at 0.38 per cent, of the
income per head and 0.19 per cent, of the reference wage in 1953; the corresponding percentages for 1951 were 0.33 and 0.18. The cost of the care
received under the Saskatchewan hospital scheme can thus be estimated at
1.91 per cent, of the income per head and 0.96 per cent, of the reference wage
in 1953; the corresponding percentages for 1951 were 1.73 and 0.94.
If the estimated expenditure on medical practitioner care provided in
hospital wards in the Swift Current region is added to the total net operating
expenditure of all Saskatchewan hospitals, including mental and tuberculosis
institutions, the total cost of hospital care works out, per head of the population, at 2.73 per cent, of the income per head and 1.37 per cent, of the reference
wage for 1953. For 1951 the cost (excluding that of private hospitals and of
out-patient care in public general hospitals) was 2.46 per cent, of the income
per head and 1.33 per cent, of the reference wage.
For the whole of Canada the total net operating expenditure of all hospitals
in 1953 was 2.12 per cent, of the national income and, per head of the population, 1.07 per cent, of the reference wage. If the estimated amount of payments
made by hospital patients to private practitioners, based on the experience of
the Swift Current scheme, is added, then the total estimated cost of hospital
care was 2.50 per cent, of the income per head and 1.26 per cent, of the reference wage. The inclusion of the cost of construction brings the over-all hospital
expenditure in 1953 to 3.12 per cent, of the income and 1.58 per cent, of the
reference wage. No comparable data are available for 1951.a
Belgium.
Under the Belgian sickness and invalidity insurance scheme hospital care,
including treatment, is provided without limit of duration, even for long-term
diseases such as tuberculosis, mental disease, cancer and poliomyelitis, but
not for care or treatment in a mental institution.
1
For a detailed explanation of the calculations on which these estimates are
based see p. 162.

EXPENDITURE AND COST

The expenditure of the Belgian scheme on hospital care * was 0.64 per cent.
of the income per head or 0.55 per cent, of the reference wage in 1953. The
corresponding percentages for 1951 were 0.63 and 0.52. The scheme either
pays the hospital directly or reimburses the patient part of his expenses, in
either case on the basis of the insurance tariff. In the former case the patient
pays the difference, if any, between the fees charged by the hospital or doctor
and the payment made by the scheme to the hospital. The insurance tariff
specifies the total amount payable per day of hospitalisation for maintenance
and certain general expenses but exclusive of medical treatment. The amount
payable depends on the nature of the illness, whether surgical, non-surgical,
cancer, tuberculosis, poliomyelitis, treatment in preventoria, etc. The patient
does not pay a share of the cost provided that the latter does not exceed the
amount fixed in the official tariff. Separate payments are made by the insurance
scheme for medical treatment in hospital at insurance tariff rates for surgery
and for essential proprietary medicines, and regular weekly amounts are paid
for other medical care.
It will thus be seen that the payments made by the Belgian scheme do not
cover the entire cost of hospital care. A very rough estimate of the cost of the
days spent in hospital by persons protected by the sickness and invalidity insurance scheme in 1951 (including medical fees, the cost of medicines and
depreciation of equipment) revealed that the total cost per person protected
amounted to Frs. 292, that is to say, 0.81 per cent, of the income per head
or 0.67 per cent, of the reference wage, while the expenditure of the insurance
scheme on hospital care per person protected amounted to 0.63 per cent, of
the income per head and 0.52 per cent, of the reference wage. This estimate
suggests that the scheme was paying, on the average, about 78 per cent, of the
cost of the hospital care received by the persons protected. Another estimate
reckons the cost of hospital care per person protected at 1 per cent, of the
income per head and 0.83 per cent, of the reference wage; if this figure is
correct, then the scheme paid only 63 per cent, of the cost. The estimated cost
in 1953 was 0.98 per cent, of the income per head or 0.83 per cent, of the
reference wage, the scheme paying, per person protected, 0.64 per cent, of the
income per head, or about 65 per cent, of the cost.2
According to a report published by the national committee for the study
of certain aspects of social medicine, which was set up by the National Federations of Mutual Benefit Societies, capital expenditure on hospitals amounted
to Frs. 852.5 million in 1954 and Frs. 917 million in 1955. This represented 0.24
and 0.25 per cent, respectively of the national income or, per head of the population, 0.10 per cent, of the average income per economically active person.
However, the report does not permit of a compilation of hospital operating
costs, since no distinction is made between the cost of medical practitioner
care and of pharmaceutical supplies for ambulatory patients on the one hand
and for hospital in-patients on the other. 3

All payments to doctors for hospital treatment, including surgery, as well
as those for pharmaceutical supplies in hospitals have been included in the percentages
shown in table E. However, expenditure on special therapies in hospital cannot be
separated from that on special treatments given outside hospitals.
2
For a detailed explanation of the calculations on which these estimates are based
see p. 160.
3
"Rapport de la Commission nationale belge sur l'étude de certains aspects
du problème de la médecine sociale", in La mutualité professionnelle (Brussels, Union
nationale des mutualités professionnelles de Belgique), 10th Year, No. 4, Oct. 1957,
11th Year, Nos. 1-3, Jan. 1958, Apr. 1958 and July 1958.

THE COST OF MEDICAL CARE

Federal Republic of Germany.
The hospital care provided under the general sickness insurance scheme of
the Federal Republic of Germany includes maintenance, nursing, treatment,
pharmaceutical supplies and all other auxiliary services in all residential
institutions, including convalescent homes. Persons suffering from tuberculosis
are normally looked after by invalidity insurance schemes; this may also be
the case for persons suffering from rheumatism or other chronic diseases. Care
is available to insured persons as a statutory benefit for not more than 26
weeks per case, but the rules of the sickness fund may extend this period to
52 weeks. If the insured person has exhausted his right to hospital care and
the medical adviser of the fund is of the opinion that there is a reasonable
prospect of his recovering working capacity if care is continued the fund may
go on providing benefit until working capacity is restored. There is no costsharing. The fund pays the hospital directly.
For dependants, however, hospital care is a supplementary benefit. It is
granted for not more than 26 weeks by the majority of funds ; in a small number
of funds the insured person pays the hospital between 10 and 20 per cent, of the
cost of treatment for his dependants.
The scheme's expenditure on hospital care per person protected in 1953
amounted to 0.81 per cent, of the income per head or 0.58 per cent, of thè
reference wage; the corresponding percentages for 1951 were 0.74 and 0.50.
The sickness funds do not pay the full cost of providing hospital care for
persons protected ; moreover, the average number of hospital days per person
protected is lower than that per head of the population. In 1953 the number of
patient-days paid for by sickness insurance was approximately 2.06 per person
protected, while the total number of patient-days per head of the population
was 3.41. The average cost of hospital care per head of the population is
estimated, on the basis of official data, at DM 47.16, or 2.23 per cent, of the
income per head or 1.60 per cent, of the reference wage, while the expenditure
of the sickness insurance scheme per person protected amounted to only 0.81
per cent, of the income per head and 0.58 per cent, of the reference wage. If
the average cost per patient-day in hospital under the sickness insurance scheme
is assumed to be the same as for all hospitals (DM 13.83) then the cost per person
protected of hospital care received under the scheme would be DM 28.42 as
compared to the DM 17.20 spent by the scheme, representing about 60 per cent.
of the actual cost, which would thus work out at 1.34 per cent, of the income
per head and 0.97 per cent, of the reference wage.
The cost of mental institutions per head of the population is estimated at
0.25 per cent, of the income per head or 0.18 per cent, of the reference wage. 1
Italy.
The Italian general sickness insurance scheme grants hospital care in
respect of diseases other than tuberculosis and mental or nervous disorders;
certain communicable diseases for the care of which the communes are responsible are also excluded. Employment injury is covered by a differenrscheme, as
is also tuberculosis. The sickness insurance scheme grants hospital care,
including treatment by doctors, to insured persons for up to 180 days in any
calendar year. However, where there has been a continuous period of incapacity
requiring hospital care or the payment of cash benefit (or both) of 180 days
(a period is deemed continuous if it is not interrupted by more than 60 days)
the insured person may not begin a fresh benefit period even in the next year,
before 75 days have elapsed, at least 15 of which were days of work. In the
1
For a detailed explanation of the calculations on which these estimates are
based see p. 173.

EXPENDITURE AND COST

case of chronic disease the maximum is 180 days in any three years. Dependants are entitled to hospital care for the same periods except that the dependants
of insured persons employed in industry, commerce, banking, credit and
insurance are entitled to only 30 days' care per calendar year. Persons protected
are admitted to public and other hospitals under agreement with the institution
administering the general sickness insurance scheme; they do not pay any
of the cost. The inclusive fees charged by public hospitals to the institution
are calculated at special rates and do not always meet the full cost. Lump-sum
payments for medical treatment are made to doctors for each case of hospitalisation.
The years 1953 and 1952 have been selected for the purpose of estimating
the Italian cost of hospital care, since more complete data are available for
1952 than for 1951.
The expenditure of the Italian general sickness insurance scheme per person
protected on hospital care in 1953, as shown in table E, was 0.69 per cent, of
the income per head and 0.70 per cent, in 1952; no reference wage figure is
available for 1953, but the expenditure of the scheme in 1952 amounted to 0.41
per cent, of the reference wage.
Some adjustment of these figures might be made in view of the fact that not
all the persons protected by the scheme are entitled to hospital care, but the
effect would be insignificant.
To these figures should be added the expenditure on sanatorium care under
the tuberculosis insurance scheme, which covers some 20 million persons,
including practically all employees and their dependants and some otrnr
groups. The expenditure per person protected by the general sickness insurance
scheme in 1953 then works out at 1.43 per cent, of the income per head, the
corresponding percentage for 1952 being 1.52. The reference wage for 1953
is not known; the expenditure in 1952 amounted to 0.90 per cent, of that
wage.
On the other hand the expenditure of all public and private hospitals
and of the sanatoria owned by the tuberculosis insurance scheme represented
1.81 per cent, of the national income or, per head, 1.10 per cent, of the
reference wage in 1954: the corresponding percentages for 1952 were 1.99
and 1.17.1
Netherlands.
Under the compulsory medical care insurance scheme for employees and
their dependants in the Netherlands hospital care, including medical treatment
and all auxiliary services, was granted for a maximum period of 42 days per
case until 1955, when the limit was raised to 70 days. Treatment by specialists
in hospital and pharmaceutical benefits, however, are granted without limit
of duration at the expense of the scheme except for mental cases. The patient
does not pay part of the cost unless he goes into a private or semi-private
ward. The rates per patient-day charged by public hospitals to the sickness
funds include all hospital costs properly so called except that of teaching and
first aid. Mental patients are hospitalised at the expense of the sickness
insurance scheme for up to 42 days (now 70 days) per case if hospitalisation is
necessary from a medical point of view for purposes of observation or treatment. Care in tuberculosis sanatoria is granted without limit of duration,
75 per cent, of the cost being paid by the sickness insurance scheme. As a
rule the funds pay hospitals directly.
The expenditure of the medical care insurance scheme in the Netherlands
shown in table E does not, however, include that part of the cost of treatment
1

For a detailed explanation of the calculations on which these estimates are
based see p. 174.

THE COST OF MEDICAL CARE

by specialists not covered by the inclusive hospital fees, which accounts for
about 70 per cent, of the total expenditure on specialist care in hospital wards
(see table C). About 90 per cent, of insured persons and their dependants
are voluntarily insured under supplementary hospital insurance schemes for
hospital care beyond the maximum period.
If adjustments are made to allow for these two factors the total cost of
hospital care per person protected in 1953 works out at 1.01 per cent, of the
income per head and 0.76 per cent, of the reference wage, while the expenditure
of the scheme amounted to only 0.76 per cent, of the income per head and 0.57
per cent, of the reference wage. The corresponding percentages for 1951 were
0.97 and 0.69 as regards the actual cost and 0.73 and 0.52 as regards the
expenditure of the schemes.1
The recent inquiry into national expenditure already mentioned reveals
that the total operating cost of hospitals, including those for mental disease and
for tuberculosis, amounted to 276.8 million florins, in 1953. This represented
1.43 per cent, of the national income (19,360 million florins). Per head of the
population (10,493,000) it represented 26.38 florins, or 1.07 per cent, of the
reference wage of 2,471 florins. Mental hospitals cost 59.1 million florins,
representing 0.31 per cent, of the national income, or, per head, 0.23 per cent.
of the reference wage. Without mental hospitals, the operating cost was
1.12 per cent, of the income per head of the population as compared to the
estimated cost per person protected under the sickness insurance scheme of
1.01 per cent. The cost of mental hospitals thus accounted for the greater
part of the difference between the cost per head of the population and the
estimated cost per insured person. However, fees paid to doctors not employed
by the hospitals for care of hospitalised patients do not appear to be included.
Norway.
The Norwegian sickness insurance scheme, during the period under
review, provided hospital care in public wards (or made a corresponding
contribution to care in private wards), including treatment and pharmaceutical
supplies as well as auxiliary services, for a maximum duration of 52 weeks
per illness in general and 104 weeks for tuberculosis, cancer or arthritis and
some other diseases. The patient did not contribute. These time limits were
abolished in July 1953, and hospital care is now granted as long as the illness
lasts, provided it is curable.
For the purposes of this part of the study 1949 and 1952 have been selected
as reference years because data on the cost of hospitals were available for
these years at the time of writing.
Hospital expenditure under the Norwegian scheme per person protected
was 0.76 per cent, of the income per head and 0.52 per cent, of the reference
wage in 1952, compared to 0.63 and 0.49 per cent, respectively in 1949.
The sickness insurance scheme does not pay the full cost of the hospital
care received by the persons protected. In 1949 the cost per patient-day in
general hospitals (not including capital expenditure and depreciation) was
18 crowns. On the other hand, the operating expenses of mental hospitals
and tuberculosis sanatoria were only 11 crowns per bed-day for the former
and 12 crowns for the latter.2 The cost of treating mental cases is not likely
to have been borne to any considerable extent by the sickness insurance
scheme, since it does not cover incurable cases.
1
For a detailed explanation of the calculations on which these estimates are
based see p. 176.
2
Samordning av de Nordiske Lands Statistikk, verdrorende den Sostale Ix>vgivning
(Oslo, Nationaltrykkeriet, 1953), pp. 47-48. The data on the cost per patient-day
in 1953 were obtained from the I.L.O. Correspondent in Oslo.

EXPENDITURE AND COST

The total operating expenditure of hospitals (other than maternity homes)
per head of the population is estimated to have been 1.59 per cent, of the income
per head and 1.10 per cent, of the reference wage in 1952. For 1949 the total
expenditure represented 1.22 per cent, of the income per head and 0.96 per
cent, of the reference wage.
The total cost of the hospital care received by the persons protected by the
sickness insurance scheme (including the share of public authorities) per
person protected is estimated at 1.11 per cent, of the income per head or
0.76 per cent, of the reference wage for 1952, while the expenditure of the
sickness insurance scheme amounted to only 0.76 per cent, of the income per
head and 0.52 per cent, of the reference wage. The sickness insurance scheme
thus paid about 66 per cent, of the cost. For 1949 the cost per person protected of the hospital care received by persons covered by sickness insurance
was 0.95 per cent, of the income per head and 0.75 per cent, of the reference
wage, while the expenditure of the scheme was 0.63 per cent, of the income
per head
and 0.49 per cent, of the reference wage, or 68 per cent, of the total
cost.1
The recent estimates of national expenditure on health services in 1955-56,
already referred to 2, give the operating cost of general hospitals, maternity
clinics, tuberculosis sanatoria and institutions for mental disease at 350.6 million
crowns of which 69.1 million are for mental institutions. Operating costs
would thus have amounted to 1.80 per cent, of the national income or, per
head, 0.77 per cent, of the income per economically active person. If the cost
of construction (60 million crowns) is added, the cost is 2.11 per cent, of the
national income or, per head, 0.90 per cent, of the average income per economically active person. The operating cost of mental institutions is 0.35 and
0.15 per cent, respectively, in terms of the two units. If the expenses of
homes for the feeble-minded, of institutions for the physically handicapped
and of rehabilitation institutes are added, the operating cost of all medical
institutions is raised to 376.5 million crowns, representing 1.93 per cent, of the
national income or, including construction, to 2.24 per cent, which, in terms
of the income per economically active person, represents per head of population 0.95 per cent.
In some countries (Denmark, New Zealand and Switzerland),
expenditure on hospital care was markedly lower than in the others.
The social security medical care benefits in these countries obviously
covered only a small fraction of the total cost of hospital care.
Denmark.
Under the Danish voluntary subsidised sickness insurance scheme for
persons of limited means, hospital care, including treatment and all auxiliary
services as well as pharmaceutical supplies, is provided for a maximum duration of 420 days in any three consecutive calendar years. The patient does not
pay part of the cost if he is treated in a general ward.
The expenditure on hospital care of the public sickness funds per person
protected amounted to 0.19 per cent, of the income per head and 0.10 per
cent, of the reference wage in 1953, as compared to 0.17 per cent, and 0.09
per cent, respectively in terms of the two units, in 1951.
If expenditure on out-patient care and convalescent care is deducted,
the expenditure on in-patient care in hospitals per person protected in 1953
1
For a detailed explanation of the calculations on which these estimates are
based see p. 164.
s
Karl EVANG: Health Services in Norway, op. cit., p. 150.

THE COST OF MEDICAL CARE

works out at 0.14 per cent, of the income per head and 0.07 per cent, of the
reference wage; the corresponding percentages for 1951 were 0.13 and 0.07.
This is less than 11 per cent, of the full cost of the hospital care received by the
persons protected, which is estimated, on the basis of the average operating
costs of all hospitals per day, to have been 1.37 per cent, of the income per
head and 0.71 per cent, of the reference wage, the corresponding percentages
for 1951 being 1.27 and 0.65.
The cost per head of the population of all patient-days spent in general,
maternity, mental and tuberculosis hospitals (excluding depreciation, interest
and—apparently—capital expenditure) has been estimated, on the basis of
official information on the cost per patient-day, at 1.88 per cent, of the income
per head and 0.97 per cent, of the reference wage in 1953 (for 3.12 patient-days
per head of population); the corresponding percentages for 1951 (calculated
for 3.09 patient-days per person) were 1.77 and 0.90.1
On the other hand the inquiry into health expenditure in 1952-53 and
1953-54, already referred to 2, covering, inter alia, fees paid by patients but not
the current expenditure of private hospitals, revealed that such expenditure
amounted to 451,908,000 crowns in 1952-53 and (if the expenditure of subsidised institutions for chronic disease is included) 461,544,000 crowns in
1953-54. These sums represented 2.09 per cent, of the national income in
1953 and 2.05 per cent of that for 1951 respectively.
It is assumed that these figures include the cost of hospital out-patient
care; the overstatement due to this inclusion is in all probability more or less
compensated by the exclusion of the expenditure of private hospitals and
convalescent homes, but this is by no means certain.
New Zealand.
The New Zealand social security medical care service, which covers the
whole population, provides hospital care for all residents at no direct cost to
the patient if he is treated in a public hospital; public hospitals have no private
wards. There is no limit on the duration of treatment. The social security
fund pays a fixed amount per patient-day to public hospitals, the remainder
of the cost (which is by far the greater part) being defrayed out of general
revenue and local rates. The fund also pays a fixed amount per day towards
the cost of hospital care in private hospitals and other approved institutions.
During the period under review most of the public hospitals were administered by regional bodies (the hospital boards) and financed by local rates and
state subsidies; the latter were paid in addition to the payments made by the
social security fund. The fund's contribution originally corresponded more or
less to the fees that were charged to patients before the social security medical
care service was introduced; it was raised considerably in 1954. There are also
institutions which belong to the Department of Health, as well as state mental
hospitals, where care is provided at government expense.
By adding up the expenditure of hospital boards (which includes capital
outlay and payments from the social security fund), the expenditure of the
Department of Health on its own institutions and that of state mental hospitals
and the contributions of the social security fund to private hospitals or approved
institutions, one arrives at a total for hospital expenditure in 1953-54 of 2.79
per cent, of the national income or, per head of the population, 2 per cent.
of the reference wage. The expenditure of the social security fund, on the other
hand, amounts to only 0.30 per cent, of the national income or, per head,
1

For a detailed explanation of the calculations on which these estimates are
based see p. 178.
2
See above, p. 27.

EXPENDITURE AND COST

0.22 per cent, of the reference wage. In 1951-52 the total hospital expenditure
(not including payments by patients to private hospitals and institutions)
amounted to 2.73 per cent, of the national income and 2.09 per cent, of the
reference wage, while the expenditure of the social security fund amounted to
only 0.34 per cent, of the national income and 0.26 per cent, of the reference
wage.
On the other hand, these figures do include the cost of out-patient care in
public hospitals, which is estimated, per person protected, at 0.14 per cent, of
the income per head and 0.10 per cent, of the reference wage for 1953-54. On
this basis the cost of in-patient care would be 2.65 per cent, of the income per
head and 1.90 per cent, of the reference wage. The corresponding percentages
for 1951-52 are 0.12 and 0.09 for out-patient care and 2.61 and 2.00 for inpatient care.
The cost of hospital care is somewhat overstated in that it includes the cost
of homes for old people, but understated in that it does not include expenditure
on the construction of mental hospitals (figures for which have been available
annually only since 1948-49 and which represents between 0.04 and 0.06 per
cent, of the income per head) or payments by patients to private hospitals.
If capital expenditure on construction for hospitals other than mental
hospitals is excluded from the total, the operating cost of hospitals for the care
of in-patients works out at 2.19 per cent, of the income per head and 1.57 per
cent, of the reference wage in 1953-54; the corresponding percentages for
1951-52 were 2.20 and 1.68.1
Switzerland.
The Swiss subsidised sickness insurance funds are obliged to make a contribution towards the cost of medical and pharmaceutical treatment in hospital.
Maintenance costs are not a statutory benefit, but many funds make contributions to these costs also. The maximum benefit period must be at least 270 days
in any period of 360 consecutive days for the fund to qualify for a federal
subsidy, but a large number of funds have longer benefit periods (usually
360 days in any 540 consecutive days). For tuberculosis, which is covered by a
special insurance scheme, the maximum benefit period must be at least 720 days
in any five consecutive years with a possibility of extension to 1,080 days if the
doctor of the medical establishment certifies that this will improve the prospect
of recovery. The majority of funds fix a maximum of 1,800 days in seven years.
The funds insuring against tuberculosis usually pay prescribed daily allowances
during periods of sanatorium care and also pay for certain medicines and
surgical operations.
The expenditure per person protected on hospital care of the funds publishing statistics was 0.33 per cent, of the income per head and 0.25 per cent, of
the reference wage in 1953. The corresponding percentages for 1950 2 were
0.35 and 0.26. If the patient's share of the cost (averaging 17 per cent.), which,
as a rule, is paid to the fund, is deducted the expenditure works out at 0.27 per
cent, of the income per head and 0.21 per cent, of the reference wage for 1953
and at 0.29 per cent, of the income per head and 0.22 per cent, of the reference
wage in 1950.
This expenditure is comparatively low and covers only a fraction of hospital
costs.
1
For a detailed explanation of the calculations on which these estimates are
based see p. 177.
2
Since data on the number of patient-days spent in all hospitals are not available
for the year 1951, the years 1953 and 1950 have been selected for purposes of
comparison.

THE COST OF MEDICAL CARE

The number of days of hospital care for which these sickness funds paid
benefit in 1953 was 2.11 per person protected. Of these, 0.62 days were for
care in tuberculosis sanatoria. On the basis of the average cost per patient-day
of sanatorium care, as established for hospitals reporting expenditure, and the
average cost in general hospitals with over 75 beds (assumed to be representative of this type of hospital) these days cost 36 francs per person protected,
representing 0.85 per cent, of the income per head or 0.64 per cent, of the reference wage. The corresponding percentages for 1950 are 0.88 and 0.65. The
sickness funds were thus paying less than 40 per cent, of the cost of the hospital
care received by the persons protected.
On the other hand, in 1953 the total number of patient-days spent in .all
Swiss hospitals was 4.32 per head of the population, making an average cost
per head of about 63.72 francs (1.70 per cent, of the income per head or 1.27
per cent, of the reference wage; the corresponding percentages for 1950 were
1.57 and 1.16).1
Some countries, however, d o not fall into any of these groups.
Mexico.
The Mexican Social Insurance Institution, which grants hospital care on the
same conditions as other care, spent, per person protected, 0.98 per cent, of
the income per head on this type of care in 1953 and 0.87 per cent, in 1951. This
expenditure appears to include medical and other salaries, but not the cost of
pharmaceutical supplies. The institution owned nine hospitals, with 1,366 beds,
from 1950 to 1953 and 27 with 2,663 beds in 1956.2 It also made use of private
hospitals.
Venezuela.
The Venezuelan scheme spent per person protected 0.78 per cent, of the
income per head on hospital care (not including surgical and obstetrical fees)
in 1953. For 1951 the cost is available only in terms of the reference wage; it
was 0.40 per cent. Hospital care is provided for the same duration as other
care.
United States.
Private expenditure on hospital services (including that covered by voluntary
health insurance) per head of the population in the United States amounted
to 0.93 per cent, of the income per head and 0.55 per cent, of the reference
wage in 1953; the corresponding percentages for 1951 were 0.82 and 0.51.
This expenditure includes payments by patients in all types of general and
special hospitals (other than those specialising in treating long illnesses),
the estimated expenditure of unregistered hospitals and the estimated income
from patients received by general and special hospitals treating long illnesses,
mental and allied hospitals and tuberculosis sanatoria. The amount of private
expenditure on hospital services is overstated by an unknown amount representing payments to non-profit-making hospitals on behalf of individual patients
by government and welfare agencies and by workmen's compensation funds,
but this is offset by the fact that no estimate has been included for private
expenditure for care in private nursing homes. 3 Payments in respect of outpatient treatment appear to be included in these figures.
1

For a detailed explanation of the calculations on which these estimates are
based see p. 181.
2
International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Mexican Social Insurance Institute, p. 11.
s
United States Department of Health, Education and Welfare, Social Security
Administration: Social Security Bulletin (Washington), Dec. 1954, No. 12, pp. 5 ff.

EXPENDITURE AND COST

The figures do not include payments for treatment by medical practitioners
who are not employed by the hospitals; such payments are included in the totals
in table C. It is estimated that 40 per cent, of the amount shown in that table
was for treatment of in-patients by private practitioners. The addition of the
corresponding amount to the expenditure shown in table E would bring expenditure for 1953 from 0.93 to 1.31 per cent, of the income per head and from
0.55 to 0.77 per cent, of the reference wage.
For 1951 the corresponding percentages were 1.19 and 0.74.
These figures therefore approximately indicate total private expenditure
on hospital care, including expenditure on treatment.
In order to arrive at the over-all cost of hospital care, the expenditure on
hospitals by public authorities must be added.
Now the total operating expenditure of all hospitals in the United States,
as shown in table E, was 1.56 per cent, of the national income or, per head of
the population, 0.93 per cent, of the reference wage in 1953; the corresponding
percentages for 1951 were 1.41 and 0.87. Of the total, 14.6 per cent, was for
mental hospitals other than those run by the federal Government. Here
again, the figures do not include the private expenditure of patients on treatment in hospital by their attending medical practitioners. If the estimated
cost of such treatment is added, the cost of hospital care per head of the population rises to 1.94 per cent, of the income per head and 1.16 per cent, of the
reference wage for 1953, the percentages for 1951 being 1.78 and 1.10. Finally,
if the cost of hospital construction is added, the total for 1953 is found to be
2.16 per cent, of the national income or, per head, 1.29 per cent, of the reference
wage. The corresponding percentages for 1951 are 2.11 and 1.30. These
figures include the cost of out-patient care.1 The value of construction
represented 0.22 per cent, of the national income in 1953 and 0.33 per cent.
in 1951.2
General Remarks.
The expenditure on hospital care of the social security medical
care services studied, as shown in table E, represented, in the majority
of cases, only a fraction of the real cost of the care received by the
persons protected. Moreover, the cost of hospital care per head of the
population in the country concerned was usually higher than the cost
of that received by the persons protected under the social security
scheme, either because the scheme did not cover all types of diseases
or illness or because the benefit period was limited. In addition, certain
types of illness, especially mental or nervous disorders, may not have been
prevalent to any considerable extent among the persons protected
where these are chiefly economically active persons.
It has been possible to make fairly complete estimates of the overall cost of hospitals (including capital expenditure for construction)
in Canada, England and Wales, the Federal Republic of Germany and
1
It is not known whether the total income of medical practitioners includes
some income for treatment of out-patients at hospitals, which is included in the
total cost of hospitals.
2
For a detailed explanation of the calculations on which these estimates are
based see p. 182.

THE COST OF MEDICAL CARE

New Zealand for at least one or the other of the years 1951 and 1953.
Similar estimates have been made for the United States.
The total operating cost—that is the cost exclusive of capi tal expenditure for construction—has been estimated for Canada (both for the
country as a whole and for Saskatchewan), Denmark, England and Wales,
France, New Zealand, Norway and Switzerland, as well as for the
United States, for one of the years 1949, 1950 or 1951 and for 1952 or
1953.
The cost of the hospital care provided by the social security medical
care services, including, where appropriate, the fraction financed out
of public funds (other than in the form of direct contributions to the
medical care service) and the patient's share, if any, has been estimated
for Belgium, Canada (Saskatchewan), Denmark, France, the Federal
Repubhc of Germany, Italy, the Netherlands, Norway and Switzerland.
For France the cost including the expenditure of the employment
injury insurance scheme is also given.
The operating cost of mental hospitals is estimated for Canada,
Denmark, the Federal Republic of Germany, the Netherlands, New
Zealand and Norway as well as for the United States.
For Mexico and Venezuela only the expenditure of the sickness
insurance schemes is available.
Finally, the cost of hospital care (not including expenditure on
construction or care in mental institutions) is estimated for Canada, the
Netherlands, New Zealand and Norway as well as for the United
States.
The cost of hospital care in terms of income per head, the reference
wage and the income per economically active person in the various
countries, in so far as it can be ascertained, is shown in table 6.
(a) Cost of Hospital Care.
The cost of hospital care per head of the population in the seven
countries mentioned in section (a) of table 6 (including the cost of
construction), expressed in terms of the average income per economically
active person, ranged from 0.84 per cent, to 1 per cent, in 1951 and
from 0.85 per cent, to 1.11 per cent in 1953. In some cases, however,
the figures include expenditure on out-patient care. The average for the
United States, England and Wales and New Zealand in 1951 was
0.92 per cent, and the median 0.93 per cent. If Denmark is included
as well (1952 figures) the average was 0.95 per cent, and the medians
0.93 and 1. If Canada and the Federal Republic of Germany are
also included the average for 1953 becomes 0.99 per cent, and the median
1.01 per cent.

EXPENDITURE AND COST
TABLE 6. COST PER PERSON PROTECTED O F HOSPITAL CARE,
I N C L U D I N G PUBLIC A N D PRIVATE EXPENDITURE
Cost as a percentage of—

Country

Income
per head
1951

Income per
economically
active person

Reference wage

1953

1951

1953

1951

1953

(a) Cost of Hospital Care
England and Wales
. . . .
United States 1
Norway
Denmark
New Zealand 4
Germany (Federal Republic)
Canada

2.01
2.11
2.09
2.61

1.84
2.16
2.11 2
2.05
2.65
2.23
3.12

1.93
1.30

1.74
1.29

—

0.93
0.84

—

—
—
2.00

—

1.04
1.04 33
1.00

1.06
1.90
1.60
1.58

—
—

(b) Cost of Hospital Care (Not
Cost of Construction)
Netherlands . . .
Norway
Norway (1955-56) .
Switzerland . . .
United States . . .
France
Italy
England and Wales
New Zealand . . .
Canada:
Whole country .
Saskatchewan
Denmark
. . . .

1.57
1.78
1.41
1.99
1.91
2.20

1.43
1.59 3
1.80
1.70
1.94
1.75 3
1.81 '
1.77
2.19

2.46
1.77

2.50
2.73
1.88

1.22

—

1.07
1.10

Including

.—• 5

0.52

1.16«
1.10
1.25
1.17 3
1.84
1.68

1.27
1.16
1.64 3
1.10'
1.67
1.57

0.71
0.71
0.63
0.86
0.88
0.84

1.33
0.90

1.26
1.37
0.97

0.93
0.88

0.96

—

0.85
0.86
0.90
1.01
1.01
1.10
1.11

—

. .

0.57
0.68
0.77
0.77
0.77
0.78
0.80
0.82
0.84
0.89
0.97
0.93

(c) Cost of Hospital Care Received under
Sickness Insurance Schemes,
Including
Public and Private Expenditure (if Any)
Switzerland
Belgium
Netherlands
Norway
Italy 8
Germany (Federal Republic)
Canada: (Saskatchewan) . .
Denmark
France

0.88'
0.81
0.97
0.95 '
1.52 :
1.73
1.27
1.45

0.85
0.98
1.01
1.11
1.43
1.34
1.91
1.37
1.85

0.65
0.67
0.69
0.75
0.90

—

0.94
0.65
1.29

5
3

0.64
0.83
0.76
0.76

—

0.97
0.96
0.71
1.73

0.40 6
0.33
0.39
0.40 5
0.66 3

—

0.66
0.63
0.65

0.39
0.40
0.41
0.47
0.63
0.66
0.68
0.68
0.83

(d) Same as (c) Plus Cost of Care Received
under Employment-Injury Insurance
France

1.51

! 1.92

1.34

1.79

I 0.68 I 0.86

(Table 6 [with footnotes] continued overleqf}

THE COST OF MEDICAL CARE

TABLE 6 (cont.). COST PER PERSON PROTECTED OF HOSPITAL CARE,
INCLUDING PUBLIC AND PRIVATE EXPENDITURE
Cost as a percentage of—
Country

Income
per head
1951

1953

Reference wage

Income per
economically
active person

1951

1953

(e) Cost (Not Including Cost of Construction) of Mental Hospitals
United States •
Canada 8
Germany (Federal Republic) .
Netherlands
New Zealand
Norway
Norway (whole country, 1955-56)
Denmark

Netherlands
Norway
Norway (1955-56)
United States
New Zealand
Denmark
Canada

0.21

0.37
0.26 s

0.22
0.30
0.25
0.31
0.35 3
0.32
0.35
0.33

0.13

—
—
—

0.28 6
0.21

—

0.13
0.15
0.18
0.23
0.25 s
0.22

—

0.08

—
—
—

0.14 5
0.11

—

0.09
0.11
0.12
0.12
0.13
0.14 ;

0.15
0.16
(f) Cost (Not Including Cost of Construction) of Hospitals Other than Mental
Hospitals

0.32

0.96 '
1.57
1.83
1.45

1.12
1.27
1.45
1.72
1.84
1.55
2.20

0.16

0.17

0.16

—

0.84
0.88

0.41 5

0.75 6

—

0.97
1.40
0.74

—

1.03
1.32
0.80
1.11

—

0.63
0.70
0.72

—

0.45
0.54
0.62
0.69
0.70
0.77
0.79

1
Including expenditure on out-patient care of hospitals. * 1955-56. ' 1952. * Excluding cost of
construction of mental hospitals. * 1949. * 1950. ' 1954. * Including tuberculosis insurance. • Excluding
payments by patients to doctors.

(b) Cost of Hospital Care (Not Including Cost of Construction).
The operating cost per head of the population of all hospitals (that
is, the cost exclusive of the expenditure on construction and, in some
cases, of depreciation) in terms of income per economically active person
in the ten countries mentioned in section (b) of table 6 ranged from 0.71
per cent, to 0.93 per cent, in 1951 and from 0.57 per cent, to 0.97 per cent.
in 1953. In 1949, for Norway, the cost was 0.52 per cent. The average for
1951 for five countries (Denmark, England and Wales, France, New
Zealand, the United States) was 0.79 per cent, and the median 0.84 per
cent. ; if Saskatchewan is included the average is 0.81 per cent, and the
medians are 0.84 and 0.88 per cent. For 1953 the average for seven
countries (Canada (whole country), Denmark, England and Wales, the
Netherlands, New Zealand, Switzerland, the United States) was 0.80 per
cent, and the median 0.82 per cent. The average for the six countries
for which 1953 figures are given in section (a) of table 6 in 1953 was

EXPENDITURE AND COST

0.84 per cent; For three countries (France, Italy and Norway) the
average in 1952 was 0.76 and the median 0.78. For 1951 or the years
immediately following or preceding the average for all the countries
studied was 0.77 per cent, and the median 0.84 per cent.; for 1953 or
the years immediately following or preceding both the average and the
median were 0.80 per cent.
(c) Cost of Hospital Care Received under Sickness Insurance Schemes.
The cost of the hospital care provided by the sickness insurance
schemes concerned, including the part paid out of public funds (if any)
other than by way of subsidy to the insurance scheme, and any part
paid by the patient himself, ranged from 0.33 to 0.66 per cent, of the
income per economically active person in 1951 and from 0.39 to 0.83
per cent, in 1953. This wide range reflects, to a large extent, the differences in the benefit provisions of the services concerned in regard to
duration and contingencies covered. However, not all the figures
given include the patient's share. In most of the countries concerned
the percentages fall between 0.63 and 0.68. The average for 1951 in
five countries (Belgium, Canada (Saskatchewan), Denmark, France, the
Netherlands), was 0.53 per cent, with a median of 0.63 per cent. For 1953
in eight countries (the same with the addition of the Federal Republic of
Germany, Italy and Switzerland) the average was 0.59 per cent, and
the medians 0.63 and 0.66 per cent.
The average for all the countries studied for 1951 or the years immediately following or preceding was 0.52 per cent, and the medians
0.40 and 0.63 per cent.; for 1953 (1952 in the case of Norway) the
average was 0.57 per cent, and the median 0.63 per cent.
(d) Cost of Hospital Care Received under Sickness and Employment-Injury Insurance (France).
For France the cost of employment injury insurance has been added
to that of hospital care received under sickness insurance schemes under
[d) in table 6; this brings the total cost of hospital care received under
insurance to 0.68 per cent, in 1951 and 0.86 per cent, in 1953, while the
cost of care provided under sickness insurance was only 0.65 per cent.
of the income per economically active person in 1951 and 0.83 per
cent, in 1953. It will be seen that the cost of hospital care under employment injury insurance increased less than the corresponding cost under
sickness insurance. It should be noted that the French scheme protects
non-agricultural employees only, so that the addition of the cost of
employment injury insurance makes a greater difference than it would
under a national scheme.

THE COST OF MEDICAL CARE

(e) Cost of Care in Mental Hospitals (Not Including Cost of Construction)1
The operating cost of mental institutions ranged, for four countries
(Denmark, New Zealand, Norway, the United States), from 0.08 to
0.16 per cent, in 1951 (1949 in Norway) and, for seven countries (the
same with the addition of Canada, Germany (Federal Republic) and the
Netherlands), from 0.09 to 0.16 per cent, in 1953 (1952 in Norway).
The average in the four countries mentioned was 0.12 per cent, in 1951
(1949 in Norway) and the medians 0.11 and 0.14 per cent., and 0.12 in the
seven countries in 1953 (1952 in Norway) with a median of 0.12 per cent.
(f) Cost (Not Including Cost of Construction) of Hospitals Other
than Mental Hospitals.1
The operating cost of hospitals other than mental hospitals, as
estimated for six countries (Canada, Denmark, the Netherlands, New
Zealand, Norway, the United States), ranged from 0.41 to 0.79 per
cent, in 1951 and 1953. For 1951 the average for four countries (the same
less Canada and the Netherlands) was 0.62 per cent. In 1953, for the
six countries, it was 0.66 per cent, and the medians 0.69 and 0.70 per cent.
It thus appears that the full cost of hospital care per head of
population in Europe, in New Zealand and in North America (including the cost of constructing hospitals) was of the order of magnitude
of 0.95 to 1 per cent, of the average income per economically active
person, and 0.80 per cent, to 0.85 per cent, if the cost of construction is
excluded. The cost of a fairly comprehensive range of hospital care
provided under a sickness insurance scheme would appear to have been,
per person protected, roughly 0.60 to 0.65 per cent, of the average income
per economically active person, but considerably less in some countries.
The expenditure on hospital care (adjusted to include medical
treatment, pharmaceutical supplies and auxiliary care, wherever possible)
in terms of the average income per economically active person is shown
in table 7. This expenditure may be compared, on the one hand, to the cost
of the care received by the persons protected by social security (shown
in section (c) of table 6) and on the other hand with the actual cost per
head of all hospital care (shown in sections (a) and (b) of table 6).
Such a comparison clearly reveals that social security, unless it is a
public service, covered only part of the cost of the hospital care the persons
protected received as such; the proportion of the cost paid by the social
security schemes varied from 10 per cent, in Denmark to nearly 90 per
cent, in France.
1

Included in the totals given in section (b) of table 6.

EXPENDITURE AND COST

TABLE 7. EXPENDITURE PER PERSON PROTECTED BY
SOCIAL SECURITY SERVICES ON HOSPITAL CARE IN 13 COUNTRIES
AND PRIVATE EXPENDITURE IN THE UNITED STATES
Expenditure as a percentage of—
Income
per head

Country

Belgium
Canada (Saskatchewan)
Denmark
England and Wales
France
Germany (Fed. Rep.)
Italy :
Sickness insurance
Sickness and
tuberculosis insurance
Mexico 2
Netherlands
New Zealand
Norway
Switzerland
Venezuela s
United States *

Reference wage

Average
income per
economically
active person

1951

1953

1951

1953

1951

1953

. . . .

0.63
1.41
0.13
1.98
1.23
0.74

0.64
1.53
0.14
1.81
1.58
0.81

0.52
0.76
0.07
1.90
1.09
0.50

0.55
0.77
0.07
1.71
l Al
0.58

0.26
0.50
0.06
0.91
0.55
0.34

0.26
0.58
0.07
0.84
0.71
0.40

. . . .

0.70 » 0.69

0.41

. .

. . .
: . .

1.52 '
0.87
0.86
0.32
0.63 3
0.29 4
1.19

1.43
0.98
0.89
0.28
0.76
0.27
0.78
1.31

0.30

0.67
0.20
0.52 »
0.21

0.66
0.28
0.35
0.12
0.29
0.13

0.77

0.47

0.63
0.32
0.36
0.11
0.32 '
0.12
0.26
0.52

0.90 »

0.61
0.24
0.49
0.22
0.40
0.74

3
4

1
1952. * Probably excluding pharmaceutical supplies. '1949. '1950. 'Excluding surgical and
obstetrical fees. ' Private consumer expenditure.

Compared with the operating cost of all hospital care per head of
the population, the hospital expenditure of the social security schemes
examined varied from only 7.5 per cent, of the total cost in Denmark
to over 87 per cent, in France. The remainder of the cost was borne to a
great extent by public authorities and, to a lesser degree, by the patients.

Dental Care
Information on the cost of dental care provided under many of the
social security schemes included in the present study is incomplete or
non-existent, as will be seen from table F.
England and Wales.
The National Health Service in England and Wales provided complete
dental care, including both conservative treatment and dentures, without
charge until 1951; since then the patient has been required to pay about
50 per cent, of the cost of dentures. In 1952 a charge of £1 was imposed for
every course of conservative dental care except those for expectant mothers,

THE COST OF MEDICAL CARE

children or youths. The figures in table F therefore represent the full cost of
dental care in 1949-50 and 1950-51. It amounted to 0.45 per cent, of the
income per head and 0.41 per cent, of the reference wage in 1949-50; the
corresponding percentages for 1950-51 were 0.40 and 0.38. There was a very
great demand for dentures after the inauguration of the free dental service,
and the subsequent fall in the expenditure is not entirely due to the introduction of charges. Moreover, dentists' remuneration was reduced twice
and has only recently been increased again. The real cost (including the
patient's share) in 1953-54 was less than half of what it was in 1949-50. It
is estimated that the demand for conservative dental treatment is now about
normal but would have increased if cost-sharing had not been introduced;
the figures may fall a little short of reality since minor treatments costing less
than £1 may have been taken privately.
In 1953-54 the expenditure of the service was 0.17 per cent, of the income
per head and 0.16 per cent, of the reference wage, while the cost of the care
given (including the patients' share) was 0.22 per cent, of the income per head
and 0.20 per cent, of the reference wage. The corresponding percentages
in 1951-52 were 0.29 and 0.28 for the expenditure of the service and 0.30 and
0.29 for the actual cost.
In order of scale of expenditure the French and German schemes,
with expenditure ranging from 0.20 to 0.25 per cent, of the income per
head, come next.
France.
Under the French general social security scheme for non-agricultural
employees payments for conservative dental care were refunded subject to the
same limitations as payments for treatment by medical practitioners (that is, for
a maximum of six months in ordinary cases and three years in cases of longterm illness, although such cases were rare) until May 1955, when these time
limits were abolished. The person protected was, moreover, entitled to receive
dentures needed to permit of proper mastication or where the patient's illness
was a direct function of the deficiency of the dental system. Dentures required
for the purposes of the patient's occupation are also included among dental
benefits. The provision of dentures was subject to the approval of a special
joint committee until May 1955; since that date only the consent of the fund
has been necessary.
The insurance scheme refunds to the person protected 80 to 100 per cent.
of the fees fixed in the insurance tariff for conservative treatment and for
dentures on the basis of an agreed nomenclature fixing coefficients for each
item of service. The fees in the insurance tariff, however, are not necessarily
the same as the fees charged by the dentists to their patients.
The expenditure on dental care of the French insurance scheme was 0.25
per cent, of the income per head and 0.23 per cent, of the reference wage in
1953, the percentages for 1951 being 0.22 and 0.20 respectively. If the share
of the cost paid by the patient is taken as roughly 20 per cent, the actual cost
in 1953 would be 0.31 per cent, of the income per head and 0.29 per cent.
of the reference wage; for 1951 the corresponding percentages would be
0.28 and 0.25.
Federal Republic of Germany.
Under the general sickness insurance scheme of the Federal Republic of
Germany conservative dental treatment is provided without limit of duration
and with no cost-sharing by the patient. Dentures, however, are a supplemen-

EXPENDITURE AND COST

tary benefit, the majority of funds paying only part of the cost. The proportion
paid by the patients is not known, but is said to be about two-thirds for members
of local funds.
Table F shows the expenditure to have been 0.24 per cent, of the income
per head and 0.17 per cent, of the reference wage in 1953; the corresponding
percentages for 1951 were 0.22 and 0.15.
These figures, however, do not include expenditure on dentures, which is
included with that on pharmaceutical benefits in table D . Separate figures on
expenditure for dentures have been available only since 1951. It represented
0.16 per cent, of the income per head and 0.12 per cent, of the reference wage
in 1953; the corresponding percentages for 1951 were 0.17 and 0.11. If this
expenditure is added to that on conservative care the total rises to 0.40 per
cent, of the income per head in 1953 (0.39 per cent, in 1951) and 0.29 per
cent, of the reference wage in 1953 (0.26 per cent, in 1951). The expenditure
on dentures certainly falls well short of the actual cost and should probably
be at least doubled to take account of the patients' share in the cost.
In Belgium a n d the Netherlands the cost of insurance for dental care
per person protected was around 0.10 to 0.15 per cent, of the income
per head.
Belgium.
In Belgium, under the general sickness and invalidity insurance scheme,
dental care (including dentures) is granted without limit of duration. The
provision of dentures is subject to conditions relating to the extent of the loss
of masticatory functions and, since April 1951, age and certain other factors.
The patient is reimbursed at the rate of 75 per cent, of the fees in the insurance
tariff; in practice, however, dental fees may be in excess of those in the tariff.
The patient does not contribute to the cost of dentures provided that the latter
does not exceed that fixed in the tariff.
The expenditure of the Belgian scheme was 0.08 per cent, of the income
per head and 0.07 per cent, of the reference wage in 1953. The corresponding
percentages for 1951 were 0.10 and 0.08.
Netherlands.
Under the Netherlands medical care insurance scheme for employees
there are various restrictions on the provision of dental care and the patient
pays a considerable proportion of the cost. Dental hygiene, examinations and
routine treatment are given free of charge, but the insured person must pay
a fixed sum for each filling and pay for pulp treatment unless he has obtained
a certificate of good dental health, valid for six months, which shows that he
does not need any extensive dental care. For dentures and their repair the
insured person pays an amount which depends on the size and importance
of the denture and on the length of time he has been insured. This applies both
to persons insured in their own right and to dependants who are also deemed
to be insured persons. 1
The expenditure per person protected was 0.16 per cent, of the income per
head and 0.12 per cent, of the reference wage in 1953. The corresponding percentages for 1951 were 0.15 and 0.11. No estimate of the patients' share of
the cost can be made. It is, however, known that the aggregate incomes of
dentists represented 0.32 per cent, of the national income and, per head, 0.25
per cent, of the reference wage.
1
See " Medical Care Insurance in the Netherlands ", in International Labour
Review, Vol. LXXIX, No. 4, Apr. 1959, pp. 423-424.

THE COST OF MEDICAL CARE

New Zealand.
The New Zealand social security scheme provides conservative dental care
and some special care (but not dentures) for persons under 16 years of age
who are not or no longer covered by the school dental service of the Department of Health. The dental benefit under the social security scheme is given
by private dental practitioners under a fee-for-service arrangement. The
expenditure of the scheme per head of the population, shown in table F, was
0.09 per cent, of the income per head and 0.06 per cent, of the reference wage
in 1953-54 and 0.08 per cent, of the income per head and 0.06 per cent.
of the reference wage in 1951-52.
Dental treatment for school children not covered by the social security
scheme is given at state dental clinics staffed by dental officers of the Department of Health, while the so-called school dental nurse service, staffed by dental
nurses employed by the Department, attends regularly some 250,000 preschool and younger primary school children.
If account is taken of the expenditure of the dental hygiene division of the
Department of Health and of the fact that only children receive care, the
estimated total cost per head in 1953-54 would have been 0.53 per cent, of
the income per head and 0.38 per cent, of the reference wage. For 1951-52 the
corresponding percentages are 0.53 and 0.40. These values are somewhat
overstated, since the dental hygiene department no doubt also deals with
matters other than children's dental care. On the other hand, they are understated in that they do not include the cost of dentures. 1
Denmark.
Under the Danish voluntary sickness insurance scheme, dental care is a
supplementary benefit provided at the discretion of the fund. The expenditure
of the service is, per person protected, about 0.06 to 0.07 per cent, of the income
per head and from 0.03 to 0.04 per cent, of the reference wage. No estimate
is available as to the full cost of dental care.
Norway.
In Norway sickness insurance during the period under review only provided for extractions and the treatment of dental diseases, the cost of which
is included in table G. There is, however, a public dental service for children.
A recent estimate of the incomes in 1955-56 of dentists in private practice
in Norway shows that their aggregate earnings were about 100 million crowns. 2
In terms of the national income the cost of dental care outside hospitals
would thus have been 0.51 per cent.
Italy.
In Italy the expenditure on dental care under the general sickness insurance
scheme is being given at the polyclinics of the institution administering the
scheme and is therefore included in the figures in table C.
Mexico and Venezuela.
In Mexico and Venezuela the salaries of dentists and other expenditure on
dental care are included in the figures in table C.
1
For a detailed explanation of the calculations on which these estimates are
based see p. 178.
2
Karl EVANG: Health Services in Norway, op. cit. p. 150.

EXPENDITURE AND COST

United States.
Private expenditure per person on dental care in the United States amounted
to 0.31 per cent, of the income per head and 0.18 per cent, of the reference
wage in 1953, the percentages for 1951 being 0.32 and 0.20 respectively.
General Remarks.
The cost of dental care, so far as it can be ascertained, is shown in
table 8 for the countries for which information is available. The data,
however, are not homogeneous. For England and Wales the cost of
private dental care is not known. In France only the share of the patient
in the official fees is added, not the actual additional cost. For New
Zealand the estimate is very tentative. For the Netherlands and Norway
national estimates are used. For the United States only private expenditure is given.
TABLE 8. COST PER PERSON PROTECTED OF DENTAL CARE
(INCLUDING PATIENT'S SHARE)
Cost as a percentage of—
Income
per head

Country

England and Wales
Netherlands (whole country) .
Germany (Federal Republic)1
Norway (whole country) . . .
United States 3
1

Expenditure only.

* 1955-56.

Reference wage

Average
income per
economically
active person

1951

1953

1951

1953

1951

1953

0.30

0.22
0.32
0.31
0.40
0.53
0.51 2
0.31

0.29

0.14

0.25
0.26
0.40

0.20
0.25
0.29
0.29
0.38

0.13
0.18
0.20

0.20

0.18

0.13

0.10
0.13
0.14
0.20
0.20 2
0.21
0.12

0.28
0.39
0.53
0.32

Private expenditure.

In terms of the average income per economically active person, the
estimated cost of dental care in 1951 ranged, according to the country,
from 0.13 to 0.20 per cent, per person protected; in 1953 the range
was 0.10 to 0.20 per cent. The average was 0.16 per cent, in both 1951
and 1953. The medians were 0.14 per cent, for both years.
These figures do not include the patient's share of the cost of dentures
in the Federal Republic of Germany and only include part of his share
in France.
It is probable that the cost of dental care (particularly of dentures)
is relatively high during the years immediately following the introduction
of a free or partially free dental service.

THE COST OF MEDICAL CARE

TABLE 9. EXPENDITURE PER PERSON PROTECTED OF
SOCIAL SECURITY SERVICES ON DENTAL CARE IN FIVE COUNTRIES
Expenditure as a percentage or—
Income
per head

Country

England and Wales
France
Germany (Federal Republic) .
Netherlands
New Zealand

Reference wage

Average
income per
economically
active person

1951

1953

1951

1953

1951

1953

0.29
0.22
0.39
0.15
0.08

0.17
0.25
0.40
0.16
0.09

0.28
0.20
0.26
0.11
0.06

0.16
0.23
0.29
0.12
0.06

0.13
0.10
0.18
0.06
0.03

0.09
0.11
0.20
0.06
0.03

It will be seen later that dentures account for about one-third of
the cost.
The expenditure on dental care of the social security schemes for
which the cost was shown above is given in table 9.
It ranges, according to the country, from 0.03 per cent, to 0.18 per
cent, in 1951 and 0.03 per cent, to 0.20 per cent, in 1953.
For England and Wales cost-sharing amounted to about 10 per cent.
in 1953-54; in France " visible " cost-sharing was about 20 per cent.; for
the Federal Republic of Germany it is not known, but was probably
about 30 per cent.; in the Netherlands it was not quite 50 per cent.;
in New Zealand only children were entitled to dental benefit.
The average expenditure for the five countries was 0.10 per cent, in
both years, the medians being 0.10 per cent, in 1951 and 0.09 per cent.
in 1953. During the same years the average cost was 0.16 per cent, and
the median 0.14 per cent. However, these averages must be regarded
as very approximative, in spite of their deceptive coincidence.

Residual Care
The benefits the expenditure on which is shown in table G form a
very heterogeneous group. The figures for England and Wales there cited
cover a great variety of services, such as ophthalmic care and eye-glasses,
health visiting and home nursing, after-care, ambulance and other
services, which are partly of a preventive nature. In Belgium the cost
of so-called " special therapies " is covered in table G; these comprise
neuro-psychiatry, dermatology, physiotherapy, laboratory tests, radi-

EXPENDITURE AND COST

ology and prostheses (other than dental 1 ), which are partly included
under specialist care or under hospital care for the other services; in
order to estimate the cost of medical practitioner care, the cost of some
of these treatments has been added to the figures in table C. In the
statistics for Belgium, England and Wales, Italy, New Zealand, France,
Mexico, the Netherlands, the United States and Venezuela expenditure
on maternity care is included; sometimes, however, as in the case of
England and Wales, the figures cover only expenditure on midwifery;
elsewhere, for instance in the Netherlands and Belgium, they also cover
expenditure on maternity care provided by medical practitioners. The
expenditure on hospital care shown in table G sometimes—for instance,
in England and Wales—includes maternity care.
Prostheses (other than dental) are provided in England and Wales
by the hospital and specialist services.
In Norway the cost of transportation of doctors and patients is
included in table G. The former has been added to the cost shown
in table C for the purpose of estimating the total cost of medical
practitioner care. For a number of other services the mileage fees
paid to doctors in respect of their transport expenses are included in
table C. In Norway, too, the cost of dental care provided by sickness
insurance (mainly extractions) and of certain other services is included
in table G.
The cost of maternity cash benefit in Denmark is included in
table G.
Thus, whereas in some countries there are hardly any residual
benefits, their cost is comparatively high in others, such as England
and Wales and Belgium.
It would appear from the statistics for England and Wales that the
cost per head of the population of such residual benefits as eye-glasses
and ophthalmic care, maternity care by midwives, health visiting, home
nursing and auxiliary services accounts for something like 0.25 per cent.
of the average income per economically active person.
In the United States private expenditure on residual care (exclusive
of ophthalmic care and such services as are provided normally out of
public funds) per head of the population accounted for 0.13 per cent.
of the average income per economically active person in 1953. This
percentage, however, includes the running costs and profits of voluntary
insurance agencies, which amounted to $485 million, or, per head of
the population, 0.06 per cent, of the average income per economically
active person.
1

Dental prostheses and special dental care have been included in table F.

THE COST OF MEDICAL CARE

Total Cost of Medical Care of All Types
The expenditure of social security schemes per person protected on
all types of medical care in the countries studied (in the United States,
private expenditure on medical care of all kinds) is shown in table B.
It ranged, in the various countries, roughly from 1 to 7 per cent, of the
income per head in 1953 and from 0.90 to 7.25 per cent, in 1951. In
terms of the reference wage, the range was about 0.50 per cent, to 3.50
per cent, in 1953 and 0.45 per cent, to 3.80 per cent, in 1951.
These divergencies are largely—if not wholly—due to the fact that
the majority of medical care services do not pay the full cost of medical
care received by the persons protected, nor do they provide all types
of care.
COST OF THE FOUR MAIN TYPES OF CARE

If account is taken, first, of the part of the cost borne by the persons
protected out of their own private resources or through supplementary
insurance outside the social security medical care service concerned
and, secondly, of the subsidies paid out of public funds towards hospital
costs in addition to the subsidies that may be made to the medical
care service, the average cost per person protected of the four main
types of care (viz. medical practitioner, pharmaceutical, hospital and
dental) in terms of the average national income per economically active
person was roughly that shown in table 10.
TABLE 10.- ESTIMATED AVERAGE COST OF MEDICAL PRACTITIONER,
PHARMACEUTICAL, HOSPITAL AND DENTAL CARE PER PERSON
PROTECTED AS A PERCENTAGE OF THE AVERAGE NATIONAL
INCOME PER ECONOMICALLY ACTIVE PERSON
1951
or neighbouring
years

Type of care

Average

1953
or neighbouring
years

Medians

Average

Medians

0.28
0.18

0.31
0.20

0.28-0.29
0.20

0.28
0.93-1.00

0.27
0.99

0.23
1.01

0.84
0.40-0.63
0.11-0.14
0.14

0.80
0.57
0.12
0.16

0.80
0.63
0.12
0.14

1.63-1.70

1.73

1.66-1.67

Medical practitioner care outside
0.28
0.18
of this, general practitioner care
Pliarmaceutical care outside hospital
0.27
0.95
of this,
0.77
operating cost
0.52
social security
0.12
0.16
Total . . .

1.66

EXPENDITURE AND COST

Although these results are very tentative, they are nevertheless suggestive,
both in view of the similarity of the results for the two sets of years and
of the close correlation between medians and averages. The total cost
of the four types of care per person protected was usually about 1.65
to 1.75 per cent, of the average income per economically active person.

COST OF M E D I C A L C A R E OF EVERY DESCRIPTION

England and Wales.
The cost of all types of medical care provided under the National Health
Service of England and Wales is known but not the cost of care privately
obtained outside the service. The former attained, per head of the population,
3.69 per cent, of the income per head or 1.70 per cent, of the average income
per economically active person in 1953-54; the corresponding percentages
for 1951-52 were 3.95 and 1.82. Some addition should be made to these
percentages to take account of the fact that the unit of measurement is the
gross national product, and not the national income at factor cost, of the
United Kingdom.
The above figures differ somewhat from those arrived at in an inquiry
undertaken by the National Institute of Economic and Social Research into
the cost of the National Health Service.1 According to this inquiry the current
gross cost of the Service in terms of the gross national product for England
and Wales was 3.56 per cent, in 1951-52 and 3.42 per cent, in 1953-54. The
difference between these findings and those given above spring mainly from
the fact that the 1956 inquiry does not cover capital expenditure on hospitals,
hospital debts outstanding since 1948, compensation to general practitioners
for the loss of the right to sell their practices, purchases of land, superannuation
payments, civil defence expenditure, and expenditure on Ministry of Pensions
hospitals. Certain other items are readjusted. The total cost calculated by the
methods used in the 1956 inquiry works out at £453.4 million; in the present
survey it is estimated at £473 million. The difference is £19.6 million or 4.33
per cent, of the lower amount. If this amount were added the new total would
represent 3.57 per cent, of the gross national product.
The remaining difference of 0.12 per cent, between the two estimates can be
accounted for by the fact that the present study relates the cost of the Service in
England and Wales, per head of population, to the gross product per head in the
United Kingdom, whereas the inquiry relates the cost to the estimated national
product of England and Wales. The difference between the estimated population
of the United Kingdom (50.9 million in 1953) and that of England and Wales
(44.1 million), as used in the present study, is about 13.56 per cent, of the
former estimate. The gross national product of England and Wales in the
inquiry is estimated as being 89 per cent, of that of the United Kingdom—a
difference of 11 per cent. The difference between the estimated populations is
thus greater than that between the estimated national products.
In other words the gross product per head in England and Wales is higher
than that in the United Kingdom, and the use of the latter no doubt accounts
for much of the remaining difference between the findings of the present study
and those of the above inquiry. Moreover, the national product for England
and Wales was interpolated into financial years in the inquiry.
1

B. ABEL-SMITH and R. M. TTTMUSS: The Cost of the National Health Service
in England and Wales. National Institute of Economic and Social Research. Occasional
Papers (London, Cambridge University Press, 1956).

THE COST OF MEDICAL CARE

F o r the other countries covered by the present survey, the full cost
of medical care cannot be estimated on the basis of the accounts of the
social security service concerned. Estimates of such costs have been
m a d e for a number of them.
Belgium.
For Belgium, the report of the national committee for the study of certain
aspects of social medicine, already referred to l , estimated total expenditure
on health, including that on preventive measures and on cash benefits, at
Frs. 19,147.10 million for 1954 and Frs. 20,752.10 million for 1955. Of
these amounts, cash benefits and expenditure on preventive measures have
been deducted, and also half of the cost of accident insurance, for which the
report gives no indication of the amounts spent on medical care and cash
benefits respectively. If capital expenditure on hospitals is added, the total
expenditure on medical care thus estimated was Frs. 14,169 million in 1954
and Frs. 15,303 million in 1955. This represents 4.06 per cent, of the national
income in 1954 and 4.16 per cent, in 1955, or, per head of the population,
1.66 per cent, of the average income per economically active person in 1954
a n d 1.70 per cent, in 1955.
Canada.
In Canada, the total expenditure on health in 1953 was stated by the
Minister of National Health and Welfare to have been of the order of S840
million, of which 42 per cent, consisted of payments by governments and
15 per cent, of payments by insurance schemes. This total represented 4.41
per cent, of the national income, or, per head, 2.22 per cent, of the reference
wage and 1.57 per cent, of the average income per economically active person.
An estimate for the year 1950-51 (commencing in the autumn of 1950),
derived from another source, gives the total Canadian expenditure as $675
million.2 If this amount is related to the national income of the last quarter
of 1950 and the first three quarters of 1951, it represents 4.09 per cent, of such
income, or 1.55 per cent, of the average income per economically active person;
the latter is practically identical with the percentage estimated for 1953.
According to a second estimate, which arrives at somewhat higher figures,
personal expenditure on medical care in 1950 was S428 million. 3 Federal,
provincial and municipal government expenditure on medical care in 1950-51
or 1950 amounted to $238 million, including expenditure on hospitals and
other medical services, and the expenditure of municipalities (but not that
of federal and provincial governtnsnts) on all health services.4 The cost of
all nudical care in 1950 with these items included would have been S666
million. This amount corresponds to 4.58 per cent, of the national income
in 1950 or, psr head of population, 1.74 per cent, of the average income per
economically active psrson. The difference between the latter figure and
the lower estimate (1.55 per cent.) is due to the great increase in the national
1

See above, p. 49.
I. C. Lloyd FRANCIS: " Expenditure Patterns from the Canadian Sickness
Survey, 1950-51 ", in Canadian Journal of Public Health (Toronto), Vol. 47, No. 8,
Aug. 1956, p. 328.
3
R. KOHN: " Some Patterns of Medical Care in Canada ", in ibid., Vol. 48,
No. 3, Mar. 1957, p. 88.
4
Department of National Health and Welfare, Research Division: Government
Expenditures and Related Data on Health and Social Welfare, 1947 to 1953, Social
Security Series, Memorandum No. 14 (Ottawa, 1955), pp. 13, 21 and 32.
2

EXPENDITURE AND COST

income during the period in question (from $14,550 million in 1950 to $17,138
million in 1951). More recently the national income for those years has been
estimated at $14,075 million in 1950 and $16,552 million in 1951, which would
increase the percentage further. However, some expenditure on preventive
services is included in the estimate of the cost of medical care.
Denmark.
In Denmark the expenditure of public authorities and insurance schemes
on sickness in general amounted to 670,831,000 crowns in 1952-53, or 154.78
crowns per head of the population. 1 This amount does not include medical
expenditure under employment injury insurance or on maternity care. .
Private expenditure in Denmark has been very roughly estimated on the
basis of the medical expenditure of an insured family of four persons living in
Copenhagen 2, which in 1952 was 123 crowns per year (exclusive of contributions to sickness insurance), or 30.75 crowns per member; this represents, per
person protected, 0.62 per cent, of the income per head and 0.31 per cent, of the
average income per economically active person. If this amount is added to
the expenditure by public authorities and insurance schemes on sickness
shown above, the total comes to 3.72 per cent, of the income per head. If
0.05 per cent, (representing cash sickness benefit per head of the population)
is deducted there remains 3.67 per cent, of the income per head (or 1.83 per
cent, of the average income per economically active person). These figures
are probably somewhat overstated, since private expenditure is based on
experience in the capital city only and the total includes some expenditure on
general health care. On the other hand, the cost of medical care in respect of
employment injury and maternity is excluded, as is the private expenditure of
non-insured families.
These figures may be compared to the findings of the Danish inquiry into
expenditure on health for the years 1952-53 and 1953-54, already referred to. 3
According to this inquiry the total expenditure on medical care in 1953-54,
including the estimated private expenditure on prescribed drugs but not private
expenditure on medical and dental practitioner care or expenditure of private
hospitals, was 726,857,000 crowns. This represented 3.23 per cent, of the
national income or, per head of the population, 1.60 per cent, of the average
income per economically active person. The corresponding expenditure for
the year 1952-53 was 700,604,000 crowns, representing 3.24 per cent, of the
national income or, per head, 1.62 per cent, of the average income per economically active person. Since these percentages already include private expenditure on drugs as well as fees paid by patients in public hospitals, the only item
not included is private expenditure on medical practitioner and dental practitioner care and on nursing homes. Tentatively, for 1952-53 two-thirds of
1
Statistical Reports of the Northern Countries: 2. Co-ordination of Social Welfare
Statistics in the Northern Countries (Copsnhagen, 1955), pp. 20 if. This sum
includes contributions by employers and insured persons as well as by public authorities to sickness insurance and public expenditure on the transport of sick persons,
doctors and midwives, special subsidies in respect of medicines, medical care, home
nursing, maintenance of families in case of prolonged illness, etc. The expenditure
of sickness funds for maternity is not included. It also comprises expenditure on salaries
of medical officers and of midwives, public expenditure on hospitals, including mental
institutions and tuberculosis sanatoria, the cost of measures to combat tuberculosis,
venereal diseases and other communicable diseases, state expenditure for the care of
mental defectives and the cost of municipal school dental care, as well as the
expenditure of sickness insurance funds on dental care.
2
Statistical Reports of the Northern Countries: 1. Cost of Living and Real
Wages in the Capitals of the Northern Countries (Stockholm, 1954), p. 61.
3
See above, p. 27.

THE COST OF MEDICAL CARE

the estimated private expenditure per person of 0.31 per cent, of the average
income per economically active person may be added. 1 The total cost per
head of the population would then be 1.82 per cent, of the average income
per economically active person, which is practically the same as the percentage
found by the first method.
France.
For France national expenditure on medical care (including public, social
security and private expenditure on medical practitioner, pharmaceutical,
hospital, dental and other care but excluding expenditure on preventive care)
has been estimated at Frs. 354,389 million for 1951 and Frs. 456,836 million for
1952 2 j ( j j s represented 3.87 per cent, of the national income in 1951 and 4.43
per cent, in 1952. In terms of the average income per economically active
person the cost per head of the population was 1.73 per cent, in 1951 and 1.98
per cent, in 1952.2
Netherlands.
According to a recent inquiry, the total expenditure on medical care in the
Netherlands (including costs of administration of insurance institutions of
all kinds) 3, both public and private, was 728.9 million florins in 1953. This
represented 3.76 per cent, of the national income, or, per head, 1.51 per cent.
of the average income per economically active person or 2.81 per cent, of
t h e reference wage.
New Zealand.
In New Zealand the expenditure of the social security fund, the expenditure
of public authorities on hospital care, the estimated charges paid by patients
to medical practitioners and the estimated expenditure on dental care added
together amounted to 4.54 per cent, of the income per head in 1951-52 and
4.56 per cent, in 1953-54. These percentages are arrived at by adding up those
found for medical practitioner care 4, for pharmaceutical supplies 6, for hospital
costs 6 , for dental costs ' and the residual care figures in table G. The total
includes maternity care and special services but not payments of patients to
private hospitals, cost-sharing by the patient in the case of specialist treatment
outside hospitals or private expenditure on pharmaceutical supplies; in terms
of the average income per economically active person, it represents 1.73 per
cent, per head of the population in 1951-52 and 1.74 in 1953-54.
1

See above, p. 73.
Rapport sur les dépenses de santé, op. cit. p. 15.
The more recent inquiries of the same Institute, published after the calculations
for the present study had been completed, cover the period 1950 to 1955. The estimated
national expenditure (including some expenditure on preventive care) was Frs. 279,
368, 439, 507, 559, and 612 thousand million in each of the six years respectively,
representing respectively 3.92, 4.02, 4.45, 4.84, 4.86 and 4.92 per cent of the national
income. Per head of the population the 1955 figure represents 2.20 per cent, of the
average income per economically active person. See " Les dépenses médicales en
France de 1950 et 1955 ", in Revue de la Sécurité sociale (Paris, F.N.O.S.S.), No. 82,
July-Aug. 1957, pp. 33-86.
3
Kosten en financiering van de gezondheidszorg in Nederland in 1953, op. cit.
p. 25.
4
See above, p. 29.
6
See above, p. 39.
• See above, pp. 54-55.
' See above, p. 66.
2

EXPENDITURE AND COST

Norway.
In Norway total expenditure on " sickness " in 1952-53 (covering more or
less the same elements as in the case of Denmark) amounted to 507,878,000
crowns, or 152.65 crowns per head of the population. 1 This figure represents
3.06 per cent, of the income per head, 2.11 per cent, of the reference wage
and 1.30 per cent, of the average income per economically active person.
To this total should be added private expenditure on medical care. Very
roughly this is estimated at 0.42 per cent, of the average income per economically active person.
On the other hand, expenditure on sickness cash benefit, which is included
in the total expenditure on sickness and amounts to about 0.36 per cent, of
the national income or, per head, 0.15 per cent, of the average income per
economically active person, should be deducted. A total expenditure of 1.57
per cent, of the average income per economically active person is thus obtained.
More recently, the cost of health services has been estimated for 1955-56
at 813.5 million crowns, not including the cost of construction of new hospitals
and of the operation of the public health system of doctors, nurses and dentists,
of laboratories, etc. The cost of running homes for the feeble-minded, institutions for the physically handicapped, for alcoholics and for rehabilitation is
included. This total represented 4.17 per cent, of the national income in 1955 or,
per head, 1.78 per cent, of the average income per economically active person.
If the expenditure of 60 million crowns on construction of new hospitals is
added, the cost of medical care in Norway is 873.5 million crowns or 4.48 per
cent, of the national income, representing, per head of the population, 1.91
per cent, of the average income per economically active person. 2
United States.
In the United States total expenditure on medical care in 1951 was estimated
at $13,607 million.3 A deduction of $907 million is made to exclude the cost
of community health services, maternal and child health care and research
and training of health personnel, based on figures published for 1950-51. This
leaves a total expenditure on medical care in the strict sense of the term of
$12,700 million. This represented 4.58 per cent, of the national income
($277,000 million) or, per head of the population, 1.83 per cent, of the average
income per economically active person.
In 1953-54 public expenditure on medical care in the United States, including medical and hospital benefits under state insurance schemes as well as
hospital construction, amounted to $3,134.3 million.
If this figure is added to the estimated private expenditure in 1953 ($9,866
million) a total of $13,000.3 million is obtained. To this amount may be added
$271.7 million for private expenditure on hospital construction (arrived at
by deducting the $410.3 million spent by federal, state and local governments
for this purpose from the total of $682 million shown in table E). To allow for
1
Statistical Reports of the Northern Countries: 2. Co-ordination of Social
Welfare Statistics in the Northern Countries, op. cit., p. 26.
* Karl EVANG: Health Services in Norway, op. cit., p. 150. For a detailed
explanation of the calculations on which these estimates are based see p. 180.
3
The President's Commission on the Health Needs of the Nation: Building
America's Health, Vol. IV: Financing a Health Programme for America (Washington,
U.S. Government Printing Office), p. 151. The expenditure of the federal, state and
local authorities on hospital and medical care, including out-patient care in public
institutions but not expenditure for domiciliary care by the Veterans Administration
and institutions for chronic care, other than mental and tuberculosis, is recorded.
Expenditure on medical rehabilitation is included.

THE COST OF MEDICAL CARE

voluntary contributions to hospital expenses the amount estimated for 1951
($400 million) has been added. The total of 513,672 million thus obtained
represents 4.48 per cent, of the national income in 1953 ($305,000 million) or,
per head of population, 1.79 per cent, of the average income per economically
active person.
According to the President's message to the nation on the subject of health
in 1955, the total cost of health care in that year was estimated at $14,500
million. A deduction of 6.53 per cent, to exclude expenditure on preventive
health care (i.e. the proportion of such care to total expenditure in 1951)
would leave a total of $13,553 million spent for medical care alone. This
would represent 4.52 per cent, of the national income for 1954 ($300,000
million) or, per head of population, 1.80 per cent, of the average income per
economically active person.
General

Remarks.

The expenditure on medical care of all types for the country as a
whole and including private, public a n d social security expenditure
for civilians, in terms of national income, is reckoned at 4.06 per cent.
for Belgium (1954); 4.41 per cent, for Canada (1953); 3.67 per cent.
TABLE 11. AVERAGE COST OF MEDICAL CARE AS A PERCENTAGE
OF THE AVERAGE NATIONAL INCOME PER ECONOMICALLY
ACTIVE PERSON

Country

Cost to country
(per head of the
population)
1951

Cost to social security
(per person protected)

1953
(or other
recent year)

Belgium
1.66 !
Belgium (subsequent estimate) .
(1.70)2
1.55
Canada
1.57
Chile
1.83 3
Denmark
(1.82)
Denmark (second estimate) . .
1.82
1.70
4
England and Wales
(1.99)
(1.87)
England and Wales (percentage
1.73
1.98 3
of national income)
(2.15)6
France
(1.66)6
Germany (Federal Republic)
Italy
1.51
Mexico
1.74
1.73
1.57 3
Netherlands
s
(1.91)
New Zealand
(-)
Norway
(second estimate)
1.83
1.79
Switzerland
Venezuela
United
•1954. *States
1955. * 1952. 'Cost in terms of gross national product.

0.88

0.84

1.45
0.43

0.49

1.78

1.62

(1.95)
1.37
1.23

(1.77)3
1.53
1.46
1.36 s
2.30
0.82
0.56 3
0.59

2.35
0.82
0.58
0.53
(-)
0.66
2.49
1.24'

(-)

0.68
2.03
1.29'

In brackets, cost in terms of
national income (only recently available). 6 Arrived at by addition of
costs found for different types
1
of care. • Including sanatorium care under tuberculosis insurance.
Private expenditure.

EXPENDITURE AND COST

for Denmark (1952-53); 4.43 per cent, for France (1952); 3.76 per cent.
for the Netherlands (1953); 4.56 per cent for New Zealand (1953); 4.48
per cent, for Norway (1955); and 4.48 per cent, for the United States
(1953). In terms of the gross national product the estimate for England
and Wales was 3.69 per cent. (1953-54); in terms of the national income
it was 4.05 per cent. These estimates of the cost per head of population
of medical care to the country concerned, and of the cost per person
protected of social security benefits of every type to the social security
service concerned, are summarised in terms of the average income per
economically active person in table 11.
The expenditure per person protected on medical care under the
various schemes (except those of the Latin American countries) ranged
from 0.43 per cent, to 1.78 per cent, in 1951, and from 0.49 percent.
to 1.62 per cent, in 1953. The estimated cost of medical care per head
of the population ranged from only 1.55 to 1.83 per cent, in 1951, and
from 1.51 to 1.98 per cent, in 1953.
For the year 1951 the average for five countries (Canada, England
and Wales, France, New Zealand and the United States) was 1.73 per
cent, and the median 1.73 per cent. In more recent years the average
for the same five countries was 1.76 per cent. For nine countries (the
same plus Belgium, Denmark, the Netherlands and Norway) irrespective
of year, the average is 1.71 per cent, and the medians 1.70 and 1.74 per
cent. If the estimates shown in brackets for England and Wales and for
Norway are used, the average is 1.76 per cent, and the median is 1.79
per cent. If the total cost for the Federal Republic of Germany and
Italy (found by adding up the cost of the different types of care, including
" residual benefits " under sickness insurance (table G)) is added the
average and the median come to 1.79 per cent.
The expenditure per head of sickness insurance schemes in Mexico and
Venezuela is higher than the cost of medical care per head of population
in the other countries; that of the Chilean scheme is somewhat lower.
It certainly represents, for the persons protected, a standard of medical
care higher than the general level of medical care in the whole country.
In 1951 the average for the three countries was 2.10 per cent, and the
median 2.35 per cent.
Of the total cost of medical care per head of population in the countries for which this cost could be estimated, the social security service
paid, per person protected, the following percentage : Denmark (1952-53),
27 per cent.; England and Wales (1953-54), 95 per cent.; France (1952),
77 per cent.; Federal Republic of Germany (1953), 68 per cent.; New
Zealand (1953-54), 32 per cent.; Norway (1952), 38 per cent.

THE COST OF MEDICAL CARE

In the United States private persons paid, in 1953, 70 per cent, of
the total cost per head, either directly or through voluntary or private
insurance.
Conclusions
COST OF MEDICAL CARE OF ALL KINDS

1. It would appear, in the light of the results obtained by this
study, that the average cost of such medical care as was afforded during
the period under study, per head of the population, tended to be around
1.75 or 2 per cent, of the average income per economically active person.
2. Social security in the countries under review covered, for the
persons it protected, anything from 27 to 95 per cent, of the cost per
head of the population.
3. Social security medical care services appear to have cost more, in
terms of the average income per economically active person, where
medical facilities outside the scheme were little developed; their cost
may even have exceeded the cost per head of population of all care
received in the countries with more highly developed medical facilities.
COST OF DIFFERENT TYPES OF MEDICAL CARE

4. The cost per person protected (or, where known, per head of
the population) of each of the different types of medical care provided,
expressed as a percentage of the average income per economically active
person, can tentatively be estimated as follows:
Per cent.

(a)

(b)

(c)

Medical practitioner care outside hospital wards . .
Of this,
(i) General practitioner care . .
0.20-0.25
(ii) Specialist care
0.10-0.15
Pharmaceutical supplies (comprising drugs, preparations and minor appliances provided outside hospital
wards)
Hospital in-patient care (comprising treatment by
medical practitioners, nursing, pharmacy and all
auxiliary care in addition to maintenance) . . . .
Of this,
(i) Operating costs
(of this, operating costs of
mental hospitals
(ii) Cost of construction

0.80-0.85
0.10-0.12)
0.10-0.15

0.30-0.35

0.20-0.25

0.95-1.00

EXPENDITURE AND COST

Per cent.

(d)

(e)

Dental care including prostheses
Of this,

0.15-0.20

(i) Conservative care . . . . . . .

0.10

(ii) Dentures

0.05-0.10

Other care (comprising maternity care, care by
members of allied professions outside hospital wards,
non-dental prostheses, home nursing, etc.) . . . .

0.15-0.20

Total cost of care . . .

1.75-2.00

5. The cost of medical practitioner care for patients who are not
hospitalised represented less than one-fifth of the total cost.
6. The cost of drugs and preparations and of minor appliances,
on the other hand, varied enormously from country to country. On the
average it accounted for as much expenditure as medical practitioner
costs. However, the items included differed considerably even after
adjustments have been made. It would appear possible to keep the
cost of drugs, preparations and minor appliances within reasonable
limits, since countries where there is no restriction on the provision
of such supplies—other than cost-sharing on a minor scale—have
succeeded in doing so.
7. Hospital in-patient care was by far the most expensive item,
accounting for about one-half of the total cost. For a social security
scheme limited to employees, it would appear to be too high to be borne
entirely by contributions of employers and employees.
8. Conservative dental care, if regularly available, does not seem
to have been an expensive item, while the cost of dentures is likely
to be high at the inception of a free or partially free dental care service,
but eventually settles down to a fairly low rate.
9. Auxiliary care takes a great variety of forms. Part of the cost
of maternity care was often included under other items, such as hospital
costs, and its full incidence was difficult to assess. Prostheses and many
modern auxiliary services (such as massage and other forms of physiotherapy, home nursing, after-care and the like) may be costly and may
have to be introduced gradually by the social security service. On the
other hand certain of these items, such as home nursing, may help
to reduce the need for hospital care and thus in the long run prove
economical.

THE COST OF MEDICAL CARE

10. It is difficult to estimate the cost of restricted provision of any
of the items of care listed above. A limitation of benefit to a maximum
period of 26 weeks, for instance, does not appear appreciably to
reduce the cost of medical practitioner care or of hospitalisation. The
effect of the complete exclusion of certain items from the range of
benefits, such as dental prostheses, on the other hand, could be more
easily estimated. However, allowance would have to be made for the
gradual reduction of the cost of dentures.
11. Cost-sharing by the patient under social security does not appear
necessarily to reduce the cost of care, although it may reduce expenditure.
In the case of dental care it would appear to reduce demand below
the desirable level.

CHAPTER III
TRENDS IN EXPENDITURE ON MEDICAL CARE
In the preceding chapter an attempt was made to estimate the full
cost of medical care in a number of countries and to examine the composition of medical costs.
In this chapter the trend of medical expenditure under the social
security systems covered by the present study and of private consumer
expenditure in the United States during the period under review is
examined and the changes in the relative importance of the different
types of medical care provided are discussed.
The first section deals with trends in the expenditure on medical
practitioner care and, to some extent, in the expenditure on general
practitioner and on specialist care, their share in total expenditure on
medical benefits, and the cost of all types of care.
In the second section trends in pharmaceutical expenditure and its
relative importance are analysed.
In the third section the trend in hospital expenditure and its share in
total expenditure and in the cost of all medical care are dealt with, while
the fourth section deals with the evolution and volume of dental expenditure.
Finally, changes in the relative volume of expenditure on all medical
benefits and general trends are discussed.
It should be recalled in this context that national income estimates
prior to 1953 (or, in some cases, 1952) were not as a rule revised subsequently, which may account for certain breaks in the continuity of
trends.
General Practitioner and Specialist Care
GENERAL PRACTITIONER CARE

For the countries for which the relevant expenditure is separately
recorded, the amount spent per person protected on general practitioner
care was found to be between 0.18 to 0.20 per cent, of the average income
per economically active person.

THE COST OF MEDICAL CARE

We shall now consider how the amount paid to a general practitioner
per person in his charge has varied during the period under review and
what relationship it bears to the total expenditure of the social security
scheme on the one hand and to the total cost of medical care in the
country on the other.
Denmark.
The expenditure per person protected of the sickness insurance scheme
in Denmark on general practitioner care, after a sharp drop from the pre-war
value, remained remarkably stable from 1947 to 1952, at 0.29 to 0.34 per cent.
of the income per head and 0.16 to 0.17 per cent, of the reference wage. It
then rose considerably, owing to an increase in remuneration, to 0.41 per cent.
of the income per head and 0.21 per cent, of the reference wage, remaining
at that level in 1954 and 1955.
The general practitioner's share took up 35 to 38 per cent, of total expenditure on medical benefits (except for a drop in 1945) until 1953, when it
rose to 42 per cent. By 1955 it had fallen back to 38 per cent.
However, the cost of general practitioner care (per head of the population,
0.34 per cent, of the income per head in 1952 and 0.41 per cent, in 1953)
represented less than one-tenth of the full cost of medical care per head in
1952-53 (estimated at 3.67 per cent, of the income per head).1
The cost of specialist care given outside hospital wards, which is a supplementary benefit in Denmark, rose from 0.05 per cent, of the income per head
in 1945 to 0.08 per cent, in 1955, and from 0.03 to 0.04 per cent, of the reference wage during the same period.
The number of consultations and visits is not known. However, the number
of adult members reported sick per 1,0002 reached a peak in 1953, as did the
number of days spent at home per member. This peak in morbidity is reflected
in the expenditure on general practitioner care but not in that on specialist care.
England and Wales.
In the National Health Service of England and Wales the expenditure of the
service on general practitioner care per head of the population fell slightly from
0.43 per cent, of the income per head in 1949-50 to 0.38 per cent, in 1954-55
and from 0.40 to 0.36 per cent, of the reference wage. In 1955-56 the percentages were 0.38 and 0.36. The increase in 1952-53 is due to back payments
following an increase of about 22 per cent, in the capitation fee. In the following
year the relative cost was more or less what it was at the outset, but a slight
decrease occurred in 1954-55.
The general practitioner's share of the total cost to the National Health
Service of the care provided by it (that is, the total cost exclusive of the patient's
share) rose slightly, from 10.44 per cent, in 1949-50 to 11.07 percent, in 1954-55;
it was 10.80 per cent, in 1955-56.
Compared with the total cost of the care received (including the part paid
directly by patients) the percentage rose very slightly from 10.36 in 1949-50
to 10.63 in 1954-55. This is much the same proportion of the total cost as is
found for Denmark.
The share of general practitioners in the national product has declined
less than the total share of the national product devoted to medical care:
from 1949-50 to 1954-55, the general practitioner's share declined by 12 per
cent., while the total cost of medical care declined by about 15 per cent.
1
2

See above, p. 76.
See below, p. 99.

TRENDS IN EXPENDITURE

At one time the general practitioner's share in the national product was
exceeded by that of pharmaceutical costs and at another by that of dental costs;
but the cost of general practitioner care per head was the same in 1954-55 as
it was in 1951-52 (before the increase in the capitation fee), at 0.38 per cent.
of the income per head, while both the expenditure of the Service and the full
cost of pharmaceutical supplies, hospital care and dental care declined.
Between 1951-52 and 1954-55 pharmaceutical costs (including the patient's
share) fell from 0.41 per cent, of the income per head to 0.36 per cent., hospital
expenditure from 2.23 per cent, to 2.02 per cent, and dental costs from 0.30
per cent, to 0.22 per cent. Thus, in terms of income per head, the general
practitioner's income remained more stable than the cost of other types of care.
The report of the committee of inquiry into the cost of the National Health
Service x states that the cost of general medical services (including maternity
care), based on somewhat adjusted data and expressed in constant 1948-49
prices, rose from £46.6 million in 1949-50 to £47.1 in 1953-54. However, these
figures represent total expenditure, not expenditure per head of the population.
Italy.
The cost of general practitioner care per person protected under the Italian
sickness insurance scheme rose steadily from 0.16 per cent, of the income per
head in 1947 to 0.37 per cent, in 1950 and 0.63 per cent, in 1955. In terms of
the reference wage—which is much higher than the income per head—it
increased from 0.05 to 0.41 per cent, between 1947 and 1955. It may be recalled
that the difference between the reference wage and the income per head gradually diminished throughout the period under review 2; consequently the two
percentages were not nearly as far apart in 1955 as in 1947. The rise in expenditure towards a level corresponding to that required to maintain a fairly
comprehensive general practitioner's service is due to various causes, including
an increase in the amount of care provided and an adjustment of doctors'
remuneration to the rising cost of living.3
The workload of general practitioners developed between 1950 and 1955 4
in the manner shown in table 12.
TABLE 12. ITALY: NUMBER OF ITEMS OF SERVICE GIVEN BY
GENERAL PRACTITIONERS UNDER SICKNESS INSURANCE PER
PERSON PROTECTED, 1950-55
Year

Remuneration by fees for
items of service
Consultations

1950
1951
1952
1953
1954
1955
1

1.65 1
1.66 11
2.17
2.25
2.29
2.43

Remuneration by
capitation fee

Visits

Total

Consultations

Visits

Total

1.19 1
1.31 1!
1.81
2.02
1.90
2.06

2.84
2.97
3.98
4.27
4.19
4.49

0.57
0.73
0.60
0.55
0.68
1.04

1.33
1.52
1.32
1.17
1.08
1.21

1.90
2.25
1.92
1.72
1.76
2.25

Estimated.

Report of the Committee of Inquiry into the Cost of the National Health Service,
Cmd. 9663 (London, H.M. Stationery Office, 1956), p. 21.
2
See table A.
s
Cf. International Social Security Association, 12th General Meeting (Mexico
City, Nov.-Dec. 1955): Sickness Insurance, op. cit., pp. 229 ff.
* Idem, 13th General Meeting: Sickness Insurance (Annex to Report II), op. cit.,
reply of the Italian National Sickness Insurance Institute, pp. 4-5.

THE COST OF MEDICAL CARE

It will be seen that the number of items of service rendered by practitioners
remunerated by the fee-for-service system has greatly increased.
The cost of general practitioner care rose from 14.23 per cent, of the total
expenditure of the general sickness insurance scheme on medical benefits in
1946 to 24.55 per cent, in 1955.
The cost per person protected of the specialist and dental care given at the
polyclinics of the scheme and of care by specialists treating persons protected
under an agreement with the insurance institute rose from 0.26 per cent, of
the income per head in 1947 to 0.37 per cent, in 1950, then remained at 0.36
to 0.37 per cent, until 1955. It has thus been much more stable than that of
general practitioner care. As a proportion of the total expenditure of the
scheme on medical care it remained around 15 per cent, but occasionally rose
somewhat higher.
The number of items of service rendered per person protected in the polyclinics, including consultations (general and specialist), injections, physiotherapy, laboratory tests and radiographs, etc., rose from 2.51 in 1949 to 2.67
in 1954, but not in constant progression ; it was 2.44 in 1955. However,
between 1946 and 1949 the rise was considerable.
Netherlands.
In the Netherlands expenditure on general practitioner care per person
protected under the medical care insurance scheme (which grants full care
without cost-sharing or time limit) remained comparatively stable in terms
of the income per head from 1948 onward, after fluctuating considerably
during and immediately after the Second World War; it fell slightly from
0.36 per cent, in 1948 to 0.33 per cent, in 1952, then rose to 0.35 per cent, in
1953 and 1954. In terms of the reference wage its stability from 1946 to 1952
is remarkable. The rise in 1953 and 1954 is due to an increase in the capitation
fee in the course of 1953.1
However, as a proportion of the total expenditure on medical benefits,
expenditure on general practitioner care steadily declined from over 29 per
cent, in 1945 to about 17 per cent, in 1954.
TABLE 13. NETHERLANDS: EXPENDITURE ON SPECIALIST CARE,
1950-55
Expenditure per person protected 1
as a percentage of—
Year
in florins

1950
1951
1952
1953
1954
1955

3.73
4.03
4.08
4.94
5.24
6.95

income per head

average income
per economically
active person

0.24
0.24
0.24
0.27
0.26
0.33

0.096
0.096
0.096
0.107
0.105
0.133

Source: International Social Security Association, 13th General Meeting: Sickness Insurance
op. cit., reply of the Netherlands Council of Sickness Funds, p. 5.
1
The number of persons protected shown in this document is somewhat higher than that used
in the present study, the former being the number as of 31 December of the year, the latter the average
of 52 weekly records.
1

See appendix, p. 176.

TRENDS IN EXPENDITURE

If the cost of general practitioner care as a percentage of the national
income (0.35) is compared with the total cost of medical care per head of the
population in 1953 (which was estimated at 3.76 per cent, of the national
income), it is found to represent just under one-tenth of the total cost, or about
the same proportion as in Denmark and in England and Wales.
The expenditure on specialist care shown in table C for the Netherlands
includes about 70 per cent, of the cost of such care provided in hospitals.
The trends in expenditure on care provided by specialists outside hospital
wards between 1950 and 1955 are shown in table 13.
The actual amount expended on specialist care for non-hospitalised patients
increased throughout the six years; in terms of the income per head it remained
stable from 1950 to 1952, then rose in 1953, fell in 1954 and rose steeply in
1955. In fact, fees for specialist care, which are payable per case per month,
were raised both in 1954 and in 1955.
New Zealand.
In New Zealand the expenditure per head of the population of the social
security fund on general practitioner care rose from 0.36 per cent, of the
income per head in 1943-44 to 0.55 per cent, in 1948 and thereafter moved
irregularly, falling to 0.42 per cent, in 1955-56. In terms of the reference wage
the trend is less irregular, but expenditure fell from 0.37 per cent, of that wage
in 1947 to 0.33 per cent, in 1955-56; in 1945 the percentage was 0.28.
The general practitioner's share of the total expenditure on medical benefits
of the social security fund rose from 25 per cent, in 1943-44 to 31 per cent, in
1947-48, but by 1955-56 had fallen to less than 23 per cent. However, if the
patient's estimated share in the cost is added, the cost of general practitioner
care per head of the population represented 0.63 per cent, of the income per
head in 1951-52 (the estimated total cost of medical care during the same period
being 4.54 per cent.) and 0.60 per cent, in 1953-54 (as against a total cost of
4.56 per cent.) Thus the proportion of the total cost received by the general
practitioner was between 13 and 14 per cent.
The average number of consultations and visits per person protected rose
from 2.4 in 1946-47 to 4.0 in 1955-56.1 The increase is attributed mainly to an
increase in the number of medical practitioners; since the earlier shortage of
doctors had been overcome, people were availing themselves of their services
more freely. It will be seen from table C that this increase in services did not
result in a rise in the expenditure in terms of national income, which was 0.48
per cent, in 1946-47 and 0.42 per cent, in 1955-56.
MEDICAL PRACTITIONER CARE, INCLUDING CARE BY SPECIALISTS

We now turn to the countries for which the expenditure on medical
practitioner care under social security, including care by specialists,
is known but not the respective shares of general practitioners and
specialists.
Belgium,
For Belgium the expenditure shown in table C includes all payments made
by the insurance scheme in respect of consultations and visits by general
1

p. 7.

Report of the Special Committee on Pharmaceutical Benefits (Wellington, 1957),

THE COST OF MEDICAL CARE

practitioners and specialists but not expenditure on special treatment. The
expenditure fell from 0.40 per cent, of the income per head in 1950 to 0.33 per
cent, in 1955, and from 0.33 per cent, to 0.27 per cent, of the reference wage.
This fall is somewhat greater than that of the total expenditure on medical
benefits. In fact, the share of the total which was devoted to consultations
and visits by general practitioners and specialists fell from about 19 to less
than 17 per cent, in the six-year period.
The number of consultations and visits of medical practitioners between
1950 and 1955 per person protected is shown in table 14.
TABLE 14. BELGIUM: CONSULTATIONS OF AND VISITS BY
MEDICAL PRACTITIONERS PER PERSON PROTECTED, 1950-55
Year

Consultations

Visits

Total

1950
1951
1952
1953
1954
1955

2.55
2.78
2.78
2.69
2.74
2.80

1.86
2.07
2.04
2.03
2.06
2.14

4.41
4.85
4.82
4.72
4.80
4.94

The peak in 1951 was largely due to a severe influenza epidemic. 1 The
accounts for 1953 were closed a month earlier than in previous years.
It may be concluded that the income per head rose faster than the volume
of care provided.
Canada (Swift

Current Region,

Saskatchewan).

The total expenditure on general practitioner and specialist care per person
protected (including that on hospital calls) under the physicians' service in
the Swift Current region of Saskatchewan fell, from 0.93 per cent, of the
income per head in 1948 to 0.75 per cent, in 1953, then rose to 0.79 per cent.
in 1954. In terms of the reference wage, it declined continuously from 0.46
in 1948 to 0.36 per cent in 1954.
The number of items of medical practitioner service (including hospital
visits, operations and special services, both within the Swift Current region
and outside it) diminished from 4.79 per person protected in 1950 to 4.00
in 1954. This decline was partly due to the fact that from September 1951
onwards payments for diagnoses effected in doctors' surgeries were discontinued. The number of consultations at the surgery rose only slightly, from
3.8 in 1950 to 3.9 in 1952, then declining to 3.6 in 1954; cost-sharing was
introduced in August of that year. The number of domiciliary visits rose from
3.2 per person protected in 1950 to 4.0 in 1952 but then fell abruptly to 1.6
in 1953 and 1.8 in 1954 owing to the introduction of cost-sharing in 1953. The
effect of this measure on the number of visits was thus much greater than its
effect on the number of consultations. The number of hospital visits was
about the same in 1954 as in 1950, while the number of confinements in hospitals
rose.
'International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Belgian National Sickness and Invalidity Insurance
Fund, p. 4.

TRENDS IN EXPENDITURE

France.
In France the expenditure per person protected on care given by medical
practitioners (including both general practitioners and specialists) and by
members of allied professions, as shown in table C, under the general insurance
scheme for non-agricultural employees rose steadily from 0.52 per cent, of the
income per head in 1947 to 0.73 per cent, in 1953, then to remain stationary
from 1953 to 1955, at 0.72 and 0.74 per cent. In terms of the reference wage
the expenditure rose from 0.44 per cent, in 1947 to 0.70 per cent, in 1954, the
ratio of that wage to the income per head having declined from 1.18 in 1947 to
1.04 in 1954. The reference wage for 1955 is not known.
However, expenditure on medical practitioner care fell from some 28 per
cent, of the total expenditure of the scheme on medical benefits in 1947 to
about 19 per cent, in 1955, for the total expenditure rose much more steeply
than expenditure on medical practitioner care. The decline occurred before
1951, since when the proportion has remained stable. It should be recalled
that these percentages include not only expenditure on care given by members
of allied professions, but also the cost of surgical and other specialist care in
private clinics, of minor surgery and of mileage fees. If the expenditure on
care given by members of allied professions is deducted, the cost of medical
practitioner care to the sickness insurance scheme in 1953 is 0.67 per cent.
of the income per head or a little less than one-fifth of the total expenditure
of 3.72 per cent. The full cost of the care received, including the patient's
share, was 0.87 per cent, of the income per head in 1953. This may be compared with the total cost of all medical care per head of population in 1952
(4.43 per cent.1) of which it represents about one-fifth.
The number of consultations and visits under short-term sickness insurance
reported to the central fund of the Paris region for insured persons fell from
2.89 in 1947 to 2.44 in 1953 per insured person, but the total number of items of
service provided (including those for dependants) rose from 4.07 to 4.59 per
insured person. For all local funds, data are available only for the years 1951
to 1953. The number of consultations and visits per person protected rose from
2.31 in 1951 to 2.43 in 1953.
It will be seen that expenditure (including, however, that on long-term
sickness and on care by allied professions) rose much more rapidly: than the
volume of consultations and visits per insured person.
Federal Republic of Germany.
In the Federal Republic of Germany, under the general sickness insurance
scheme, in which expenditure on general practitioner care is not recorded
separately from that on specialist care, expenditure on all medical practitioner
care outside hospital wards per person protected, as shown in table C, rose
between 1937 and 1949 from 0.81 to 0.97 per cent, of the income per head.
Comparable data for the intermediate years are not available. After a decline
in 1951, expenditure rose again, passing from 0.90 to 1.03 per cent, of the
income per head in 1954 and from 0.60 to 0.79 per cent, of the reference wage.
In 1955 the two percentages diverged; in terms of income per head there was
a slight fall to 1 per cent., whereas in terms of the reference wage the expenditure rose to 0.86 per cent. In fact, over the period 1951 to 1955, for which
the reference wage is available, the expenditure, in terms of the income per
head, rose from 0.90 to 1 per cent, or by one-tenth, whereas in terms of the
reference wage it rose from 0.60 to 0.80 per cent, or by one-third, the ratio
1

See above, p. 74.

THE COST OF MEDICAL CARE

of the reference wage to the income per head having fallen from 1.48 in 1951
to 1.17 in 1955.
Expenditure on medical practitioner care has fallen from 40 per cent.
of the total expenditure on medical benefits in 1937 to 33-36 per cent, in recent
years, the total expenditure having risen more steeply than that on medical
practitioner care. The latter, however, has been regaining lost ground since
1953.
If the expenditure on medical practitioner care (0.50 per cent, of the average
income per economically active person in 1953) is compared to the estimated
cost of all medical care in the same year (2.15 per cent.) the practitioner's
share of the total expenditure works out at rather less than a quarter.
Mexico.
The total expenditure of the Mexican sickness insurance scheme appears
to include under the heading " medical assistance " the salaries and wages
of all medical, dental and auxiliary staff employed by the social insurance
institution at its dispensaries or for domiciliary visiting. This expenditure
decreased slightly, per person protected, in terms of income per head, from
3.22 per cent, in 1950 to 3.12 per cent, in 1953.
The trend in the cost of all medical practitioner and auxiliary care between
1950 and 1955 is shown in table 15.

TABLE 15. MEXICO: EXPENDITURE PER PERSON PROTECTED
ON DISPENSARIES UNDER SICKNESS, MATERNITY,
EMPLOYMENT INJURY AND PENSION INSURANCE, 1950-55
Year

Expenditure
(in pesos)

Expenditure
(as percentage of income
per head)

1950
1951
1952
1953
1954
1955

49.73
61.92
66.44
61.38
73.58
81.45

3.39
3.48
3.44
3.43
3.59
3.23

Source: International Social Security Association, 13th General Meeting: Sickness Insurance,
op. cit., reply of the Mexican Social Insurance Institute, p. 6. The figures are based on revised data
concerning persons protected and include expenditure on medical care provided outside hospitals under
employment injury and pension insurance schemes.

If employment injury insurance is taken into account there is no definite
trend in relative expenditure, except for a drop in 1955.
The number of consultations and visits per person protected by general
practitioners under all branches of social security during the same period
is shown in table 16.
The fall in relative expenditure in 1955 does not correspond to a reduction
in the amount of care given by general practitioners. However, the expenditure
includes the cost of specialist and dental care, as well as other expenses of the
institution's disDensaries.

TRENDS IN EXPENDITURE

TABLE 16. MEXICO: NUMBER OF CONSULTATIONS OF AND
VISITS BY GENERAL PRACTITIONERS PER PERSON PROTECTED,
1950-55
Year

Number of
consultations

Number of visits

Total number
of items

1950
1951
1952
1953
1954
1955

2.78
3.16
3.00
2.81
2.78
2.59

0.85
1.10
0.95
0.93
0.83
1.21

3.63
4.26
3.95
3.74
3.61
3.80

Source: International Social Security Association, 13th General Meeting : Sickness Insurance,
op. cit., reply of the Mexican Social Insurance Institute, pp. 5-6.

Norway.
In Norway the expenditure per person protected on general practitioner
and specialist care outside hospital wards under the sickness insurance scheme
declined from 0.48 per cent, of the income per head in 1939 to 0.39 per cent, in
1947, but remained comparatively stable from 1947 to 1952, varying between
0.35 and 0.41 per cent. The percentage was lowest in 1951 ; by 1953 it had risen
to 0.44; this increase was mainly due to a rise in medical fees introduced
in July 1952. Moreover, as from 5 October 1953 the income limit for liability
to insurance was abolished. However, in 1954 and 1955 the percentage
declined to 0.42, although new rates came into force for the payment of X-ray
treatment in 1954. It should be noted, however, that a revised estimate of
the number of dependants gave higher ratios of dependants to insured persons
than those in the earlier estimates. The percentages relating to years prior
to 1953 may therefore be comparatively overstated.
The medical practitioners' share of the total expenditure on medical
benefits declined from 36 per cent, in 1939 to 28 per cent, from 1951 to 1955.
This trend stands out in sharp contrast to the steady rise in the proportion
absorbed by hospital costs.
The total estimated cost of medical care per head of population in 1952
was 1.57 per cent, of the average income per economically active person.
The medical practitioners' share per head of the population (including
estimated payments by patients) was about 0.23 per cent, of that average
income, or 15 per cent, of the total.
Switzerland.
In Switzerland the cost of the medical practitioner care received by the
persons protected (including the patient's share, which, as a rule, is paid to
the sickness insurance institution and not to the attending practitioner) rose
from 0.69 per cent, of the income per head in 1946 to 0.80 per cent, in 1955,
with slight variations in the intervening period. In terms of the reference
wage the percentage rose from 0.51 in 1946 to 0.61 in 1955. This rise is
somewhat greater than that of total expenditure on medical benefits. Thus
the medical practitioner's share in the total has risen slightly, from about
52 per cent, in 1946 to about 54 per cent, in 1955.
The number of persons protected who were ill during the year under
review (irrespective of the number of cases of illness) constituted 63.6 per cent.
of the population in 1949 and 60.0 per cent, in 1955. However, the number

THE COST OF MEDICAL CARE

of spells of illness per person ill rose from 1.40 in 1949 to 1.58 in 1955. Per
100 persons protected, the number of cases of illness therefore increased
from 88.9 to 94.6, or by about 6.4 per cent. The relative cost increased
between 1949 to 1955 from 0.76 to 0.80 per cent, of the income per head
—an increase of about 5.3 per cent.
The number of consultations and visits per person protected given by
medical practitioners (whether general practitioners or specialists) remained
fairly stable from 1950 to 1954. The number of consultations was 4.0 per
person protected both in 1950 and in 1954, and the number of visits was
1.3 in both years. The average cost per consultation rose from Frs. 4.28
to Frs. 5.04 and the cost per visit from Frs. 5.99 to Frs. 7.56.1 However, in
terms of income per head, the cost per consultation remained practically
the same (0.111 per cent, in 1950 and 0.112 per cent, in 1954), while the cost
per visit rose from 0.155 to 0.167 per cent. only.
Venezuela.
The expenditure shown for Venezuela in table C includes all salaries
and wages of persons rendering medical or allied services—other than surgical
interventions and obstetric care—at dispensaries under the sickness and
maternity insurance scheme. Expenditure per person protected rose from
0.96 per cent, of the reference wage in 1946-47 to 1.37 per cent, in 1952-53 2,
after a decline in 1951-52. The national income was not fully assessed until
1952. In terms of income per head expenditure declined from 3.01 per cent.
in 1952-53 to 2.85 per cent, in 1953-54.3
The proportion of the expenditure on all medical benefits represented
by remuneration for personal health services other than surgery rose from
44 per cent, in 1946-47 to 49 per cent, in 1952-53 but fell back to 47.5 per cent.
in 1953-54.
The number of hours spent by general practitioners and pediatricians
on consultations, per 100 persons protected, rose from 34.40 in 1951 to
36.59 in 1952, while the number of hours spent on domiciliary visits rose
from 31.18 to 33.76. This increase in the volume of care may account for
some of the increase in the cost per person protected (in terms of the reference
wage) from 1951 to 1952. Between 1952 and 1953 the number of hours spent
on consultations rose further, to 41.07 per 100 persons protected, but the
number of hours spent on visits fell slightly, to 33.38. The cost fell from
3.01 to 2.85 per cent, of the income per head. However, hours spent on
consultations by specialists showed a general tendency to rise between 1951
and 1953, except that the amount of time spent on dental consultations fell
in 1953.
If expenditure on surgical interventions (included in the figures in table G)
is added to the salaries and wages of medical and auxiliary staff, the resultant
total expenditure on salaries and wages per person protected was 1.33 per cent.
of the reference wage in 1947-48 and 1.55 per cent, in 1952-53. In terms
1
International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Federal Social Insurance Office and the Federation
of Swiss Sickness Funds, pp. 1-4.
2
The reference wage in 1953 is not known.
3
The number of dependants entitled to medical benefits diminished from
208,284 in the second half of 1951 to 172,320 in 1952 as a result of the enforcement
of more stringent conditions regarding the admission of unmarried wives. At the
same time the income limit for liability to insurance was raised and the number of
insured persons rose from 105,453 to 118,402. These changes in the proportion
of insured persons and dependants may have affected the cost per person protected.

TRENDS IN EXPENDITURE

of the income per head (available since 1952) it represented 3.42 per cent.
in 1952-53 but only 3.26 per cent, in 1953-54.
The number of surgical interventions (other than obstetrical) increased
from 121 per 1,000 insured contributors in 1950 to 130 in 1953.
United States.
Private expenditure on medical care (including voluntary insurance expenditure) in the United States, as shown in table C, includes fees for treatment
in hospital paid to independent practitioners by the patients. It fell from
1.08 per cent, of the income per head in 1949 to 0.92 per cent, in 1951, then
rose to 0.94 per cent, in 1953, 0.99 per cent, in 1954 and 0.96 per cent, in 1955.
The rise between 1953 and 1954 is partly accounted for by a fall in national
income.
The cost of medical practitioner care fell slightly, from 31 per cent, of
total private expenditure (including expenditure under voluntary insurance)
in 1948 to about 28 per cent, in 1955. Again, pharmaceutical and hospital
costs rose in comparison.
According to the findings of a study undertaken for the American Medical
Association, the medical practitioner's share in private expenditure on medical
care declined from 33 per cent, in 1929 to 28 per cent, in 1953, while the share
of hospitals increased from 14 to 261 per cent, and that of drugs and preparations fell from 20 to 16 per cent.
According to the same inquiry 11 consultations at a general practitioner's
surgery cost the production worker one week's wages in 1937, while the
same number of consultations cost only 51 per cent, of a week's wages in
1954. The wages taken for this calculation were the average gross weekly
earnings of production workers in manufacturing industries. From 1929 to
1951 the physician's average income rose slightly less than the average income
of all gainfully employed persons.
General Remarks.
The expenditure per person protected on general practitioner care
in the five countries for which data are available remained comparatively
stable in three of the five countries (Denmark until 1952, England
and Wales 2 and the Netherlands 3) in terms of both the income per
head and the reference wage. There was a considerable rise in Denmark
from 1953 onwards.
In Italy the expenditure rose steadily and since 1951 has overtaken
that of England and Wales and New Zealand. In New Zealand
expenditure tended to decline after 1948.
The trend of the share of the total expenditure on medical benefits,
under the social, security systems covered by the survey, received by
general practitioners is shown in table 17.
1

The Economic Position of Medical Care, 1929-1953, op. cit., p. 5.
The peak in 1952-53 is due to back payments for previous years under an award
granting an increase in remuneration.
3
The peak in 1945 is due to a drop in the income per head resulting from war
conditions.
2

THE COST OF MEDICAL CARE
TABLE 17. EXPENDITURE ON GENERAL PRACTITIONER CARE
OUTSIDE HOSPITAL WARDS AS A PERCENTAGE OF TOTAL
EXPENDITURE ON MEDICAL BENEFITS UNDER FIVE
SOCIAL SECURITY SCHEMES
England and Wales
Year

Before 1944
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1

Denmark

Italy
Expenditure

Cost

—
—
—
—
—

36.12 !

—

32.59
33.39
36.63
35.71
35.54
34.94
36.17
37.69
41.76
40.28
38.57

10.44
10.24
9.91
16.23
11.52
11.07
10.80

10.36
10.16
9.71
15.56
10.93
10.63
10.28

—
—

14.23
13.92
14.02
18.11
18.34
20.80
21.20
22.53
23.48
24.55

Netherlands

24.68 2
25.73
29.31
25.77
22.15
19.85
18.95
17.51
16.52
16.38
16.92
17.48
17.81

New Zealand

24.95 2
24.59
25.78
24.44
31.09
29.41
29.96
30.62
29.48
29.23
29.11
26.62
22.83

1938. ' 1943 or 1943-44.

It will be seen that the general practitioners' share rose in Denmark,
especially after 1950, in Italy after 1948 and in New Zealand up to
1948 ; on the other hand, it remained fairly stable in England and Wales
and actually fell in the Netherlands, where, however, the decline has
been arrested by recent increases in remuneration.
The proportion of the expenditure on all medical benefits received by
general practitioners varied in the five countries covered from approximately 11 per cent, under a comprehensive medical care service (that of
England and Wales) to 42 per cent, under a sickness insurance scheme
covering only a small proportion of hospital costs (that of Denmark).
For the countries for which separate figures for expenditure on
general practitioner care are not available, its scale and variations
can be inferred from the figures for expenditure on all medical practitioner care.
Expenditure on medical practitioner care, as will be seen from
table C, expressed in terms of the income per head, rose almost continuously and rapidly in France and in Italy up to 1953, when it levelled
off in France but continued to rise in Italy. It rose slowly but steadily
in Switzerland up to 1953. In Denmark, Germany (Federal Republic),
the Netherlands and Norway an earlier decline was followed by a rise up
to 1953 or 1954. Except for France, Italy and Germany (Federal Republic), expenditure was rather more stable in terms of the reference
wage than in terms of the income per head. In Germany (Federal
Republic) the increase was more pronounced. Expenditure fell in

TRENDS IN EXPENDITURE

TABLE 18. EXPENDITURE ON MEDICAL PRACTITIONER CARE AS A PERCENTAGE
OF TOTAL EXPENDITURE ON MEDICAL BENEFITS UNDER TEN SOCIAL SECURITY
SCHEMES AND PRIVATE EXPENDITURE ON MEDICAL PRACTITIONER CARE AS A
PERCENTAGE OF TOTAL PRIVATE EXPENDITURE ON MEDICAL CARE IN THE
UNITED STATES, 1945-55
Year

Prior to
1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

.
.
.
.
.
.
.
.
.
.
.
.

Belgium

Denmark

France

—
—
—
—
—
—

41.51 »
38.15
39.11
42.99
42.16
42.48
41.97
43.63
44.94
47.97
47.12
45.89

_
—
—

18.93
18.56
17.46
17.67
16.89
16.29

' A l l expenditure on dispensaries.
• 1943. • 1939.

28.29
25.14
21.65
19.75
21.24
19.59
19.31
19.41
19.40

Germany
(Fed.
Rep.)

39.96 «

—
—
—
—

31.69
33.43
33.66
34.17
34.55
36.10
36.10

Italy

—
—

29.76
37.29
29.62
34.30
36.71
37.54
36.94
37.70
38.70
39.04

Mexico Netherlands
i

—
—
—
—
—
—

45.10
44.65
42.62
43.84

—
—

37.86 •
42.69
40.40
36.43
33.91
34.34
33.84
32.09
32.24
33.92
34.20
34.62

Norway

Switzerland

36.35 •
36.72
35.67
31.67
28.64
31.70
30.56
27.84
28.09
28.81
27.90
27.94

—
—

52.41
53.26
52.30
52.02
52.95
53.58
53.94
54.36
54.43
54.39

"All wages and salaries except for surgery and obstetrics.

Vene- United
zuela ' States

—
—

44.04
44.92
46.26
44.97
47.49
44.87
48.95
47.52

—
—
'1938.

Belgium between 1950 and 1955. In the Swift Current region of Saskatchewan (Canada) it fell between 1948 and 1953 in terms of both the
income per head and the reference wage; in 1954 it rose in terms of the
income per head but fell in terms of the reference wage.
Private and voluntary insurance expenditure in the United States
expressed in terms of national income declined from 1949 to 1951,
after which it rose slowly until 1954.
In terms of the income per head expenditure per person protected
on medical practitioner care was roughly similar, in 1953 or 1954,
in the Swift Current region of Saskatchewan, France, the Federal
Republic of Germany, Italy, the Netherlands, Switzerland and the
United States, ranging from 0.70 and 1 per cent, approximately. However, as shown in Chapter II, the content of the care provided is by
no means identical.1
On the other hand, the proportion of expenditure on all medical
benefits received by medical practitioners (or, in the United States,
their share of private expenditure on medical care) as shown in table 18,
has declined since 1945 in Belgium, France, the Netherlands, Norway
and the United States, while it rose in Denmark after 1950, in the
Federal Republic of Germany after 1949, in Italy after 1948, and, more
slowly, in Switzerland, after 1950.
1

See above, p. 17.

—
—
—
—

31.04
31.01
30.39
29.84
29.43
28.98
28.87
27.89
'1937.

THE COST OF MEDICAL CARE

The trends may be summarised as follows:
1. A rise in the expenditure on medical practitioner care was accompanied—at least during the latter part of the period understudy—by a rise
in the share of the medical practitioner in the expenditure on all medical
benefits in Denmark, the Federal Republic of Germany, Italy, the
Netherlands and Switzerland, where the expenditure on medical practitioner care has risen faster, or has declined more slowly, than the expenditure on all medical benefits.
2. In France the expenditure rose during the more recent years
studied, but the medical practitioners' share of the expenditure on
medical benefits fell, total expenditure having risen faster than the cost
of medical practitioner care. Private expenditure on treatment by practitioners in the United States rose after 1951, but the practitioners' share
of the total outlay fell somewhat.
3. In Norway expenditure rose from 1951 onwards, but the medical
practitioners' share remained quite stable.
4. In Belgium expenditure on medical practitioner care declined,
and the practitioners' share in the total expenditure on medical benefits
also declined, the former to a greater extent than the latter.

Pharmaceutical Preparations
Changes in the relative expenditure on drugs and appliances of
the social security systems covered by the present study, and in private
expenditure on this item in the United States, during the periods under
review do not in general bear out the commonly accepted belief that such
expenditure is rising everywhere and continuously. Expressed in terms
of income per head or the reference wage, expenditure per person
protected was comparatively steady in most countries.
In view of the great interest aroused by trends in pharmaceutical costs
in recent years, a detailed analysis of the factors involved is undertaken
in this section.
Belgium.
In Belgium the expenditure per person protected of the insurance scheme on
pharmaceutical benefits (excluding pharmaceutical supplies provided to beneficiaries in hospital) rose from 0.47 per cent, of the income per head in 1950 to
0.49 per cent, in 1951, falling back to 0.44 per cent, in 1952. From 1953
onwards the accounts of the scheme were closed at an earlier date than previously, so that comparison with earlier years is difficult. However, the cost
remained at a lower level until 1954, rising again from 0.42 per cent, of the
income per head in that year to 0.46 per cent, in 1955. In terms of the reference
wage, the expenditure rose from 0.39 per cent, in 1950 to 0.40 per cent, in 1951,
then fell to 0.35 per cent, in 1953 and rose again to 0.38 per cent, in 1955.

TRENDS IN EXPENDITURE

Expenditure on pharmaceutical benefits accounted for 21 to 22 per cent, of
the total expenditure on medical benefits, except for peaks of about 24 per cent.
in 1951 and 23 per cent, in 1955.
The variations in the amount of pharmaceutical benefits in the period
1950-55 are shown in tables 19 to 24.
The trends in the volume of pharmaceutical benefits supplied reflect changes
in the range of pharmaceutical supplies paid for under the scheme, in the
morbidity rate and in practice in prescribing. The number of prescriptions
issued per person protected rose from 7 in 1950 to 7.9 in 1951. This rise may at
least in part be attributed to an outbreak of influenza in January 1951; it
accompanied an increase in the number of consultations per person protected.
TABLE 19. BELGIUM: NUMBER OF PRESCRIPTIONS PER PERSON
PROTECTED BY TYPE OF PREPARATION, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .
Proprietary
of which :
Indispensable . .
Other

3.13
3.87

3.20
4.70

3.53
2.68

3.65
1.26

3.82
1.65

3.95
1.95

0.28
3.59

0.47
4.23

0.57
2.11

Total . . .

7.00

7.90

6.21

4.91

5.47

5.90

TABLE 20. BELGIUM: PERCENTAGE DISTRIBUTION OF PRESCRIPTIONS
BY TYPE OF PREPARATION, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .
Proprietary
of which:
Indispensable . .
Other

44.68
55.32

40.45
59.55

56.83
43.17

74.34
25.66

69.80
30.20

66.94
33.06

4.01
51.31

5.99
53.56

9.24
33.93

Total . . .

100.00

TABLE 21. BELGIUM: PERCENTAGE DISTRIBUTION OF PROPRIETARY
PREPARATIONS BY TYPE, 1950-52
Type of preparation

Indispensable
Other
Total . . .

1950

1951

1952

7.24
92.76

10.06
89.94

21.41
78.59

100.00

THE COST OF MEDICAL CARE

TABLE 22. BELGIUM : NUMBER OF PRESCRIPTIONS PER CONSULTATION
OR VISIT BY TYPE OF PREPARATION, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .
Proprietary
of which:
Indispensable . .
Other

0.71
0.88

0.66
0.97

0.73
0.56

0.77
0.27

0.80
0.34

0.80
0.40

0.06
0.82

0.10
0.87

0.12
0.44

Total . . .

1.59

1.63

1.29

1.04

1.14

1.20

The number of consultations and visits per person protected was as follows: 1950, 4.41; 1951, 4.85;
1952, 4.82; and 1953, 4.72.

TABLE 23. BELGIUM: PERCENTAGE DISTRIBUTION OF PRESCRIPTIONS
PER CONSULTATION OR VISIT BY TYPE OF PREPARATION, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .
Proprietary
of which:
Indispensable . .
Other

44.65
55.35

40.49
59.51

56.59
43.41

74.04
25.96

70.18
29.82

66.67
33.33

3.78
51.57

6.13
53.38

9.30
34.11

Total . . .

100.00

100.00 100.00

100.00

TABLE 24. BELGIUM: INDICES OF THE VOLUME OF PHARMACEUTICAL
BENEFITS SUPPLIED, 1950-55
(1950 = 100)
Benefits supplied

1950

Per person protected .
Per consultation . . .

100
100

1951

112.86
102.52

1952

1953

1954

1955

88.71
81.13

70.14
65.41

78.14
71.70

84.29
75.47

More striking than the increase in volume in 1951 is the decrease in 1952 and
1953. By the latter year the number of prescriptions issued per person protected
had fallen to 4.91 and the number of prescriptions per consultation, which was
1.63 in 1951, to 1.04. This decrease was due to the radical reduction in June
1952 in the range of proprietary preparations not deemed indispensable for
which payment was made. However, the decrease in the number of ordinary
proprietary preparations provided under the scheme in 1952 and 1953 was
to a certain extent offset by a rise in the number of non-proprietary medicaments prescribed for the persons protected. In 1954 and 1955 the volume of
prescriptions increased again, especially for proprietary preparations, a large
number of new preparations having been included among those for which
payment is made. However, the number of non-proprietary prescriptions
issued per person protected also increased.

TRENDS IN EXPENDITURE

Tables 25 to 29 show the trends of expenditure on pharmaceutical benefits
during the period 1950 to 1955.
TABLE 25. BELGIUM: EXPENDITURE PER PERSON PROTECTED AS
PERCENTAGE OF INCOME PER HEAD BY TYPE OF PREPARATION,
1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .
Proprietary
of which:
Indispensable . .
Other

0.217
0.254

0.219
0.267

0.266
0.172

0.303
0.110

0.293
0.130

0.305
0.153

0.039
0.215

0.050
0.217

0.061
0.111

Total . . .

0.471

0.486

0.438

0.413

0.423

0.458

TABLE 26. BELGIUM: PERCENTAGE DISTRIBUTION OF EXPENDITURE
BY TYPE OF PREPARATION, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

Non-proprietary . . .

46.03
53.97

45.14
54.86

60.76
39.24

73.49
26.51

69.30
30.70

66.70
33.30

. .

8.34
45.63

10.29
44.57

13.92
25.32

Total . . .

100.00

of which :
Indispensable
Other

TABLE 27. BELGIUM: PERCENTAGE DISTRIBUTION OF EXPENDITURE
ON PROPRIETARY PREPARATIONS BY TYPE OF PREPARATION, 1950-52
Type of preparation

Other
Total . . .

1950

1951

1952

15.46
84.54

18.76
81.24

35.49
64.51

100.00

TABLE 28. BELGIUM: EXPENDITURE PER PRESCRIPTION BY TYPE
OF PREPARATION AS PERCENTAGE OF INCOME PER HEAD, 1950-55
Type of preparation

1950

1951

1952

1953

1954

1955

All
Non-proprietary . . .

0.067
0.069
0.066

0.061
0.069
0.057

0.071
0.075
0.064

0.084
0.083
0.087

0.077
0.077
0.079

0.078
0.077
0.078

THE COST OF MEDICAL CARE

TABLE 29. BELGIUM: INDICES OF VOLUME OF PHARMACEUTICAL
BENEFITS AND OF EXPENDITURE PER PERSON PROTECTED, 1950-55
Non-proprietary
preparations
Year

1950.
1951.
1952.
1953.
1954.
1955.

.
.
.
.
.
.

Proprietary
preparations

Volume

Expenditure
in terms
of income
per head

Volume

Expenditure
in terms
of income
per head

Volume

Expenditure
in terms
of income
per head

100
112.86
88.71
70.14
78.14
84.29

100
103.12
92.96
87.56
89.79
97.15

100
102.24
112.78
116.21
122.04
126.20

100
101.13
122.70
139.79
135.27
140.77

100
121.45
69.25
32.56
43.64
50.39

100
104.82
67.59
40.26
51.00
59.95

The trend of expenditure on pharmaceutical benefits (a rise in 1951, falls
in 1952 and again in 1953 and rises in 1954 and 1955) is similar to that of the
volume of benefits provided. Although the wide variations in volume constitute the determining factor in the trend of expenditure, fluctuations in the
price of the medicaments prescribed and in the share of the cost borne by the
beneficiary have exercised a certain influence. The cost per prescription
paid for under the scheme increased from 0.067 per cent, of the income per
head in 1950 to 0.084 per cent, in 1953; the cost of non-proprietary preparations increased from 0.069 to 0.083 per cent, of the income per head and the
cost of proprietary preparations from 0.066 to 0.087 per cent, during the same
period. The increase in the average cost per prescription between 1950 and
1953 probably reflects the use of more costly remedies and may also reflect an
increase in the price of drugs and the cost of pharmaceutical services exceeding
that which occurred in the general price level. In April 1951 an upward revision
of pharmacists' fees accounted for nearly 4 per cent, of the total expenditure on
pharmaceutical benefits in that year. It will be noted that in 1952 and 1953 the
expenditure of the scheme on non-proprietary preparations increased considerably. In 1954, however, the average cost per prescription had declined
somewhat, in terms of income per head, from its 1953 peak for both types of
preparation and remained at that level in 1955. The rise in expenditure per
person protected from 0.42 per cent, of the income per head in 1954 to 0.46 per
cent, in 1955 was therefore due to a rise in the volume of pharmaceutical
supplies provided. The increase would have been even greater had not the
share to be paid by the beneficiary been raised from Frs. 7 to Frs. 8 per nonproprietary prescription in June 1952. The change in the regulations concerning reimbursement for ordinary proprietary preparations which was made in
June 1952 can have had little effect on the total expenditure for the remainder
of 1952 and for 1953 since such preparations constituted only a very small
proportion of the benefits provided during that period. The increase in 1954
and 1955 is due both to the admission of new proprietary preparations benefits
and to a greater consumption of medicines.
Denmark.
In 1945 the cost of pharmaceutical benefits to the state-subsidised sickness
funds in Denmark per person protected was 0.14 per cent, of the income per
head as against 0.18 per cent, in 1938. After a fall from 1949 to 1952, it returned
to 0.14 per cent, in 1954 and 1955. The expenditure of the funds on pharmaceutical benefits accounted for 16 per cent, of their expenditure on all medical

TRENDS IN EXPENDITURE

benefits in 1945. This rate fell to 14.5 per cent, in 1947, rose gradually to
nearly 16 per cent, in 1950 and then fell back to between 12 and 14 per cent.
The trends of expenditure as shown in table D may be correlated with trends
in morbidity. The number of members reporting sick per thousand and the
number of benefit days spent at home per member during the period under
review are shown in table 30. The number of benefit days spent in hospital has
been disregarded because the cost of the medicaments supplied to hospital
patients is not included in the expenditure by the funds on pharmaceutical
supplies. It should be remembered that members are not necessarily covered
for cash benefits.
TABLE 30. DENMARK: PREVALENCE OF SICKNESS AMONG
ADULT MEMBERS, 1945-55
Year

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Number of adult members reported sick
per thousand adults

Number of benefit days spent at home
per adult member

136
142
136
134
144

2.13
2.34
2.24
2.05
2.23

—

139
141
155
149
149

2.01
2.05
2.23
2.19
2.10

The fall in expenditure in 1951 was in part due to the effect of the new
regulations concerning the range of compulsory and of optional benefits
provided, which were in force for the last six months ofthat year. In 1952, the
first full year in which the new regulations were in effect, the rate of expenditure
by the funds per person protected fell to the lowest point in the period 1946-55,
reaching 0.11 per cent, of the income per head. It rose again to 0.12 per cent.
TABLE 31. DENMARK: PERCENTAGE DISTRIBUTION OF EXPENDITURE
BY TYPE OF PREPARATION, 1946-55
Type of medicine
(percentage of total)
Year
Vital

1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

10.87
12.13
12.66
13.50
12.45
13.57
14.95
14.62
16.16
16.65

Important

Very important

89.13
87.87
87.34
86.50
87.55
86.43
65.70
68.20
68.26
66.78

19.35
17.18
15.58
16.57

100

THE COST OF MEDICAL CARE

in 1953, a year in which the number of adults notified sick per thousand reached
its highest peak. However, in 1954 and 1955 the expenditure was even higher,
at 0.14 per cent., although morbidity declined. Expenditure on vital preparations, however, had continued to increase, reaching nearly 17 per cent, of all
pharmaceutical expenditure in 1955, as compared with 12 per cent, in 1947.
England and Wales.
The cost per head of the population of pharmaceutical supplies provided
under the National Health Service of England and Wales, expressed as a
percentage of the income per head, rose from 0.33 in 1949-50 to 0.35 in 1950-51
and to 0.41 in 1951-52. Cost-sharing by the beneficiary at a flat rate of 1 shilling
per prescription form 1 and 5 shillings to 10 shillings per scheduled appliance
was introduced in June 1952 and for 1952-53 the expenditure of the Service per
head of the population on pharmaceutical supplies (excluding cost-sharing)
fell to 0.36 per cent, of the income per head; in 1953-54 and 1954-55 it was lower
(0.31 per cent.); while the cost (i.e. including cost-sharing) was 0.40 per cent, of
the income per head in 1952-53 and 0.36 in 1953-54, 1954-55 and 1955-56. In
terms of the reference wage the cost per head of the population rose from
0.30 to 0.40 per cent, between 1949-50 and 1951-52; in 1952-53 it fell back to
0.38 per cent, (or 0.34 per cent, if the patient's share is excluded). In 1953-54
the corresponding percentages were 0.34 and 0.29; in 1954-55, 0.34 and 0.30
respectively; and in 1955-56, 0.34 and 0.29. It should t e recalled that these
percentages do not include expenditure on prescriptions issued t y specialists
in hospital out-patient departments.
In 1949-50 the expenditure of the National Health Service on pharmaceutical
supplies represented 7.90 per cent, of its expenditure on medical care. By
1951-52 it had reached 10.67 percent, of the total, but has since fallen to about
9 per cent. The total cost of pharmaceutical supplies, including the patient's
share, expressed as a percentage of the total cost of the care provided under the
National Health Service (including the patient's share of the cost of other types
of care) ranged from a minimum of 7.84 per cent, in 1949-50 to a maximum of
10.44 per cent, in 1951-52; the percentage had fallen to 9.89 in 1954-55, a
figure which was 26.15 per cent, higher than the corresponding figure for
1949-50.
The trend of the volume of prescriptions during the period 1949-54 is
shown below.
Year

Number of prescriptions
per head

1949
1950
1951
1952
1953
1954

4.612
4.958
5.198
4.920
4.983
4.915

The figures given above show a rise in the average number of prescriptions
issued between 1949 and 1951, followed by a slight decline in 1952, when costsharing was introduced; for 1952,1953 and 1954 the average has been relatively
stable.
If the number of prescriptions issued is analysed on a month-by-month
basis the influence of weather and of seasonal epidemics becomes apparent.
The high rate in 1951 may be attributed almost entirely to the large number of
prescriptions dispensed in January of that year, when there was an epidemic of
influenza. The number of prescriptions issued in December 1952 was 12.8 per
3
In 1956 an amendment was introduced making this charge payable in respect
of each individual prescription.

101

TRENDS IN EXPENDITURE

cent, higher than the number issued in December 1951 ; this is attributed to the
relatively high incidence of sickness in December 1952 caused by the dense
fogs in London.
Tables 32 and 33 show the trend of the total cost per prescription between
1949 and 1955 and the estimated composition of payments made to pharmacists from 1950 to 1954.
TABLE 32. ENGLAND AND WALES : AVERAGE COST PER PRESCRIPTION \
1949-54

1949
1950
1951
1952
1953
1954
1

Cost per prescription
(in pence)

Cost per prescription as percentage
of income per head

36.04
38.47
43.91
48.63
48.82
50.44

0.0692
0.0703
0.0729
0.0748
0.0699
0.0680

Based on calendar year.

TABLE 33. ENGLAND AND WALES : COMPOSITION OF PAYMENTS *
TO PHARMACISTS, 1950-54
Item

1950

1951

1952

1953

1954

Dispensing fees and payments
for services outside hours . .

33.1

29.2

26.4

25.9

25.0

Cost of ingredients and allowances for containers . . . .

56.1

55.0

59.4

59.8

60.5

Overheads and profits

. . . .

10.8

15.8

14.2

14.3

14.5

Total . . .

100.0

Including participation by patients after introduction of cost-sharing in 1952.

The report of the committee of inquiry which investigated the cost of the
National Health Service, submitted in 1956, stated that over the period 1949-53
the expenditure of the pharmaceutical service had been rising in terms of actual
prices, having risen by 19 per cent, between 1949 and 1953. The committee
was unable on the basis of the information available to give a complete or
satisfying explanation for the trends it found in the expenditure of the pharmaceutical service. In the view of the committee the two principal causes of the
increase in the cost of the Service between 1949 and 1953 were—
(1) the increased use of new and expensive drugs (particularly the antibiotics), whether in the form of proprietaries or otherwise, and—
(2) the increased quantity of drugs prescribed (caused more by an increase in
the average quantity per prescription than in the number of prescriptions issued). 1
1

Report of the Committee of Inquiry into the Cost of the National Health Service,
op. cit., p. 23.

102

THE COST OF MEDICAL CARE

The committee noted, however, that a reduction in the rates of payment
to pharmacists had resulted in a slight offset to the rising trend.
In the present study the expenditure per head of the population of the
Service on pharmaceutical supplies has been measured in terms of the income
per head and of the reference wage. In these terms the expenditure of the
Service on pharmaceutical supplies per head of the population rose from 1949-50
to 1951-52 but declined after the introduction of cost-sharing in 1952, being
slightly lower in 1954-55 than it had been in 1949-50. The total cost per head
of the pharmaceutical supplies received by the persons protected (expenditure
by the Service plus the amount paid by the patients) in terms of the income per
head and of the reference wage remained almost the same in 1951-52 and
1952-53, declining by about 10 per cent, in 1953-54 and remaining unchanged
in 1954-55 and 1955-56. The cost per person protected of the pharmaceutical
products supplied (including, since 1952, the patients' share) expressed in
terms of the income per head was some 9 per cent, higher in 1954-55 than it
had been in 1949-50, while in terms of the reference wage the cost was 13 per
cent, higher in 1954 than it had been in 1949-50.
France.
In France the expenditure per person protected of the social insurance
scheme for non-agricultural employees on pharmaceutical supplies and
services (including eye-glasses, orthopaedic appliances and laboratory analyses)
in cases of short-term and long-term illness rose steadily from 0.38 per cent, of
the income per head in 1947 to 0.94 per cent, in 1954 and 0.99 per cent, in 1955
and from 0.32 per cent, of the reference wage in 1947 to 0.90 per cent, in 1954
(see table D). Thus in the eight-year period 1947-54 the expenditure of the
scheme per person protected increased by 147 per cent, in terms of the income
per head and by 181 per cent, in terms of the reference wage, the latter having
increased more slowly than the former.
Expenditure on pharmaceutical benefits accounted for about 21 per cent.
of the total expenditure of the scheme on medical benefits in 1947 and 26 per
cent, in 1955. The portion of the total expenditure on medical benefits used
for pharmaceutical benefits was fairly stable in 1947, 1948 and 1949 and also
in 1951, 1952 and 1953; it rose by 24 per cent, during the period under review,
the greatest single increase was from 21.79 per cent, of the total in 1950 to
24.12 per cent, in 1951. The amount spent on pharmaceutical consumption
(including private expenditure) made up about one-quarter of the national
cost of medical care, the former representing, in 1952, 0.53 per cent, of the
average income per economically active person and the latter 1.98 per cent.
This is practically the same proportion as that found for the expenditure of
the scheme.
Prior to 1955 the social insurance scheme covered some 75 to 80 per cent.
of the cost of the pharmaceutical supplies and services for persons entitled to
pharmaceutical benefits under the scheme. These supplies and services included
medicaments (products listed in the national pharmaceutical tariff), preparations made up on the doctor's prescription, approved proprietary preparations
and standard preparations (called produits sous cachet) \ laboratory examinations and analyses, surgical dressings, orthopaedic and prosthetic appliances,
and eye-glasses. In 1948 the number of proprietary preparations which had
previously been reimbursable was restricted by the deletion from the list of
1
Medicaments prepared in advance and sold under common names or under
their scientific designations in accordance with regulations which differ from those
governing the sale of proprietary preparations (spécialités).

TRENDS IN EXPENDITURE

103

certain items of little therapeutic value, those that were advertised to the
public and those whose retail price exceeded by 20 per cent, the price obtained
by applying the national pharmaceutical tariff to the component parts. In
1954, approximately 12,000 proprietary preparations, out of some 16,000
commercially available in France, were approved for refund.1a By 1950
approximately 8,000 produits sous cachet had been registered and were
thus reimbursable under the scheme. The benefits were furnished by means
of partial or full reimbursement to the beneficiary of his expenditure for the
supplies prescribed for him. The rate of reimbursement was 80 per cent.
of the tariff in case of short-term sickness and 100 per cent, in case of longterm sickness. The prices charged for medicines could not exceed the tariff
price. However, the charge for certain pharmaceutical supplies and services
other than medicaments, for example, optical supplies and medical analyses
which were fixed within the limits of a prescribed scale, was frequently higher
—and considerably so—than the tariff rate for reimbursement, so that the
beneficiary bore more than 20 per cent, of the cost.
The expenditure on pharmaceutical benefits in cases of long-term sickness,
for which the scheme paid 100 per cent, of the tariff rate and thus generally
covered the full cost, constituted a small but steadily rising percentage of the
total expenditure of the scheme on pharmaceutical benefits; this percentage
increased from 2.6 per cent, of the total in 1947 to 8.51 per cent, in 1954.
No distinction has been made between short-term and long-term sickness
since July 1955, the time limit having been abolished.
No information is available on the proportion of the cost paid by the beneficiaries for pharmaceutical benefits provided by the scheme. A study on the
consumption of pharmaceutical products made on the basis of 1,000 files,
chosen at random, dealt with in January 1954 in a Paris primary social security
fund 3, showed that the beneficiaries concerned paid 25.32 per cent, of the cost
of the pharmaceutical products prescribed or ordered for them ; this included
the charges for non-reimbursable items, 20 per cent, of the cost of reimbursable
items (excluding those provided in cases of long-term sickness) and the difference between the social security tariffs and the price charged for eye-glasses
and appliances. The same study showed that the beneficiaries paid 23.17 per
cent, of the cost of all reimbursable pharmaceutical supplies and services
and 20.67 per cent, of the cost of reimbursable pharmaceutical supplies,
excluding eye-glasses and orthopaedic appliances.
In connection with cost-sharing it should be noted that in France many
insured persons belong to mutual-aid societies which refund the amount
charged for the pharmaceutical benefits which is not reimbursable under the
social security scheme, and sometimes effect payment on behalf of the purchaser,
thus relieving their members of the need to make the initial outlay at the
time of obtaining pharmaceutical products.
Recent annual reports on the application of the social security legislation
show separately the amount expended on eye-glasses and appliances and the
amount expended on other pharmaceutical benefits. Eye-glasses and appliances
accounted for 7.82 per cent, of the total expenditure of the scheme on pharmaceutical benefits in 1950, but this proportion later declined, reaching 6.13
per cent, in 1955. There was no indication of the expenditure on the various
types of medicaments. The study on the consumption of pharmaceutical
1
Bulletin trimestriel de la Fédération nationale de la Mutualité française, No. 29,
Mar. 1954, p. 22.
8
" Le coût des spécialités pharmaceutiques ", in Revue de la Sécurité sociale, No. 6,
Nov. 1950, p. 13.
3
Dr. Norbert MARX : " La consommation pharmaceutique ", in ibid., No. 46,
June 1954, pp. 13-44.

104

THE COST OF MEDICAL CARE

products in the Paris primary social security fund, referred to above, showed
the distribution of expenditure on pharmaceuticals for the beneficiaries concerned by type of benefit in January 1954 to be as follows:
Item

Proprietary preparations . . .
Produits sous cachet
Sera and vaccine
Magistral preparations . . . .
Dressings, etc
Orthopaedic appliances . . . .
Optical supplies
Analyses

Percentage

77.54
3.62
1.33
5.65
1.23
1.88
2.36
6.39
100.00

Although statistical data on the annual consumption of pharmaceutical
supplies per person protected by the French social insurance scheme between
1947 and 1955 were not available at the time of writing, there are many
indications that the volume of reimbursable products prescribed under the
scheme rose considerably during that period. It would seem that the number
of medicaments provided per insured person increased fourfold between 1946
and 1951.1 New drugs and products—many of them expensive—were introduced and widely prescribed. On the basis of the material at hand it is not
possible to indicate the general trends of prices of pharmaceutical products
in France during the period under review.
Federal Republic of Germany.
In the Federal Republic of Germany expenditure per person protected on
pharmaceutical supplies, including dentures, as shown in table D, more than
doubled between 1937 and 1949, but subsequently fell from 0.99 per cent, of
the income per head in that year to 0.76 per cent, in 1951, after which it slowly
rose again, reaching 0.83 psr cent, in 1953, falling back to 0.73 per cent, in 1955.
In terms of the reference wage (available only since 1951) expenditure rose
from 0.51 per cent, in 1951 to 0.63 per cent, in 1955, the reference wage having
increased less than the income per head.
Expenditure on pharmaceutical supplies and dentures, after rising from
19 to 32 per cent, of total expenditure on medical benefits between 1937 and
1949, remained between 28 and 29 per cent, up to 1953, subsequently falling
to about 26 per cent. For purposes of comparison, medical practitioner care
accounted for 33 to 34 per cent, and hospital care for 27 to 28 per cent, of all
expenditure.
The great increase in pharmaceutical expenditure per person protected
since the Second World War, and especially from 1949 onwards, was largely
due to changes in the statutory provisions applicable and in the rules of the
sickness insurance institutions concerning supplementary benefits. In 1937
only 45 per cent, of the members were entitled to major therapeutic appliances
and only 37 per cent, to prostheses, whereas the vast majority of members
became entitled to both these benefits (or part of their cost) in the post-war
years.
Only about one-half of the insured persons were entitled to receive 60 to
80 per cent, of the cost of medicines and minor appliances for their dependants
in 1937; the other members received only 50 per cent, of such cost, which was
the statutory benefit. During the years immediately following the Second
1
Pharmacie et sécurité sociale (Etudes et documents du centre de recherches
économiques et sociales, Oct. 1952), p. 69.

TRENDS IN EXPENDITURE

105

World War all the insurance institutions in Lower Saxony, North RhineWestphalia, Hamburg and Schleswig-Holstein (the British occupation zone)
had to provide medicines and minor appliances for dependants to the same
extent as for members. The insurance institutions in the other Länder, which
were required by law to pay 50 per cent, of the cost, actually paid 60 to 80
per cent, of the cost of medicines and minor appliances supplied 1to the dependants of the majority of their members as an additional benefit.
The number of members entitled to receive 70 to 80 per cent, of the cost
of pharmaceutical products supplied to their dependants in these funds increased
steadily, from 5,108,439 in 1951 to 6,683,533 in 1955, or by about 30 per cent.,
while the total number of insured persons (including those in the four Länder
where dependants are entitled to the full cost of medicines and minor appliances) increased between 1951 and 1955 from 16,155,940 to 18,330,243, or
by 13 per cent. The payment of contributions by sickness insurance institutions
towards the cost of larger appliances and prostheses for dependants were also
becoming increasingly common.
Italy.
Under the Italian general sickness insurance scheme pharmaceutical
expenditure per person protected, expressed in terms of the income per head,
rose sharply between 1947 and 1948 and fell again in 1950. Since then general
practitioners have only been allowed to prescribe medicines for persons
incapacitated for work or suffering from specified diseases; this rule does not,
however, apply to the institution's dispensaries. Nevertheless, expenditure
continued to rise after 1950, attaining 0.75 per cent, of the income per head
in 1955. In terms of the reference wage—which is not available for every
year—it rose from 0.26 per cent, in 1949 to 0.49 per cent, in 1955.
Pharmaceutical expenditure also rose from 20 to 32 per cent, of total
expenditure on medical benefits between 1947 and 1948, then declined somewhat; it has since remained between 28 and 29 per cent. It should, however,
be recalled that of the persons protected for medical benefits under
the scheme
only about two-thirds are entitled to pharmaceutical benefit.2
Table 34 shows the average expenditure on prescriptions per person protected and entitled to pharmaceutical benefit and the cost per prescription, both
in terms of the income per head, the number and percentage of prescriptions per
person protected which were for proprietary medicines or for non-proprietary
medicines and the proportions of the two types of prescription.
It will be seen that the expenditure per person protected in 1955 was much the
same as in 1948, being 0.99 per cent, of the income per head in the former and
0.97 per cent.in the latter year. However, the expenditure had fallen to 0.73 per
cent, in 1950, after which it again rose. This latter rise coincided with an increase
of the number of prescriptions issued each year from 3.42 per person protected
in 1950 to 5.49 in 1955. Nevertheless, the increase in the number of prescriptions was over 60 per cent., whereas the increase in the expenditure per person
protected was only 36 per cent. The average expenditure per prescription,
although it increased from 309 lire to 398 lire, in fact declined in terms of
income per head, from 0.21 per cent, in 1950 to 0.18 per cent, in 1953, 1954
and 1955.
To sum up, the expenditure on pharmaceutical benefits provided per person
protected rose after an initial decline, but levelled off in 1953—even though the
volumi of prescriptions per person protected continued to rise slightly—owing
to a fall in the average expenditure per prescription expressed in terms of income
per head.
1
2

See above, p. 37.
See above, p. 9.

106

THE COST OF MEDICAL CARE

TABLE 34. ITALY: AVERAGE NUMBER OF PRESCRIPTIONS PER PERSON
PROTECTED BY TYPE OF MEDICINE AND AVERAGE EXPENDITURE
PER PRESCRIPTION, 1948-55
Average number of prescriptions
per person protected

Year

Proprietary
medicines

Non-proprietary
medicines

Percentage
Number Percentage
of total Number of total

1948
1949
1950
1951
1952
1953
1954
1955

2.27
2.08
1.62
1.81
2.22
2.75
2.82
2.96

61.5
55.4
47.5
48.7
47.5
52.1
53.3
53.9

Average expenditure

1.42
1.68
1.80
1.91
2.46
2.54
2.48
2.53

38.5
44.6
52.5
51.3
52.5
47.9
46.7
46.1

Per person protected
Total
number

3.69
3.76
3.42
3.72
4.68
5.29
5.30
5.49

In
lire

As
percentage
of income
per head

1,248
1,140
1,072
1,347
1,719
1,834
1,904
2,184

0.97
0.85
0.73
0.80
0.98
0.95
0.94
0.99

Per prescription

In
lire

As
percentage
of income
per head

338

0.262

309
357
366
347
360
398

0.210
0.213
0.208
0.179
0.177
0.180

Thus expenditure on pharmaceutical benefits under the Italian scheme has
contributed relatively little to the general rise in the total expenditure on
medical benefits, which is mainly due to the increase in the comparative cost of
general practitioner care.
Mexico.
Under the Mexican social insurance scheme pharmaceutical expenditure
per person protected, both in and outside hospital, as shown in table D, rose
from 3.02 per cent, of the income per head in 1950. to 3.37 per cent, in 1952,
but fell again to 3.01 per cent.—or about the same level as in 1950—in 1953.
The share of pharmaceutical supplies in total expenditure on medical
benefits rose slightly, from 42.38 per cent, in 1950 to 45.33 per cent, in 1952,
then fell back to the 1950 level in 1953.
Netherlands.
In the Netherlands the expenditure on pharmaceutical supplies per person
protected (shown in table D), after violent fluctuations during and immediately
following the Second World War, levelled off at 0.36 to 0.38 per cent, of the
income per head until 1952, after which year it fell to 0.35 per cent, and then
0.33 per cent. In terms of the reference wage, however, expenditure rose from
0.18 per cent, in 1946 to 0.27 per cent, in 1951, after which year it fell first
to 0.26 per cent, and then to 0.24 per cent.
As a proportion of total expenditure on medical benefits under the compulsory medical care insurance scheme, pharmaceutical expenditure declined from
about 22-23 per cent, just after the Second World War to 15 per cent, in 1955.
This decline is partly due to the growing proportion of hospital expenditure in
the total. In 1953 the percentage of total expenditure devoted to pharmaceutical benefits was about the same as the percentage devoted to medical practitioner care.
Pharmaceutical expenditure, as shown in table D, relates to medicines and
dressings but does not include prostheses. About 64 per cent, of pharmaceutical

107

TRENDS IN EXPENDITURE

supplies are provided through pharmacies, while the other 36 per cent, are
dispensed by doctors. 1
Insured persons register with a pharmacist of their choice if their general
practitioner is not a dispensing doctor.
In virtue of agreements between the Pharmaceutical Association and the
organisations of the medical care insurance institutions, a pharmacist receives
the following items by way of remuneration and payment :
(1) A fixed annual amount (capitation fee) for every person protected who
is registered on his list.
(2) A fixed amount per delivery. Up to 1 October 1948 this amount was
paid for every delivery, whether of medicines or dressings, as a compensation
for packing and other costs; since October 1948, however, it has included an
amount calculated to cover the wages and social security contributions of the
staff, which were formerly included in the capitation fee; also, it is no longer
payable for dressings.
(3) Payments for the medicines and dressings supplied, calculated in
accordance with a sickness insurance tariff established and kept up to date by a
permanent committee of experts; this tariff is based on the wholesale prices of
the substances used with an additional 10 per cent, (now 8 per cent.) for wastage.
The average number of deliveries increased from 5.5 per person protected
in 1946 to 7.6 in 1953, as shown in table 35. The average cost of medicines and
dressings increased from 0.331 florin in 1946 to 0.484 florin in 1951, but then
decreased to 0.435 florin in 1953. This average cost does not include the
capitation fee nor the fixed amount payable per delivery.
TABLE 35. NETHERLANDS: NUMBER OF DELIVERIES PER PERSON
AND COST, 1946-53

Year

Average number of
deliveries per person
protected

1946. . .
1947.
1948.
1949.
1950.
1951.
1952.
1953.

5.5
5.8
6.3
6.6
6.9
7.3
7.2
7.6

Cost of medicines and dressings per delivery
In florins

As percentage of income
per head

0.331
0.357
0.362
0.405
0.440
0.484
0.468
0.435

0.033
0.031
0.028
0.029
0.029
0.029
0.027
0.024

The decline in the average cost in 1952 is due to a fall in the number of
deliveries following the exclusion, under a decree of 1 February 1952, of a
number of simple remedies from the list of supplies covered, a reduction, as
from 1 August 1952, of the allowance for wastage from 10 to 8 per cent, of the
wholesale price, and the introduction of rules on economical prescribing
(issued by the Central Medico-Pharmaceutical Committee) fixing the maximum
quantities per prescription, from which the medical practitioner many deviate
1
L . V. LEDEBOER: "The Problem of the Cost of Medical and Pharmaceutical
Benefits for Insured Persons in the Netherlands ", in Bulletin of the International
Social Security Association (Geneva), Apr. 1955, pp. 119 ff.

108

THE COST OF MEDICAL CARE

only in exceptional cases. Moreover, certain medicines cannot be prescribed
without previous authorisation by the medical adviser of the sickness insurance
institution, which is withheld when the medicine can be replaced by a cheaper
one of equal efficacy, when the medicine is a proprietary preparation which can
be replaced by a non-proprietary preparation of equal value, or in the case of a
medicine still in the experimental stage. The Committee, in order to assist
the medical advisers, has established a list of medicines not normally admitted
for prescription with indications of their value, possible use, etc. The effect
on the expenditure on pharmaceutical supplies by chemists of these measures
has been a decrease in terms of the income per head and, to a lesser degree,
in terms of the reference wage. The decline is even more marked if the
expenditure per prescription in terms of the income per head is considered, as
appears from table 35. This expenditure, as already stated, does not include
the capitation fee or the fixed amount per delivery paid to the pharmacist.
Since July 1952 it has included expenditure on the pharmaceutical benefits
supplied to hospitalised patients granted after the maximum benefit period for
hospital maintenance and nursing has expired, to the extent that this expenditure is not covered by all-inclusive fees (as in fact it usually is).
Dispensing general practitioners receive a fixed amount per person protected on their list (capitation fee), which includes dispensing fees and covers
the greater part of the cost of the medicines and dressings supplied, including
those prescribed by specialists. In addition, the doctor receives an amount
corresponding to the cost of very expensive or special medicines which are
separately paid for, including those prescribed by specialists. Also, a supplementary allowance is paid for persons aged 65 or over. The capitation fees
paid to dispensing doctors were increased from 2.50 florins in 1946 to 3.58
florins in 1953, and the cost of medicines paid for separately rose from 0.15
florin per head in 1946 to 1.06 florins in 1953.
New Zealand.
The expenditure per person protected on pharmaceutical benefits for outpatients under the New Zealand social security scheme was 0.24 per cent, of
the income per head in 1943-44. By 1955-56 the rate had risen to 0.48 per cent.,
but the trend had been erratic; expenditure reached 0.47 per cent, in 1952
but fell to 0.38 per cent, in 1954-55. The trend of the expenditure per person
protected expressed in terms of the reference wage was similar. The cost
per person protected varied from 0.22 per cent, of the reference wage in 1945-46
to 0.34 per cent, in 1952-53; then it declined to 0.29 per cent, in 1954-55 but
rose to 0.37 per cent, in 1955-56.
In 1943-44 expenditure on pharmaceutical benefits accounted for about
17 per cent, of the total expenditure on medical benefits under the social
security scheme. The proportion rose and fell irregularly thereafter, reaching
nearly 29 per cent, in 1952-53, then falling to 24 per cent. In 1955-56 it was
26 per cent., while general practitioner care accounted for only 23 per cent.
and hospital care for 31 per cent.
The pharmaceutical benefits available under the scheme are specified in
the drug tariff issued by the Minister of Health. It includes all official drugs
and preparations in the British pharmacopoeia, the British pharmaceutical
codex and the official New Zealand formulary, unless or to the extent that they
are specifically excluded or only conditionally admitted. New drugs of proven
therapeutic value that have not yet appeared in the official pharmacopoeia
are added to the list from time to time. The scheme does not generally cover
proprietary preparations, although when such preparations are identical in
composition with essential medicines it pays the equivalent of the cost of the
corresponding official preparations. There is a general tendency to liberalise
the range of pharmaceutical benefits fixed when the scheme was set up in 1941.

TRENDS IN EXPENDITURE

109

The drug tariff sets out the prices and fees payable from the fund to the chemists
and others who supply the drugs. The quantity of medicines that may be
provided at the cost of the fund on one prescription is limited.
As from 1 March 1955 a number of new and expensive drugs, such as
cortisone, corticotrophin and hydrocortisone, were included among the
benefits for patients suffering from diseases in which these drugs were essential
to save life or (in certain cases) from rheumatoid arthritis. Some new antibiotics were also admitted. These additions added to the expenditure of the
social security fund in 1955-56.
Practically all the chemists in New Zealand have entered into contracts
with the Minister of Health to provide benefits under the scheme.
The fund meets the cost of the pharmaceutical products furnished to
hospital out-patients by the boards of public hospitals and in certain cases of
medicines dispensed by medical practitioners; the cost of the pharmaceuticals
thus provided accounted for less than 5 per cent, of the total.
The number of prescriptions, its relation to doctors' services and the cost
of prescriptions per head and per prescription for the period 1946-56, are
shown in table 36.
TABLE 36. NEW ZEALAND : NUMBERS AND COST OF PRESCRIPTIONS ISSUED
IN RELATION TO POPULATION AND SERVICES PROVIDED BY DOCTORS UNDER
THE SOCIAL SECURITY SCHEME, 1946-56
Cost of prescriptions
Year
1 April31 March

1946-47
1947-48
1948-49
1949-50
1950-51
1951-52
1952-53
1953-54
1954-55
1955-56

Number Number Number
of preservices
of pre- of
scriptions scriptions
provided
issued
by doctors
issued
(in
(in
millions) per head millions)

6.1
6.3
6.5
7.24
7.3
7.85
9.15
9.76
10.3
11.25

3.4
3.5
3.5
3.8
3.8
4.0
4.5
4.7
4.9
5.3

4.2
5.3
5.6
6.2
6.5
6.7
7.4
7.5
8.3
8.7

Number
of services Number
of preprovided scriptions
Per head
by doctors
in
1 per service
per head
s. d.

2.4
3.1
3.1
3.3
3.4
3.4
3.7
3.7
3.9
4.0

1.4
1.2
1.2
1.2
1.1
1.2
1.2
1.3
1.2
1.2

16 3
17 3
19 5
21 9
21 11
24 10
30 0
28 3
28 11
37 8

Per prescription
In
s. d.

4 81/ 2
4 lH/2
5 6
5 7i/ 2
5 9
6 21/4
6 7
5 IP/4
5 11
7 2

Percentage of
income per head •
Percentage 1946=100
0.113
0.109
0.120
0.109
0.090
0.098
0.102
0.084
0.077
0.090

100
96
106
96
80
87
90
74
68
80

Source: Report of the
Special Committee on Pharmaceutical Benefits, op. cit., p . 7, for all but the last two columns.
a
Mean population.
The income per head used is that shown in table.

The Special Committee on Pharmaceutical Benefits appointed to inquire
into the increasing cost of pharmaceutical benefits considered that the rise in
the number of prescriptions issued per person protected (from 3.4 in 1946-47 to
5.3 in 1955-56, or 56 per cent.) is closely related to the increase in the number
of consultations and visits per head of the population, the number of prescriptions per " service " having remained practically constant (at 1.2). The increase
in the number of prescriptions issued was therefore due to the fact that doctors
were consulted more frequently.
During the same period the cost of prescriptions per head of population
rose from 16s. 3d. to 37s. 8d. or by 132 per cent. The Committee found that this
increase was due to the use of new and expensive methods of treatment, which

110

THE COST OF MEDICAL CARE

were often, but not always, more effective than older methods; to pressure from
the manufacturing industry; to laxity in regard to the supply of medicines
without renewed medical prescription; to the practice of telephoning prescriptions; to demands by patients for prescriptions; to the inadequacy of the staff
in the Department of Health; to the inadequacy of the regulations on extravagant prescribing and on excessive claims for general medical services, the
increase in which was seen to be the cause of the increase in the number of
prescriptions per head of population.
The cost per prescription, on the other hand, increased during the same
period from 4s. 8V2d. to 7s. 2d., or by about 50 per cent. From 1952-53 to
1954-55 there was even a decline in the absolute cost; the cost per prescription
fell even more sharply from 0.120 per cent, of the income per head in 1948-49 to
0.077 per cent, in 1954-55. This trend was attributed in part to a reduction in
the prices of many drugs. To a greater extent it was attributed to administrative
action taken by the Department of Health in co-operation with the pharmaceutical and medical professions. For example, it was found that the general
practice of writing prescriptions for one month's supply resulted in wastage of
unused drugs; therefore, on the recommendation of the Chemists' Pharmaceutical Advisory Committee the initial supply of the medicine was restricted
to the quantity necessary for 15 days, the prescription being renewable for
a further 15 days if necessary. This change in the regulations did not entail
any real restriction on supplies but resulted in a considerable saving to the fund.
On the advice of the medical association, prescribing notes and information
concerning the cost of various expensive preparations were circulated to
members of the medical profession; it was thought that this contributed to the
reduction in the average cost of prescriptions.
However, owing largely to the extension of the pharmaceutical benefit
scheme which took place on 1 March 1955, both the average cost per prescription and the average number of prescriptions issued per head, as well as the
total cost per head, increased in 1955-56. However, the cost per prescription
was still one-fifth lower than in 1946-47.
The Special Committee on Pharmaceutical Benefits has recommended a
number of measures to reduce expenditure on pharmaceutical supplies. These
include a review of the basis of pricing prescriptions ; the introduction of a flatrate charge per prescription; power for the Minister to lodge a complaint with
the Disciplinary Committee where a doctor's prescribing costs exceeded the
Dominion average during a substantial period by at least, say, 50 per cent. ;
and amended regulations providing for reference to the Disciplinary Committee
for investigation of cases where a doctor provides an excessive number of
services and the possibility of reducing the payment per service after an informal
preliminary joint inquiry.
As regards the drug tariff, the Committee recommends a " positive " tariff
in which all items would be listed, with a " star " system showing the more
expensive items, a revision of the tariff with a view to economy, and a regulation that any advertising statement by drug manufacturers to the effect that a
product is " free on social security " must be accompanied by a statement of its
basic cost to the social security fund—which is not at present done. The
Committee also considers that a further restriction of the quantity allowed on
one prescription to a maximum often days' supply (rather than 14 days) with
the possibility of renewal for a further ten days would be justifiable, as for most
short illnesses such a supply would be more than adequate.
Other recommendations of the Committee include the introduction of
check prescriptions to ensure compliance with drug standards and quantity
specifications, and various measures of a general nature, such as the appointment of a senior general practitioner as Assistant Director of Clinical Services,
who would visit doctors, prepare notes on prescribing and attend committees

TRENDS IN EXPENDITURE

111

concerned with pharmacology and therapeutics. The establishment of a
pharmaceutical statistics section is proposed; this service would notify doctors
from time to time of the average cost of their prescriptions compared with the
figures for other doctors in the same district and in the Dominion. Also the
training of medical students in the art of prescribing should be improved.
Medicines should be clearly labelled so that unused amounts can be used under
the doctor's direction by another patient in the same household. Unnecessary
telephone prescribing and the supply of repeat prescriptions not ordered
directly by a medical practitioner should be discouraged.
The Committee concludes by stressing two facts :
(1) Efficient treatment in general practice with modern remedies often
keeps patients out of hospital, or even at work, and must result in enormous
benefit to the nation.
(2) If the service is to be kept at a high level of efficiency and abreast of
modern advances, pharmaceutical benefits must include an increasing proportion of expensive preparations. "Waste and extravagance must be checked;
but when everything possible towards that end has been done, so long as the
present phase of rapid development in therapeutics continues, the cost will
still show some tendency to rise." l
It is therefore particularly interesting to note that the cost of prescriptions
per head represented the same proportion of the income per head in 1954-55 as
in 1947-48. Consumption had therefore just kept abreast of the increase in
prices and in wealth.
Switzerland.
The outlay per person protected of the Swiss sickness insurance funds
reporting regularly on pharmaceutical products (including the patients' share
of the cost) as will be seen from table D, has remained fairly stable since
1946, having risen from 0.31 per cent, of the income per head in 1946 to 0.35
per cent, in 1955, after a slight fall in 1947 and 1948. In terms of the
reference wage it rose from 0.23 per cent, in 1946 to 0.27 per cent, in 1955.
As a proportion of the total outlay on medical benefits, including the
patients' share, it has remained around 22 or 23 per cent, throughout the
period covered.
Pharmaceutical supplies provided by the sickness insurance institutions
are statutory benefits as regards pharmacopoeia recipes (that is to say, nonproprietary drugs and preparations) and certain appliances. In addition,
sickness funds may supply certain proprietary drugs mentioned in a list
established by a federal committee of experts as a supplementary benefit.2
All funds seem to provide the medicines listed. The list has been kept up to
date so as to include all proprietary preparations of proven value and efficacy.
Nevertheless, costs have not increased to any appreciable extent, in terms of
either the income per head or the reference wage.
Venezuela.
The expenditure per person protected of the Venezuelan sickness insurance
scheme for industrial workers on pharmaceutical products—including eyeglasses and orthopaedic appliances—supplied, as far as can be ascertained,
both inside and outside hospitals, rose from 0.45 per cent, of the reference
wage in 1946-47 to 0.58 per cent, in 1951-52, and, as can be seen from table D,
has since remained at that level. The reference wages for 1948 and 1949
and the years following 1952 are not known.
1
2

Report of the Special Committee on Pharmaceutical Benefits, op. cit., p. 25.
See above, p. 40.

112

THE COST OF MEDICAL CARE

The national income estimates have been reasonably complete since 1952
only. In terms of the income per head expenditure on pharmaceutical supplies
rose slightly, from 1.27 per cent, in 1952-53 to 1.29 per cent, in 1953-54,
although the aggregate expenditure on medical care during the same period
decreased owing to a fall in the expenditure on wages and salaries and on
hospital care.
The number of prescriptions per person protected fell from 3.6 in 1952-53
to 3.3 in 1953-54.
The share of pharmaceutical benefits in the total expenditure on medical
benefits under the Venezuelan sickness insurance scheme was practically the
same in 1952-53 as in 1946-47, with 20.56 per cent, in the former and 20.60
per cent, in the latter year. In 1953-54 it rose to 21.46 per cent. In the intervening years the share of pharmaceutical supplies first fell considerably (to less
than 18 per cent, in 1947-48), then rose again, levelling off at about 20 or 21
per cent.
United States.
Private and voluntary insurance expenditure on pharmaceutical supplies
in the United States, which includes ophthalmic products and orthopaedic
appliances and may include some hospital expenditure, is steadily falling, as
can be seen from table D. Apart from a rise in 1949 it declined from 0.81
per cent, of the national income in 1948 to 0.72 per cent, in 1953. A slight
rise occurred in 1954 which, like the rise in levels of expenditure on other
items of care, is partly due to a fall in the national income, but the percentage
fell back again to 0.72 in 1955.
In terms of the reference wage, expenditure per head on pharmaceutical
supplies declined from 0.47 per cent, in 1950 to 0.43 in 1953.1
The share of pharmaceutical supplies in total private expenditure on medical
care also decreased, from about 25 per cent, in 1948 to about 21 per cent.
in 1955. The medical practitioners' share also declined during this period,
from 31 to 28 per cent., whereas the share of hospital expenditure rose from
23 to 30 per cent.
According to a study undertaken by the Bureau of Medical Economics
of the American Medical Association 2, the share of drugs and appliances,
exclusive of artificial limbs and eye-glasses, in the total outlay on medical care
fell from 20 per cent, in 1929 to 16 per cent, in 1953. The exclusion of artificial
limbs and eye-glasses, accounts, in 1953, for most of the difference between
the figure of $2,192 million on which table D is based and the $1,615 million
recorded in the statistics of the American Medical Association.
The number of prescriptions filled per head of the population increased
from 1.39 in 1939 to 2.59 in 1950.3 However, from 1945 to 1950 the number
rose from 2.29 to 2.59 only. The increase between 1948 and 1950 was from
2.55 to 2.59; during that period, expenditure, as shown in table D, fell from
0.81 per cent, to 0.79 per cent, of the income per head. It should, however,
be recalled that the figures shown in table D include a large number of items
other than medicines as such.
General Remarks.
Contrary to the commonly accepted belief that pharmaceutical
costs have been rising rapidly everywhere, the figures given in this section
1

The reference wage is not available for the years prior to 1950 or after 1953.
The Economic Position of Medical Care, 1929-1953, op. cit.
3
Building America's Health, op. cit., Vol. Ill: A Statistical Appendix, p. 295.
2

113

TRENDS IN EXPENDITURE

do not reveal any general tendency, during the period under review,
for expenditure per person protected on pharmaceutical benefits,
expressed in terms of the income per head or the reference wage, to rise.
Even in the three countries (France, Italy and Venezuela) where expenditure rose considerably, the increase was not more than that for hospital
care in France, less than the increase in general practitioner expenditure
in Italy, and less than the increase in the cost of medical practitioner
care in Venezuela. In any case, the upward trend eased off towards
the end of the period.
In all other countries the expenditure of the social security service
on pharmaceutical supplies, in terms of national income or basic wages,
either remained comparatively steady or declined, except for a rise in
1955 in some countries.
The share of pharmaceutical products in the total expenditure on
medical benefits, as will be seen from table 37, varies in most countries
between 20 and 30 per cent. It decreased in Denmark, the Federal
Republic of Germany (since 1949) and the Netherlands. In Italy, Mexico
and Venezuela it moved irregularly. In France, Italy (since 1950) and
New Zealand (until 1952) it rose. In Belgium and Switzerland it remained
comparatively steady.
It is impossible to state whether the full cost of pharmaceutical
TABLE 37.
HOSPITAL
BENEFITS
TURE ON

Year

Prior
to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

EXPENDITURE ON PHARMACEUTICAL SUPPLIES PROVIDED OUTSIDE
WARDS AS A PERCENTAGE OF TOTAL EXPENDITURE ON MEDICAL
UNDER ELEVEN SOCIAL SECURITY SCHEMES, AND PRIVATE EXPENDIPHARMACEUTICAL SUPPLIES AS A PERCENTAGE OF TOTAL PRIVATE
EXPENDITURE ON MEDICAL CARE IN THE UNITED STATES,
PRIOR TO 1945 AND 1945-55

Belgium

22.23
23.93
21.33
21.39
21.38
22.76

Denmark

16.48 s
16.07
15.58
14.49
15.19
15.31
15.89
13.92
12.34
12.58
13.17
13.37

England and
Wales '
Expendi- Cost
ture

Germany
New
France (Federal Italy Mexico i Netherlands Zealand
Republic)

19.43 '

7.90
8.47
10.67
9.20
8.87
9.05
8.78

7.84
8.41
10.44
9.80
9.77
9.89
9.62

1
Excluding prescriptions by specialists.
1943 or 1943-44.

20.83
20.14
20.35
21.79
24.12
24.63
24.49
25.09
26.24

32.37
28.85
28.68
28.57
28.12
26.84
26.43

27.61
20.43
31.79
26.14
23.71
25.23
28.56
28.75
28.05
28.61

42.38
43.32
45.33
42.33

21.55'
22.30
20.55
19.60
19.81
19.25
18.51
18.60
18.22
16.90
16.23
15.04

'Including supplies to hospitals.

16.73 '
20.47
23.25
22.35
22.86
24.26
24.13
27.94
28.93
27.54
24.22
25.99
* 1938.

Switzer- Veneland
zuela

United
States

23.34
23.06
22.39
22.38
21.93
22.53
22.57
22.82
22.78
23.55

24.82
23.81
23.22
23.85
23.06
22.22
21.40
20.71

20.56
17.71
18.57
21.30
20.11
21.46
20.60
21.46

* 1937 (German Reich).

114

THE COST OF MEDICAL CARE

supplies per head of the population, including the part of the cost paid
by the patients and any subsidies payable by public authorities, also
remained steady or rose. In England and Wales it remained at about
one-tenth of the total cost since 1951.
In the United States private expenditure on drugs, preparations and
appliances also declined since 1949 onwards in proportion to all private
expenditure on medical care.
The stationary or declining trend of pharmaceutical expenditure
during this period under most of the social security systems covered by
the present survey was, to some extent, due to the introduction of measures
aimed at achieving greater economy in prescribing or of restrictions
regarding proprietary medicines. Such information as is available
on the volume of prescribing suggests that an increase in this volume
has not always entailed an increase in relative cost.
It might tentatively be inferred that the relative cost per prescription
declined, possibly owing to the great reductions in the prices of a
number of antibiotics.
The increase in the proportion of proprietary medicines prescribed
in some countries did not appear to lead to any corresponding increase
in expenditure.
Hospital Care
The development of hospital expenditure in the countries covered
by this study is illustrated in table E. Whereas in Chapter II hospital
care is defined, for the purpose of arriving at comparable figures, as
including not only maintenance but also medical treatment, pharmaceutical supplies and all auxiliary services, the figures in table E, as
explained in the course of Chapter II, do not in every case include expenditure on these items.
Belgium.
Hospital expenditure under the Belgian sickness and invalidity insurance
scheme rose from 0.63 per cent, of the income per head in 1950 to 0.70 per
cent, in 1952, then fell to 0.64 per cent, in 1955.
The proportion of the expenditure on all medical benefits devoted to hospital
care also rose from approximately 30 per cent, to a peak of 34 per cent, in 1952
and then fell slightly. In 1955 it was about 32 per cent. The share of hospital
care in the total expenditure has fallen less than the share of medical practitioner care outside hospital.
Of the expenditure on hospital care of the Belgian scheme shown in table E
38.57 per cent, went on medical fees, 2.55 per cent, on pharmaceutical supplies
separately paid for and nearly 59 per cent, on maintenance, nursing and other
services, in 1953.* The number of hospital days per 100 persons protected rose
1

All these items, as well as similar expenditure on cancer, tuberculosis, etc., are
included in the figures in table E.

TRENDS IN EXPENDITURE

115

from 137.05 in 1950 to 160.91 in 1955, although expenditure in terms of the
income per head was practically the same in the two years. In fact, the average
cost of maintenance per day fell from 0.28 to 0.26 per cent, of the income
per head during that period. 1
However, the social security scheme does not cover the whole cost of
hospital care, as was shown in Chapter II. The total cost of the hospital care
received by the persons protected by insurance in 1953 has been estimated
at 0.98 per cent, of the income per head, while the payments of the scheme
only amounted to 0.64 per cent, of the income per head. The cost per head
of the population for the whole country is not known.
Canada

(Saskatchewan).

The expenditure, per person protected, of the Saskatchewan hospital
services plan (not including payments by hospitalised patients to private
practitioners and some other items 2) has risen almost continuously since the
inception of the scheme, from 1.05 per cent, to 1.76 per cent, of the income
per head and from 0.56 per cent, to 0.85 per cent, of the reference wage, between 1947 and 1955. The benefit payable in respect of hospital care obtained
outside the province was increased in 1948. Some important drugs were from
time to time added to the list of benefits available, and in 1949 blood plasma
was admitted as a benefit.
The total number of patient-days per 100 persons protected increased
from 167.8 in 1947 to a peak of 223.5 days in 1950. It then declined until
1954, but rose slightly in 1955 (205.1 days) and in 1956 (208.5 days).
Denmark.
The expenditure on hospital care per person protected of the subsidised
sickness funds in Denmark (shown in table E) expressed in terms of the income
per head was lower after than before the Second World War and remained
very stable between 1947 and 1954 (0.19 per cent, in both years). In 1955
the percentage was 0.20. Expressed in terms of the reference wage, which is
known only for alternate years up to 1953, expenditure was equally steady,
varying between 0.08 and 0.09 per cent, from 1947 to 1951 and rising to 0.10
per cent, in 1953, at which level it remained in 1954 and 1955.
These trends, however, relate to the expenditure of the sickness funds,
which, as was shown in Chapter II, represents only about one-tenth of the total
cost of hospital care. 3
The number of benefit days spent in hospital (by both adults and children)
per adult person protected rose from 3.05 in 1949 to 3.19 in 1953, then fell
to 3.12 in 1955. Total hospital costs per head rose from 1.77 per cent, of the
income per head in 1951 to 1.88 per cent, in 1953.
The share of hospital expenditure in the total expenditure on medical
benefits is lower than before the Second World War, and the decline has
continued since 1945. In that year 23 per cent, of the expenditure of the insurance went on hospital care, but the figure for 1955 was only 18.57 per cent.
while medical practitioner care steadily increased its share. This decline is
due no doubt to a decrease in the part of the cost of hospital care borne by
the sickness funds. The increase has presumably been paid out of public
funds.
1

These figures include maternity care, the cost of which is not included in table E.
See above, pp. 47-48.
* See above, pp. 53-54.
2

116

THE COST OF MEDICAL CARE

England and Wales.
The outlay on hospital care (including maternity care) per head of the
population under the National Health Service in England and Wales (both
including and excluding payments by patients) declined in terms of both the
income per head and the reference wage, after an initial rise in the first full
year of operation of the service. The total cost of the hospital service fell
from 2.29 per cent, of the income per head in 1950-51 to 2.02 per cent, in
1954-55 and from 2.19 to 1.93 per cent, of the reference wage during the same
period. The expenditure of the scheme itself declined even more—by as
much as 12 per cent. However, by 1955-56, costs had risen to 2.10 per cent.
of the income per head.
The share of hospital expenditure in the total expenditure of the National
Health Service oscillated between 53 and 58 per cent., but no definite trend
could be distinguished. The cost of the hospital service (including payments
by patients) varied between 53 and 56 per cent, of the total cost of the medical
care provided under the service. It should be recalled that these percentages
cover all specialist care, including that given to out-patients.
According to the report of the Committee of Inquiry into the Cost of the
National Health Service1, the gross cost (including the patients' share) of
the hospital service at 1948-49 prices rose from £169.2 million in 1948-49 to
£186.0 million in 1949-50 and to £215.6 million in 1953-54.
On the other hand, the cost per head of population actually decreased,
from 2.24 per cent, in 1949-50 of the income per head to 2.02 in 1954-55,
or by about one-tenth.
From 1949 to 1955, the average number of beds occupied daily in hospitals in England and Wales rose from 397,570 to 426,047. The number of
new out-patients increased from 6.15 to 11.64 million and the total number
of attendances by such patients from 36.11 to 39.58 million.2
Both the increase in the volume of care provided and its cost were thus
outweighed by the rise in population and national income.
France.
There has been a pronounced rise in the expenditure on hospital care under
the French general insurance scheme for non-agricultural employees in terms
of both the income per head and the reference wage. The expenditure increased
from 0.55 per cent, of the income per head in 1947 to 1.58 per cent, in 1955,
and from 0.46 to 1.54 per cent, of the reference wage in the same period—
an increase of 200 per cent.
In 1954 the rise slowed down, and in 1955 expenditure in terms of the
income per head was slightly lower. However, in terms of the reference wage
the rise continued in 1954 (the last year for which the reference wage is known).
The hospital expenditure of the scheme covers about 90 per cent, of the
full cost of hospital care, which has been estimated per head of the population
at 1.75 per cent, of the income per head in 1952. Since the figures in table E
do not include the cost of treatment in spas 3 or that of specialist care given
in private clinics, the expenditure of the sickness insurance scheme (including
the cost of these two items, which is comprised in the total cost of hospital
care for the whole country) would be even higher than 90 per cent, of the total
outlay.
1
Report of the Committee of Inquiry into the Cost of the National Health Service,
op. cit., pp. 13 if.
2
See The Lancet (London), 12 Oct. 1957, p. 739.
8
See above, p. 46.

117

TRENDS IN EXPENDITURE

No doubt the gradual increase in the volume of long-term hospital care
accounts for a considerable proportion of the rise; such care was granted for
up to three years in respect of serious illness until 1955, when the time limit was
abolished. In fact, in terms of national currency hospital expenditure under
long-term sickness insurance increased more than 40 times between 1947 and
1953, whereas expenditure under short-term sickness insurance increased
about seven-and-a-half times. A certain liberalisation of benefit by a remission
of cost-sharing in all serious cases may have contributed to the increase.
The proportion of the total expenditure of the scheme taken up by hospital
expenditure increased from 30 per cent, in 1947 to over 43 per cent, in 1950
—an increase even greater than that of pharmaceutical expenditure. However,
the proportion has since remained somewhere between 40 and 42 per cent.
Federal Republic of Germany.
Although much higher than before the last war, the expenditure on hospital
care of the general sickness insurance scheme of the Federal Republic of
Germany has not risen since 1949. In fact, it declined from 0.83 per cent, of
the income per head in 1950 to 0.74 per cent, in 1951, rose again to 0.81 per
cent, in 1953, then fell to 0.74 per cent, in 1955. In terms of the reference wage
(available only since 1951), however, expenditure has increased considerably,
from 0.50 per cent, in 1951 to 0.63 per cent, in 1955.
Hospital costs have remained comparatively stable, at between 27 and 29
per cent, of total expenditure on medical benefits. This is much the same as
expenditure on pharmaceutical products (about 28 per cent.) and somewhat
less than expenditure on medical practitioner care (about 33 to 34 per cent.).
Apart from minor payments for medical care, the fees paid by sickness
funds to hospitals for the care and treatment of persons protected by sickness
insurance include doctors' fees, since the hospital usually pays the doctor.
The volume of hospital care provided by the general sickness insurance
scheme in the years 1937 and 1950-55 is shown in table 38.
TABLE 38. FEDERAL REPUBLIC OF GERMANY: NUMBER OF DAYS
OF HOSPITALISATION FOR MEMBERS AND FOR DEPENDANTS
PER 100 MEMBERS, 1937 AND 1950-55
Members
Year

Total

Hospitals

Convalescent
homes,
preventoria, etc.

(All types of
institutions)

171.5
204.3
201.1
197.4
199.2
199.2
205.6

2.55
4.29
6.29
7.23
7.55
7.96
8.37

87.4
150.1
154.1
152.2
157.5
153.6
148.5

261.5
358.7
361.5
356.8
364.3
360.8
362.5

1937 1
1950
1951
1952
1953
1954
1955
1

Dependants

German Reich.

It will be seen that the number of days spent in both hospitals and convalescent homes per 100 members was considerably higher after the Second
World War than before it; in the years 1950 to 1952 the number of days spent
in hospital declined, while the number of days spent in convalescent homes

118

THE COST OF MEDICAL CARE

continued to rise. By 1955 the volume of hospital care had risen again to
slightly above the 1950 level.
The total volume of hospital care provided for members and dependants
was about the same in 1955 as in 1951—about 3.6 days per member. The
cost of hospital care in terms of the income per head was also the same in
1951 and in 1955, although it varied more than the amount of care provided
in the intervening years. For dependants, the number of days spent in hospitals
(including convalescent homes) per 100 members rose from 87.4 in 1937 to 150
in 1950—a rise largely due to the improvement in the benefits provided.
Between 1950 and 1953 the number of days spent by members in hospitals
fell from 204.3 to 199.2 per 100 members; if days spent in convalescent homes,
etc., are included the fall was only from 209 to 207 days. The number of days
spent by dependants in all institutions, however, rose from 150 to 157.5 per
100 members.
The cost of hospital care per person protected fell from 0.83 per cent, of
the income per head in 1950 to 0.81 per cent, in 1953. By 1955 the amount of
hospital care had again risen to 205.6 days per 100 members (215 including
care in convalescent homes, etc.) but that for dependants had fallen to 148.5
per 100 members. From 1953 to 1955 the cost per person protected fell from
0.81 to 0.74 per cent, of the income per head but rose from 0.58 to 0.63 per cent.
of the reference wage.
The expenditure of the sickness insurance scheme on hospital care, however,
represents only part of the total cost of hospital care, which, for the whole
country, and including the cost of mental hospitals and probably capital
outlay as well, has been estimated for 1953 at 1.10 per cent, of the average
income per economically active person. The cost per person protected of
the care received under the sickness insurance scheme was 0.66 per cent, of
that income and the expenditure of the insurance scheme on that care 0.41 per
cent. Sickness insurance thus covered about 60 per cent, of the cost of the care
received by the persons protected by social insurance but less than 40 per cent.
of the cost of hospital care per head of the population.
An ordinance of 1954 specified the items to be included in the fee per day
of hospital care that may be charged by hospitals to the scheme for the care of
insured persons. All operating expenses are to be included. This provision
was expected to lead to higher hospital expenditure on the part of the sickness
funds. In terms of income per head, however, hospital expenditure in 1955 was
lower than in 1954 or 1953.
Italy.
The expenditure per person protected on hospital care of the Italian sickness
insurance institution rose from 0.41 per cent, of the income per head in 1947
to 0.76 per cent, in 1955 but remained steady at about 0.70 per cent, between
1950 and 1953. Expressed in terms of the reference wage expenditure rose from
0.13 per cent, in 1947 to 0.50 per cent, in 1955.
In relation to the expenditure on all medical benefits, however, expenditure
on hospital care has fallen steadily from about 37 per cent, to a little less than
30 per cent., whereas the share of medical practitioner costs has risen.
The number of hospital days per 100 persons protected \ excluding maternity cases, both for insured persons and dependants, rose from 55.8 in 1950 to
61.5 in 1955 2 : if maternity cases are included the number increased from
1
The number of persons protected for hospital care is slightly lower than the
total used for computing the cost in table E.
2
International Social Security Association, 13th General Meeting: Sickness Insurance, op. cit., reply of the Italian National Sickness Insurance Institute, p. 20.

TRENDS IN

119

EXPENDITURE

61.4 to 68.1, or by about 11 per cent. The cost of this care per person protected
rose from 0.70 per cent, of the income per head to 0.76 per cent., or by about
9 per cent.1 The increase in the amount of care provided thus corresponds
approximately to the increase in the cost.
The total operating cost of hospital care per head of the population was
estimated for 1952 at 0.86 per cent, of the average income per economically
active person. On the other hand, the expenditure on hospital care of the
general sickness insurance and tuberculosis insurance schemes in the same
year amounted to only 0.66 per cent, of the average income per economically
active person; 0.35 per cent, was spent by tuberculosis insurance and about
0.30 per cent, by sickness insurance. Thus the sickness insurance scheme only
covered part of the cost of hospital care.
Mexico.
The expenditure of the Mexican sickness insurance scheme shown in
table E relates to hospital expenditure and appears to include doctors' salaries
but not pharmaceutical supplies. It increased per person protected from
0.89 per cent, of the income per head in 1950 to 0.98 per cent, in 1953. In
terms of the reference wage the expenditure was 0.89 per cent, in 1952.
The share of hospital expenditure in the total expenditure of the scheme
on medical benefits remained around 12 per cent, during the years 1950-52,
but rose to nearly 14 per cent, in 1953.
The number of days of hospital care provided, including treatment of
employment injuries but not care of pensioners and their dependants, during
the period 1950-55 is shown in table 39.
TABLE 39. MEXICO: HOSPITALISATION UNDER SICKNESS,
MATERNITY AND EMPLOYMENT INJURY INSURANCE, 1950-55

1950
1951
1952
1953
1954
1955

.
.
.
.
.
.

Number of days
spent in hospital

Number of persons
protected

Number of days per
100 persons protected

424,292
482,782
520,604
542,758
607,935
674,908

974,115
1,012,024
1,095,204
1,216,791
1,341,836
1,464,468

43.6
47.7
47.5
44.6
45.3
46.1

Source: revised data supplied to the I.S.S.A.

It will be seen that the volume of hospital care is very low—only about
half a day per person protected per year—and that the amount of care provided
has increased but little during the period under consideration.
The rise of about 10 per cent, in the cost between 1950 and 1953 in terms
of the income per head by about one-tenth is therefore mainly due to increased
hospital expenditure per day, which rose from 2.29 per cent, of the income
per head in 1950 to about 2.44 per cent, in 1953 or by roughly 7 per cent.;
it includes, however, the cost of hospitalisation of victims of employment
injury.
1
The number of persons protected for hospital care is slightly lower than the
total used for computing the cost in table E.

120

THE COST OF MEDICAL CARE

Netherlands.
The hospital expenditure of the Netherlands medical care insurance scheme
(shhwn in table E), which excludes about 70 per cent, of the expenditure for
specialist care at hospitals, fell in 1946, after a rise during the years 1943 to
1945, then rose steadily from 0.48 per cent, of the income per head in 1946
to 0.77 per cent, in 1952, falling very slightly in 1953 and 1954 to 0.76 per cent.
and rising to 0.89 per cent, in 1955. In terms of the reference wage there was
no decline from 1945 to 1946, that wage having remained more stable than the
income per head. However, the subsequent rise—from 0.23 per cent, in 1945
to 0.57 per cent, in 1953—was steeper than the rise in terms of the income per
head. In 1954 the percentage was 0.55 and in 1955, 0.71.
If comparative hospital expenditure per person protected has increased, so
has the proportion of the total expenditure of benefits which is devoted to
hospital care; it rose from 24 per cent, in 1945 to about 38 per cent, in the
years 1952 to 1955.
The number of days spent in hospitals other than sanatoria per 100 persons
protected under the scheme rose continually, from 67.7 in 1943 to 77.5 in 1946
and to 119.3 in 1954. The amount of care provided between 1946 and 1954
thus increased by about 55 per cent., while expenditure in terms of income
per head increased by about 58 per cent. It may be recalled that the duration
of hospital benefit was limited to 42 days per case until 1955, when it was
extended to 70 days.
The number of days of hospital care per 100 persons protected (including
cases treated in sanatoria) rose from 13.06 in 1950 to 15.34 in 1954 and 16.58
in 1955.1 The rise between 1954 and 1955 is due to the extension of the
maximum benefit period.
The increase in the relative cost of hospital care is thus largely due to an
increase in the amount of care provided. However, the average duration of
hospital cases diminished, largely as a result of a decline in the number of
cases of tuberculosis.
The full cost of hospital care provided per person protected by the scheme
is estimated at 0.41 per cent, of the average income per economically active
person in 1953 2, the scheme paying 0.36 per cent., including the cost of
specialist care in hospital. 3 The operating cost of all hospitals per head of
population was found to be 0.57 per cent, of the average income per economically active person. The sickness insurance scheme thus paid about
63 per cent, of the total cost per head of the population.
New Zealand.
Expenditure per person protected on hospital care under the New Zealand
social security medical care service, including some out-patient care, declined
steadily, from 0.66 per cent, of the income per head in 1943-44 to 0.30 per cent.
in 1953-54, then rising to 0.43 per cent, in 1954-55 and 0.56 in 1955-56. In
terms of the reference wage expenditure per person protected fell from 0.42
1
International Social Security Association, 13th General Meeting: Sickness
insurance, op. cit., reply of the Netherlands Council of Sickness Funds, p. 14.
2
This cost does not include the cost of mental care received after exhaustion
of the benefit period.
3
Expenditure per person protected on the hospital care covered by the figures
in table E was 14.12 florins, while expenditure on specialist care in hospital not
included in these figures amounted to 2.30 florins. Specialist care in hospital is granted
without limit of duration.

TRENDS IN EXPENDITURE

121

per cent, in 1945-46 to 0.22 per cent, in 1953-54, then rose to 0.33 per cent.
in 1954-55 and 0.44 per cent, in 1955-56.
The social security fund pays a fixed sum per day to the hospitals for each
hospitalised person; this sum was 9 shillings until October 1954, when it was
increased to 21 shillings for patients in medical and surgical hospitals and to
18 shillings for patients in hospitals dealing with non-acute diseases. This
accounts for the rise in expenditure in 1954-55 and 1955-56. Clearly the flatrate payments made prior to 1954 constituted a steadily decreasing fraction of
the total hospital costs. Total hospital costs per head of population
(excluding only payments by individuals to private hospitals) increased from
2.35 per cent, of the income per head in 1945-46 to 2.84 per cent, in 1955-56.
However, it fluctuated in the intervening period, with a sharp fall in 1950-51
which was largely due to a great increase in the income per head followed
by a temporary decline. The peak was reached in 1952-53, with 2.92 per cent.
In terms of the reference wage, which did not follow either the great increase
in the income per head of 1950 nor its fall in the following year, total hospital
expenditure rose from 1.59 per cent, in 1945-46 to 2.21 per cent, in 1955-56,
with only a slight decline in 1953-54.
The number of admissions to public hospitals (other than admissions due
to pregnancy, childbirth or puerperal conditions) rose slightly, from 6.90
per 100 of population in 1950—the first year for which such data were compiled—to 6.94 in 1954. The number of days spent in hospital, on the other
hand, fell from 174.6 to 164.0 per 100 of population, although there was a
marked rise in the amount of hospital care provided to persons (both male
and female) aged 65 and over.1
Norway.
Except for a decline immediately after the Second World War, hospital
expenditure per person protected under the Norwegian sickness insurance
scheme rose fairly steadily for some years, from 0.52 per cent, of the income
per head in 1946 to 0.76 per cent, in 1952 and 0.85 per cent, in 1953.
Subsequently, however, it declined, reaching 0.81 per cent, in 1955.
The share of hospital expenditure in the total expenditure on medical
benefits, after a fall during the Second World War, rose, with some fluctuations,
from some 42 per cent, of the total in 1945 to nearly 55 per cent, in 1953.
The expenditure of the Norwegian sickness insurance scheme on hospital
care, as was shown in Chapter II 2 , amounts to about two-thirds of the total
cost of the hospital care received under sickness insurance per person protected.
However, the cost of all hospital care per head of the population is considerably
higher than that of care received under sickness insurance. It has probably risen
at least as much as the hospital expenditure of the sickness insurance scheme.
The number of days spent in hospital per member rose from 1.48 in 1947
to 1.85 in 1952—a rise of 25 per cent.—for members, and from 1.22 to 1.57
days per member for dependants—a rise of 29 per cent. These data relate
only to members entitled to cash sickness benefit. The rise in the expenditure
on hospital care per person protected during the same period from 0.59 to
0.76 per cent, of the income per head is 29 per cent., an increase which may
therefore be largely attributed to the increase in the amount of hospital care
provided. By 1953 the number of days spent in hospital per member had
increased to 1.86 days for members but declined to 1.50 days for dependants.
The great increase in expenditure—to 0.85 per cent.—is not, therefore, due to
an increase in the amount of care provided.
1

New Zealand, Department of Health : Annual Report of the Director-General of
Health, 1957 (Wellington, Government Printer, 1957), pp. 45-46.
'See above, pp. 52-53.

122

THE COST OF MEDICAL CARE

Switzerland.
The expenditure per person protected on hospital care (chiefly for treatment and pharmaceutical supplies given in hospital) of the Swiss sickness
insurance funds reporting regularly rose somewhat in 1949 and 1950, both in
terms of the income per head and of the reference wage, but remained quite
steady from 1951 to 1953, at 0.33 per cent, of the income per head and 0.25
per cent, of the reference wage. The corresponding percentages for 1955
were 0.31 and 0.24. These figures include the share of hospital charges borne
by the patient (on the average, 17 per cent.) but not any additional cost that
may be incurred by the patient, nor the part of the cost paid by the State or
local authority.
The proportion of the total expenditure of the Swiss funds on hospital
care (added to the patient's share) remained at about 22 to 23 per cent, from
1951 to 1954, declining very slightly in 1955 to about 21 per cent.
As shown in Chapter II, the hospital expenditure of the sickness insurance
fund is only a fraction of the total operating cost of hospitals, which was estimated for 1953 at 1.70 per cent, of the income per head, while the expenditure
of the sickness funds per person protected amounted to only 0.27 per
cent, of that income. The cost of the hospital care received under sickness
insurance in the same year was estimated at 0.85 per cent, of the income per
head. It may be recalled that subsidised sickness funds are obliged to pay
only for medical treatment and pharmaceutical supplies in hospital. However,
many funds pay agreed fees to the hospitals covering most of the cost of
treatment in public wards—at least as far as the patient is concerned.
The amount of hospital care received by the persons insured with the
social insurance funds fell slightly, from 2.3 days per person in 1949 and
1950 to 2.2 days in 1951 and 1952 and 2.1 days in 1953, 1954 and 1955. On
the other hand, in 1953 the total number of days spent in hospitals throughout
the country (including mental institutions) worked out at 4.32 per head of
the population.
Venezuela.
The Venezuelan sickness insurance scheme's expenditure on hospital
maintenance (not including the salaries and wages of the scheme's medical
and auxiliary staff at dispensaries or surgical and obstetrical costs) per person
protected rose from 0.44 per cent, of the reference wage, in 1946-47 to 0.58
per cent, in 1947-48, but then fell to 0.39 per cent, in 1952-53. In terms of
the income per head the expenditure fell from 0.85 per cent, in 1952-53 to
0.78 per cent, in 1953-54.
The share of hospital maintenance expenditure in total expenditure on
medical benefits declined almost as much, from 25.5 per cent, in 1947-48 to
13 per cent, in 1953-54. This figure includes some expenditure on hospitalisation
on behalf of the employment injury insurance schemes and on behalf of the
Social Assistance Board of the Federal District.
United States.
In the United States private and voluntary insurance expenditure on
hospital care (not including private payments by hospital patients to doctors)
rose from 0.75 per cent, of the national income in 1948 to 1.04 per cent, in
1955, but fluctuated considerably in the intervening period. In terms of the
reference wage there was no steady trend between 1950 and 1953 (the years for
which the reference wage is available), but the expenditure per head of the
population in 1953 was 0.55 per cent, as compared with 0.53 per cent, in 1950.

TRENDS IN EXPENDITURE

123

The share of hospital costs in total private expenditure on medical care
has risen continuously, from about 23 per cent, in 1948 to 30 per cent, in 1955.
The total operating expenditure of all United States hospitals (including
out-patient expenditure but not private payments to doctors) increased from
1.09 per cent, of the national income in 1946 to 1.74 per cent, in 1954, after
a temporary decline in the years 1950 and 1951; the percentage for 1955 was
1.73. The expenditure of hospitals per head of the population expressed in
terms of the reference wage declined in 1953; in that year it was 0.93 per cent.
as compared with 0.98 per cent, in 1952 and 0.90 per cent, in 1950. It is not
known to what extent pharmaceutical expenditure is included.
Finally, total hospital expenditure, including the cost of construction but
not private payments to doctors, rose continuously and steeply from 1.25
per cent, of the national income in 1946 to 1.93 per cent, in 1949, fell to 1.74
per cent, in 1951, but rose again to 1.94 per cent, in 1955.
According to the survey of the American Medical Association already
mentioned, five days in a hospital room cost a production worker one week's
wages in 1937 and also in 1954. The share of hospital care in the total private
expenditure on1 medical care increased from 14 per cent, in 1929 to 26 per
cent, in 1953.
General Remarks.
The expenditure, per person protected, on hospital care of the social
security services covered by the present study (including all or part of
the cost of medical care in hospitals) rose, during the period under review,
faster than incomes per head and basic wages, either continuously or
irregularly, in Belgium from 1950 to 1952; in Denmark from 1950 to
1955; in England and Wales in 1950 and 1955; in France from 1947 to 1954;
in the Federal Republic of Germany from 1951 to 1953; in Italy from
1947 to 1955 : in the Netherlands from 1946 to 1955 ; in New Zealand from
1953 onwards; in Norway from 1946 to 1953; and in Switzerland from
Ì 947 to 1949. Expenditure on hospital care (not including private medical treatment in hospital) rose for the hospital insurance scheme in
Saskatchewan from 1947 to 1955. In many cases there was a fall in 1951.
The cost to social security schemes of hospital care declined, in terms
of income per head, in Belgium from 1952 to 1955; in Denmark from
1938 to 1950; in England and Wales from 1950 to 1954; in France, very
slightly, from 1954 to 1955; in the Federal Republic of Germany from
1953 to 1955; in New Zealand from 1943 to 1953; in Norway from 1953
to 1955; and in Switzerland, very slightly, from 1953 to 1955. This
decline was not accompanied by a corresponding decline in terms of
the reference wage in France and the Federal Republic of Germany,
where the wage increased less than the income per head.
In New Zealand, however, total hospital expenditure rose, although
not continuously, between 1945 and 1955, in terms of both the income
per head and of the reference wage.
1

The Economic Position of Medical Care, 1929-1953, op. cit., pp. 16 and 27.

124

THE COST OF MEDICAL CARE

TABLE 40. EXPENDITURE ON HOSPITAL CARE AS A PERCENTAGE OF TOTAL
EXPENDITURE ON MEDICAL BENEFITS UNDER TWELVE SOCIAL SECURITY
SCHEMES, AND PRIVATE EXPENDITURE ON HOSPITAL CARE AS A PERCENTAGE
OF TOTAL PRIVATE EXPENDITURE ON MEDICAL CARE IN THE UNITED STATES,
PRIOR TO 1945 AND 1945-55
England
and Wales
Year

Prior
to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1

Belgium

29.76
30.30
33.96
33.28
33.50
31.93

1938.

Denmark

25.80 '
23.09
21.71
20.17
20.26
20.39
20.51
19.88
19.94
18.57
18.62
18.05

Expenditure

Germany
France (Federal Italy
Republic)

NeMexi- therco
lands

Norway

45.66 s
39.26
32.08
27.95
25.46
23.88
23.23
22.56
20.48
20.60
27.11
30.66

45.65 *
42.08
43.22
47.67
51.47
48.69
50.49
54.54
54.82
54.93
54.67
54.34

Cost

27.94 '

52.69
55.04
56.88
54.18
57.60
57.72
59.06

New
Zealand

53.04
55.36
56.38
52.66
55.45
56.17
56.93

29.89
36.29
42.93
43.69
40.22
41.89
42.00
42.69
41.73

• 1937 (German Reich).

26.65
28.69
27.75
27.38
27.55
27.10
26.56

36.95
35.76
33.26
34.83
34.65
32.20
30.14
29.50
29.37
29.56

12.52
12.02
12.04
13.82

* 1943 or 1943-44.

25.59 '
23.90
26.05
29.59
31.43
31.47
33.80
36.13
37.75
37.30
37.51 s
38.25S

Swit- Vene- United
States
zer(priland zuela vate)

23.14 20.28
22.64 23.45
24.32 21.11
24.67 17.69
24.17 17.87
22.95 14.60
22.52 13.81
21.84 13.08
21.83
21.15

« 1939.

Both private expenditure on hospitalisation and the total expenditure
of all hospitals (excluding private expenditure on medical treatment in
hospital) rose in the United States, with a break in 1951. On the other
hand, private expenditure on medical practitioner care (including care in
hospitals) as shown in table C, fell from 1948 to 1951, then rose slowly
until 1954.
In Mexico the hospital expenditure per person protected, of the
sickness insurance scheme, expressed in terms of national income, has
risen since 1951. In Venezuela the expenditure (not including surgeons'
and obstetricians' fees) fell in terms of the reference wage from 1947
to 1952 and from 1952 to 1953 in terms of income per head.
The relative importance of expenditure on hospital care in the overall expenditure on medical benefits, as can be seen from table 40,
increased in France up to 1950, in the Netherlands up to 1955, in Norway
up to 1952, in Belgium from 1950 to 1952 and in the United States
from 1948 to 1955.
On the contrary, the share of hospital expenditure in the total
expenditure of the sickness insurance scheme has declined, notwithstanding a rise in the expenditure per person protected, in Italy. In the
Federal Republic of Germany it remained stable even though over-all
expenditure was rising.

23.12
24.60
26.13
26.59
27.73
28.63
28.93
30.05

125

TRENDS IN EXPENDITURE

The proportion of hospital expenditure in total social security
expenditure diminished at the same time as the actual expenditure in
Belgium from 1952 to 1955 and in New Zealand up to 1952. It fluctuated
irregularly, with a slight tendency to rise, whilst actual expenditure was
falling in England and Wales from 1950 to 1954; both rose in 1955.
In Denmark and Switzerland actual hospital expenditure remained
fairly stable, but its importance in the total expenditure of the sickness
funds diminished slightly.
It may be concluded that although the expenditure of social security
services on hospital care rose in some countries there was no general
tendency for that expenditure to rise during the period under review.
The total cost of hospital care (or the cost excluding fees paid privately)
has tended to rise in three of the countries for which the cost is available
but has fallen in the fourth.
Dental Care
During the period under review social security expenditure on dental
care tended to remain stationary or to decline. Such expenditure,
however, rarely covered the full cost of the care provided.
Belgium.
In Belgium expenditure per person protected on dental care declined from
0.12 per cent, of the income per head in 1950 to 0.08 per cent in 1953, and
from 0.10 to 0.07 per cent, of the reference wage, subsequently remaining
fairly steady. Its importance also declined from 5.53 per cent, of the total
expenditure on medical benefits in 1950 to 4.39 per cent, in 1955.
The number of consultations by dentists per person protected per year
between 1950 and 1955 is shown in table 41.
TABLE 41. BELGIUM: NUMBER OF CONSULTATIONS OF DENTISTS,
1950-55
Year

Number of consultations

Number of consultations per
person protected

1950
1951
1952
1953
1954
1955

1,610,791
1,912,658
2,068,413
1,998,268
2,144,627
2,330,698

0.37
0.42
0.45
0.43
0.46
0.49

These figures show that it was not a falling off in the amount of treatment
given that accounted for the decline in expenditure between 1950 and 1953.
An analysis of the expenditure on consultations and visits, on the one hand,
and on dentures, on the other (leaving out of account orthodontic care and
special treatment) gives the results shown in table 42.

126

THE COST OF MEDICAL CARE

TABLE 42. BELGIUM: EXPENDITURE ON CONSULTATIONS OF DENTISTS
AND ON DENTURES, 1950-55
Expenditure on consultations
of dentists per person protected

Expenditure on dentures
per person protected

Year
In francs

1950
1951
1952
1953
1954
1955

21.08
21.94
22.72
21.96
23.15
23.99

As percentage of
income per head

In francs

As percentage of
income per head

0.068
0.061
0.061
0.058
0.059
0.058

13.92
9.99
5.57
5.63
6.61
7.54

0.044
0.028
0.015
0.015
0.017
0.018

It will be seen that expenditure on conservative treatment has remained
quite stable, in terms of income per head, since 1951, in spite of the increase
in the amount of care provided, the income per head having risen more rapidly
than expenditure. On the other hand, expenditure on dentures dropped
sharply in 1951 and 1952 as a result of legislative measures restricting the
participation of the insurance scheme in the cost of dentures by depriving
persons aged 50 or over of the right to this benefit. Subsequently expenditure
on dentures rose slightly.
Denmark.
In Denmark, where the range of dental benefits is restricted, expenditure
per person protected has fluctuated but slightly since 1945, ranging between
0.06 and 0.07 per cent, of the income per head and 0.03 to 0.04 per cent, of the
reference wage until 1953. It rose somewhat in 1954 and 1955. The share of
dental care in the total expenditure rose slightly, from 7 per cent, in 1945 to
not quite 9 per cent, in 1955.
England and Wales.
The cost to the National Health Service of England and Wales of dental
care, including dentures, has fallen sharply since 1949, from 0.45 per cent, of
the income per head to 0.17 per cent, in 1954-55. This decline is partly due to
the introduction of charges to the patients for dentures in 1951, and of charges
for conservative dental treatment in 1952. It is also to some extent due to the
reduction of dentists' remuneration, which was only increased again recently.
However, it is also partly due to reduced demand, reflected in the movements
of the total cost of the dental care received under the National Health Service
(including the patients' payments), which fell only slightly less than the expenditure of the Health Service, to about one-half of what it was in 1949 (from
0.45 per cent, to 0.22 per cent, of the income per head). Private expenditure on
dental treatment obtained outside the Service is not recorded. Between 1952
and 1954 the cost of dental care has remained fairly stable. It rose in 1955-56.
The proportion of the expenditure of the National Health Service which is
devoted to dental care has also fallen steeply since 1949 from nearly 11 per
cent, to less than 5 per cent, in 1954. In 1954-55 the cost of dental care (including payments by patients) represented slightly over 6 per cent, of the total
cost of medical care. The corresponding percentage for 1955-56 was 6.76.
The amount of treatment provided by the National Health Service (as
expressed in the number of courses of treatment) is shown in table 43. It first

127

TRENDS IN EXPENDITURE

rose sharply from 1950 to 1951—a rise not reflected in the total cost, which,
however, is for the financial year starting 1 April. The fall between 1951
and 1953 was followed by a rise which almost brought the amount of care
provided back to its 1950 level.
TABLE 43. ENGLAND AND WALES: COURSES OF DENTAL TREATMENT
(INCLUDING EMERGENCY TREATMENT), 1950-55
Year

Number of treatments
(thousands )

Population
(thousands)

Number of courses
of treatment per
head of population

1950
1951
1952
1953
1954
1955

9,586
9,965
9,000
8,375
9,336
9,924

43,800
43,800
43,900
44,100
44,300
44,430

0.219
0.228
0.205
0.190
0.211
0.224

Source: Royal Commission on Doctors' and Dentists' Remuneration: Written Evidence. Volume 1 :
Factual Memorandum by the Ministry of Health and the Department of Health for Scotland (London,
H.M. Stationery Office, 1957), p. 49.

The increase in the amount of care provided in 1954 and 1955 is reflected
in the figures for 1954-55 shown in table F. The report of the Ministry of
Health for 1955 comments that the increase " may be taken as an indication
of a growing consciousness on the part of the public of the need for regular
dental treatment, and it is gratifying to note that it is increased demand for
conservative treatment rather than for dentures which accounts for the rise ". 1
Twenty-one per cent, of the state expenditure on the dental service per
person who used the service in 1955 was for dentures, compared with 59 per
cent, in 1950.2
France.
In France the expenditure per person protected under the general social
insurance scheme for non-agricultural employees, which provides a fairly full
range of dental care and essential dentures, after an initial fall during the
years 1947-49, rose again until in 1955 it reached its 1947 level of 0.24 per cent.
of the income per head. In terms of the reference wage, it rose slightly from
0.20 to 0.23 per cent between 1947 and 1955.
During the same period the proportion of total expenditure on medical
benefits devoted to dental care decreased by one-half, in 1947, from 13.15 per
cent, to 6.34 per cent, in 1955.
Federal Republic of Germany.
In the Federal Republic of Germany the expenditure of the general sickness
insurance scheme on conservative dental care also fell, in terms of the income
per head, between 1949 and 1951, but then rose slightly, reaching 0.26 per cent.
in 1954 and 1955, as compared with 0.23 per cent, in 1937. On the other hand,
it rose from 0.15 per cent, of the reference wage in 1951 to 0.22 per cent, in
1
Report of the Ministry of Health for the Year Ended 31st December ¡955 (London,
H.M. Stationery Office, 1956), p. 66.
2
International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Ministry of Health of Great Britain, p. 8.

128

THE COST OF MEDICAL CARE

1955, that wage having lagged behind the income per head. However, its
share in total sickness insurance expenditure on medical benefits did not
change appreciably between 1949 and 1953, remaining around 8 per cent.,
having fallen to that level from a peak of 11 per cent, reached in 1937. In
1955 it rose to 9.31 per cent.
During the period 1950 to 1955 the expenditure on dentures per member
remained quite stationary, at D M 5.40 in 1950 and D M 5.70 in 1955.1 The
expenditure per person protected (including dependants) and in terms of
income per head declined steadily, from 0.20 per cent, to 0.13 per cent, of
the income per head as shown in table 44. Again, it was the cost of dentures
that declined.
TABLE 44.

FEDERAL REPUBLIC OF GERMANY: EXPENDITURE PER
PERSON PROTECTED ON DENTURES, 1950-55

Year

Expenditure
(in DM)

Expenditure as percentage of
income per head

1950
1951
1952
1953
1954
1955

3.00
3.10
3.35
3.43
3.30
3.22

0.20
0.17
0.17
0.16
0.15
0.13

Netherlands.
In the Netherlands, on the other hand, the expenditure of the scheme on
dental care (which includes a contribution towards school dental services)
rose from 0.10 per cent, of the income per head in 1946 to 0.16 per cent, in
1953, 1954 and 1955, after a sharp fall between 1943 and 1946. It rose from
0.05 per cent, of the reference wage in 1946 to 0.12 per cent, in 1953, falling
to 0.11 per cent, in 1954, after which it rose again, to 0.13 per cent in 1955.
Its share in total medical expenditure has remained fairly stable at about
7 to 8 per cent., since 1947.
The rise in cost was due to increased expenditure on conservative care,
expenditure on dentures having fallen. The increase in the cost of conservative
dental care is ascribed to the greater awareness, among the insured population,
of the importance of keeping teeth in good condition and also to the extension
of school dental services. Moreover, dental fees were increased in 1951, 1954
and 1955. The expenditure on dentures declined in 1951 and 1952 as a result
of an increase in the share of the cost borne by the patient; however, in 1954
and 1955 fees for dentures were increased.8
New Zealand.
In New Zealand social security expenditure on dental care for children and
young persons introduced in 1947, which is the only dental benefit so far
provided by the social security scheme, rose, owing to the gradual extension
of this benefit to higher-age groups, from 0.03 per cent, of the national income
1

International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Association of Federations of Sickness Funds of the
Federal Republic of Germany, p. 9.
2
International Social Security Association, 13th General Meeting: Sickness
Insurance, op. cit., reply of the Netherlands Council of Sickness Funds, p. 6.

TRENDS IN EXPENDITURE

129

in 1947-48 to 0.09 per cent, in 1953-54, at which level it remained in 1954
and 1955. In terms of the reference wage it rose from 0.02 to 0.07 per cent.
The share of the total expenditure of the service on dental care rose more
steeply from 1947-48 onwards than the actual expenditure, rising from 1.51
per cent, in that financial year to 6.22 per cent, in 1953-54, then declining
slightly, to 5.14 per cent, in 1955-56. It should, however, be recalled that the
figures in table F show the expenditure per head of the population and not
per person entitled to dental benefit.1
United States.
Private and voluntary-insurance expenditure on dental care in the United
States declined on the whole—although to a lesser extent than under some of
the social security services—from 0.38 per cent, of the income per head in
1948 to 0.31 per cent, in 1955, and from 0.22 per cent, of the reference wage
in 1950 to 0.18 in 1953. The share of dental costs in total private expenditure
on medical care also declined, from 11.58 per cent, in 1948 to 9.10 per cent.
in 1955.
According to the inquiry already referred to conducted by the American
Medical Association 2, the dentists' share in private expenditure on medical
care decreased from 16 per cent, in 1929 to 10 per cent, in 1953; this is more
than the decrease in the share of medical practitioners (from 33 per cent, to
28 per cent.) and also more than that in the share of pharmaceutical supplies, from 20 to 16 per cent.
General Remarks.
Dental expenditure per person protected under the social security
services covered by the present study, as shown in table F, remained
fairly stable or declined, with a few exceptions, both in terms of national
income and of reference wages. Its share in the total expenditure of
medical benefits declined almost everywhere, as will be seen in table 45.
The decline both in the expenditure on dental care and in its relative
importance is particularly striking under the National Health Service of
England and Wales, even if the patients' contributions to the cost are
taken into account 3 ; however, the decline did not continue. Private
expenditure on dental care in the United States also remained fairly
stable after an initial decline, but its share in the total greatly diminished.
The decline appears to be due mainly to a reduction in either the
supply of or the demand for dentures.
1

See above, p. 66.
*The Economic Position of Medical Care, 1929-1953, op. cit., p. 16.
According to a survey of family medical costs and voluntary health insurance
in the United States only 17 per cent, of the persons in families with incomes under
82,000 per year had consulted dentists, while 56 per cent, of the persons in families
with incomes over 57,500 had consulted dentists. See Odin W. ANDERSON and Jacob
J. FELDMAN: Family Medical Costs and Voluntary Health Insurance : A Nationwide
Survey (McGraw-Hill, New York, Toronto, London, 1956), table A-100.
3

130

THE COST OF MEDICAL CARE

TABLE 45. EXPENDITURE ON DENTAL CARE AS A PERCENTAGE OF
TOTAL EXPENDITURE ON MEDICAL BENEFITS UNDER SEVEN SOCIAL
SECURITY SCHEMES AND PRIVATE EXPENDITURE ON DENTAL CARE
AS A PERCENTAGE OF TOTAL PRIVATE EXPENDITURE ON MEDICAL
CARE IN THE UNITED STATES
England and
Wales
Year

Prior to
1945. .
1945.
1946.
1947;
1948.
1949.
1950.
1951 .
1952.
1953.
1954.
1955.
1

1938.

Denmark

Belgium

—
—
—
—
—
—

5.53
4.76
4.18
4.26
4.34
4.39
• 1937.

Expenditure

Cost

—
—
—
—
—

10.68
9.81
7.40
4.74
4.78
4.97
5.67

10.60
9.74
7.60
5.68
5.92
6.17
6.76

France

2.19 ' —
6.89
—
6.39
—
6.84 13.15
6.96 10.69
6.90 7.76
6.54 7.28
8.23
7.35
8.12
7.10
7.46
6.51
8.13
6.48
8.60
6.34

Germany
(Fed.
Rep.)

Nether- New
United
lands Zealand , States

11.17 2 8.53 3
4.97
—
5.38
—
—. 7.30
7.39
—
8.06
7.56
8.14
7.49
8.45
7.52
8.33
7.57
8.24
7.60
9.04
7.67
9.31
6.95

—
—
—

1.51
2.85
3.86
4.44
5.02
5.23
6.22
5.69
5.14

—
—
—
—.

11.58
11.35
10.71
10.34
9.81
9.56
9.50
9.08

» 1943.

Total Expenditure on Medical Care of All Types
The general trends in expenditure on medical benefits as shown in
table B may be summarised as follows :
A marked and almost continuous rise in the cost to social security
of medical benefits per person protected, over and above the increase in
national income per head and in basic wages, is found only in two of the
services covered by the present study: the French general insurance
scheme for non-agricultural employees and the Italian general sickness
insurance scheme. Expenditure under these schemes more than doubled
from 1947 and gradually approached the full cost of medical care, which,
to judge from the findings in Chapter II, would appear to be between
4 to 5 per cent, of the income per head or, per head of the population,
1.75 to 2 per cent, of the average income per economically active person;
at the beginning of the period under review the expenditure was generally
much lower than the actual cost.
Slight rises in the cost to social security schemes of medical benefits,
in terms of income per head, occurred in Denmark from 1950 to 1955,
in the Federal Republic of Germany from 1951 to 1953, in the Nether-

TRENDS IN EXPENDITURE

131

lands from 1948 to 1955, and in Norway and Switzerland from 1946
to 1953, with intermediate fluctuations. However, these rises were by
no means striking and were in some cases preceded by falls. In three of
these countries, moreover, the cost began to fall after 1953. In terms
of basic wages the rise continued in the Federal Republic of Germany
after 1953.
The cost to social security of medical benefits declined slightly, in
comparison with income per head and basic wages, in Belgium after
1950 and fell sharply and steadily in England and Wales and sharply but
irregularly in New Zealand, between 1948 and 1953. In the last two
countries a rise occurred in 1955.
There was no definite trend in the expenditure on medical benefits
under the Chilean and Mexican sickness insurance services. In Venezuela
expenditure in terms of the reference wage increased between 1946
and 1952; thereafter, in terms of income per head, it declined. In terms
of the average income per economically active person, expenditure at the
end of the period under review was at or above the average full
cost of medical care estimated for other countries in Chapter II. This
may signify that the persons protected were receiving a higher standard
of medical care than could be granted to the whole population.
Private and voluntary insurance expenditure on medical care in the
United States in terms of income per head fell from 1949 to 1951 but
later rose slightly. There was no definite trend in terms of wages between
1950 and 1953.
A breakdown of the total expenditure per person protected under
the social security systems studied here according to the type of care
provided shows that where the cost rose in proportion to national
income and basic wages such a rise was primarily due to an increase in
hospital costs and, to a lesser extent, pharmaceutical costs, except in
Italy, where the cost of medical practitioner care rose. Since social
security systems in the majority of countries covered only a fraction of
the total cost of hospital care, it is possible that over-all hospital costs
rose in some countries to a greater extent than is indicated by the
expenditure of social security services. Such statistics as are available
on hospital expenditure (not including private payments to physicians)
in the United States and expenditure in New Zealand, where the total
expenditure on hospitals (with only minor omissions) is known, indicate
that expenditure under this head was on the rise towards the end of the
period under review.
1
Attention was drawn to this fact in an article by William FRAEYS: " Une notion
fausse: Le déficit de l'assurance maladie-invalidité ", in L'Effort (Brussels, Mutualités
socialistes de Belgique), No. 5, 1957, p. 15.

CHAPTER IV
THE INCOMES OF MEDICAL PRACTITIONERS
In the preceding chapter we saw that only a comparatively small
part of the total expenditure on medical care went to the medical practitioner in payment for treatment given inside or outside hospital wards.
It would appear, at first sight, judging from the estimated cost of the
medical treatment received by the persons protected by social security
services, that there is a definite relationship between the incomes of
doctors and the national income.
In this chapter an attempt is made to draw some inferences from
the data already analysed, and from other information, regarding the
relationship between doctors' income and national income, in the hope
that such inferences may be of some help, both to the medical profession and to social security administrations in their negotiations
on the remuneration of doctors for services rendered to the persons
protected by social security.

General Practitioners
In order to gain some idea of what the cost of medical care per person
protected represents in terms of gross income paid to a general practitioner, it is assumed that the practitioner attends 2,000 or 2,500 persons.
Where this method cannot be applied, and the average number of items
of service is not known, it is assumed that he gives 6,000 items of care
(3,600 consultations and 2,400 visits) to his insured patients.1 The
income thus estimated is expressed in terms of the average income per
economically active person in the country concerned.
For Denmark, England and Wales, Italy, the Netherlands and New
Zealand, the expenditure of the social security services concerned on
general practitioner care is known. These countries may therefore be
taken first. In Chapter II the full cost of such care was estimated in
terms of the average income per economically active person, and was
1
This standard has been adopted in consultation with the World Medical
Association.

THE INCOMES OF MEDICAL PRACTITIONERS

133

found to be, on the average, about 0.20 per cent, per person protected.
In view of the interest that may attach to this study, the actual amounts
involved in national currency are also given.
Denmark.
In 1953 the cost of general practitioner care per person protected in
Denmark was 21.37 crowns, or 0.41 per cent, of the income per head or
0.20 per cent, of the average income per economically active person. With
2,000 persons on his list (including children) a general practitioner would
have received four times the average income per economically active person;
with 2,500 persons he would have received about five times that income.
England and Wales.
In England and Wales the remuneration of general practitioners is based
on the Danckwerts adjudication in 1952 and the subsequent agreement with
the profession.
This basis provides that all practitioners in the United Kingdom who are
engaged in the service are to receive an average net income from all sources
of £2,222 a year and, in addition, an appropriate allowance to cover practice
expenses.
The first step is to calculate for each year the " remuneration pool ", that
is, the total amount of money which must be provided and distributed to
general practitioners in order to ensure that they receive an average net payment of £2,222. This amount is calculated by multiplying £2,222 by the total
number of practitioners providing general medical services. A sum is then
added as the amount to be allowed for practice expenses; this allowance is
agreed on with the members of the profession on the basis of periodic sample
surveys. A sum is deducted in respect of professional remuneration which the
doctors obtain from other sources (private practice, hospital and local authority
appointments, etc.). The total so arrived at is the " pool ".
Since the average net income of £2,222 includes the Government's contributions (as employer) for doctors' superannuation the amount due in respect
of these contributions is deducted from the " pool "; the balance is then distributed to the doctors on a basis agreed with the profession. The major part of
the " pool " is distributed in capitation payments of 17 shillings a year for each
patient on a doctor's list (£1 7s. for each patient from the 501st to the 1,500th).
The rest is paid out mainly in the form of payments for maternity services,
mileage payments in rural areas—designed to compensate the rural doctor
for the additional travelling and the fact that his total number of patients is
inevitably smaller because of the time involved in visiting—and payments for
the treatment of temporary residents. There are also certain other special
payments made to doctors in special circumstances, for example, initial practice
allowances for doctors setting up new practices where they are needed and
payments to doctors with very small lists.
The amount of the " remuneration pool " for each financial year cannot be
established until some time after the year ends. The initial payments, therefore,
which are made quarterly during the year, are calculated so as to leave a
margin. When the total amount of the " pool " is ascertained the balance is
distributed to practitioners in proportion to the payments already made by
way of capitation fees. In 1957 a provisional increase of 5 per cent, was granted
pending the inquiry of the Royal Commission on Doctors' and Dentists'
Remuneration into the remuneration of doctors under the National Health
Service.

134

THE COST OF MEDICAL CARE

The cost of general practitioner care per head of the population under the
National Health Service was £1 17s., that is to say, 0.40 per cent, of the gross
national product per head, or 0.18 per cent, of the average income per economically active person, in 1953-54. A doctor with 2,000 persons on his list
would thus have received about 3.60 times the average income per economically
active person and one with 2,500 persons about 4.50 times that income.
It will be seen that in 1953 the gross income of general practitioners per
head of the population under the National Health Service, if all elements of
pay are included, was slightly below the average (0.20 per cent, of the average
income per economically active person) observed for the five countries for
which data are available. 1 If the figure for the national income at factor cost
(published since 1957 and calculated retrospectively for earlier years) is used
instead of that for the gross national product the percentage for England and
Wales is, in fact, 0.20.
Italy.
In Italy the cost of general practitioner care per person protected under
the general scheme in 1953 was 1,023.56 lire, that is to say, 0.53 per cent, of the
income per head or 0.23 of the average income per economically active person.
A doctor attending 2,000 protected persons would thus have earned 4.6 times
the average income per economically active person and one attending 2,500
persons 5.75 times such income.
The incomes of general practitioners, however, have greatly increased since
1953. In 1955 they were 0.63 per cent, of the income per head per person
protected, or 0.28 per cent, of the average income per economically active
person (that is to say, 1,399.40 lire), which would mean that a doctor with
2,000 patients would have earned 5.6 times the average income per economically active person and one with 2,500 patients seven times that income.
In fact, general practitioners are paid either by capitation fee (which,
since 1 April 1955, varies from 900 to 1,200 lire per year according to population density) or according to the number of items of service rendered; the fee
per consultation varies from 270 to 300 lire and the fee for a visit from 500 to
600 lire. The doctors paid by items of service would thus appear to enjoy a
considerable advantage over the others.
Netherlands.
In the Netherlands the cost of general practitioner care under the medical
care insurance scheme per person protected in 1953 was 6.40 florins, that is to
say, 0.35 per cent, of the income per head or 0.14 per cent, of the average
income per economically active person. 2 The income of a practitioner with
2,000 patients from medical care insurance would have been 2.8 times the
average income per economically active person and that of one with 2,500
patients 3.5 times such income. This figure is well below the average of 0.20
per cent, per person. However, as from 1 October 1955 the capitation fee
was raised to 10.20 florins for the first 2,000 persons on the doctor's list and
to 7.50 florins per person in excess of this number. On this basis a doctor
with up to 2,000 patients on his list would be earning, per patient, 0.20 per cent.
of the average income per economically active person. If he had 2,000 persons
on his list his income from medical care insurance would be four times the
average income per economically active person. With a list of 2,500 patients
his income per patient would be 0.19 per cent, and his aggregate income about
4.75 times the average income per economically active person. As from 1 July
1957, remuneration was further increased by 6 per cent.
1

See p. 21.
For an explanation of the calculations on which these estimates are based see
p. 176.
2

THE INCOMES OF MEDICAL PRACTITIONERS

New

135

Zealand.

In New Zealand the expenditure per head of the social security fund on
general practitioner care in 1953-54 amounted to £1.51, that is to say, 0.43
per cent, of the income per head or 0.16 per cent, of the average income per
economically active person. A practitioner who had 2,000 persons in his area
relying upon him for permanent attendance would thus have had an income
representing 3.2 times the average income per economically active person and
one with 2,500 patients £3,775, or four times that average income. 1
If it is assumed that the patient's contribution to the cost is 40 per cent.
of the amount paid by the social security fund for each visit or consultation,
the estimated income of a general practitioner per head works out at 0.23 per
cent, of the average income per economically active person as against the 0.16
per cent, he receives from the scheme. If he had 2,000 patients he would be
earning about 4.75 times the average income per economically active person
and with 2,500 patients he would be earning 5.75 times that income.

In the other countries covered by the present study the expenditure
on general practitioner care is not separately recorded. The only way
to arrive at some estimate of the general practitioner's income in these
countries is to use incidental data.
Belgium.
A comparison of the fees paid by the Belgian social insurance scheme in
1954 with those charged under the national medical practitioner service
established for persons of limited means by the medical profession (which was
planned in 1954 but not started until October 1956) shows that the gross
annual income of a general practitioner giving the average number of consultations and visits to a person protected by the Belgian sickness insurance scheme
in respect of that person was Frs. 212, that is to say, 0.54 per cent, of the
income per head or 0.22 per cent, of the average income per economically
active person. 2 This includes the patient's share but not the fees for minor
surgery. A practitioner in charge of 2,000 persons would thus have a gross
income of 4.4 times the average income per economically active person and
one with 2,500 persons 5.5 times that income. The insurance scheme paid
0.12 per cent, of that income per person protected, or 55 per cent, of the cost.
In October 1956 the official insurance tariff was brought in line with that
of the national practitioner service as regards consultations and visits, so
that the majority of persons protected may now be paying in fact not more
than 25 per cent, of the cost of the care they receive under the insurance
scheme. Nevertheless, doctors joining the national practitioners' service may
also elect to charge according to a different schedule of fees, which is 50 per
cent, higher than the first.
I
According to an inquiry made by the Department of Health in 1953-54, the
expenditure on general practitioner care per head of thè population was £1.48, or 0.42
per cent, of the income per head. The slight difference between the total expenditure
under the heading of medical services and the expenditure as estimated in this inquiry
is due probably to the inclusion in the former of some special items, such as the
salaries paid to doctors in isolated areas. See New Zealand, Department of Health:
Annual Report of the Director-General of Health for the year 1954 (Wellington, Government Printer, 1955), p. 93.
II
For an explanation of the calculations on which these estimates are based see
p. 161.

136

THE COST OF MEDICAL CARE

Canada (Swift Current Region,

Saskatchewan).

In the Swift Current region of Saskatchewan, in Canada, medical practitioner care is provided on an insurance basis. As shown earlier l , 0.57 per
cent, of the income per head was spent per person protected on medical
practitioner care outside hospital wards in and outside the region in 1952.
The region was served by 31 general practitioners and two full specialists
as well as by three visiting specialists. If the cost of out-patient care at hospitals
and that of physicians' care provided outside the region are deducted, the
remaining amount per head of the population covered may be deemed to be
more or less equivalent to the aggregate income of the general practitioners
concerned. The expenditure, calculated in this manner, worked out at $5.51
per person, representing 0.44 per cent, of the income per head or 0.17 per
cent, of the average income per economically active person. However, the
service paid only 67.86 per cent, of private fees, which, according to the experience of the Swift Current scheme, would represent 0.25 per cent, of the
average income per economically active person. Nevertheless, it is unlikely
that the number of visits and consultations provided in private practice
would be as high as the numbers provided under the scheme, since the introduction of cost-sharing in 1953 considerably reduced the number of services
requested.
On the basis of the above estimates a general practitioner in the Swift
Current region attending an insured population of 2,000 persons would have
had a gross income in 1952 of 3.4 times the average income per economically
active person; with a population of 2,500 persons he would have had around
4.25 times that income.
A recent inquiry into the cost of medical services was undertaken in
Windsor (Ontario) in connection with the Windsor Medical Services, a prepayment plan which provides medical practitioner care in the home, office
or hospital on a fee-for-service basis. The average net income of general
practitioners in 1954 was S 13,232 a year ; the average number of patients
seen per week was 126 and the total population 160,000. If the net income is
increased for practice expenses (assumed to take up 40 per cent, of the gross
income) the gross income works out at $22,053.2 This represents 17.78 times
the income per head ($1,240), or 6.35 times the average income per economically active person, for 6,552 items of service. It is not yet possible to judge
the amount of income from hospital in-patient care included in this total.
Chile.
No breakdown of the total cost of medical benefits is available for the
Chilean workers' social insurance scheme. In 1953 the medical services of
the expanded social insurance scheme for workers were taken over by the
national health service established in that year.
The basic salary of a medical practitioner employed to attend to insured
persons and their dependants was 24,000 pesos a month in 1953 for six hours
of work per day. This salary is increased by 20 per cent, for every five years'
service. After ten years' service his salary would thus be 33,600 pesos a
month or 403,200 pesos a year. This represents 9.18 times the income per
head (43,906 pesos) or 3.12 times the average income per economically
active person. Since the medical practitioner works at the clinics owned by
the service, this salary may be regarded as net income; it may therefore be
notionally increased by two-thirds to arrive at an estimated gross income
1

See above, p. 26.
Public Health Economics (University of Michigan, School of Public Health),
Vol. 14, No. 11, Dec. 1957, p. 611.
2

THE INCOMES OF MEDICAL PRACTITIONERS

137

comparable to those obtained for other countries. This increase would bring
the income to 5.20 times the average income per economically active person.
On the assumption that the general practitioner is responsible for a population of 2,500 persons protected, his salary per person protected would be
161 pesos, or 0.37 per cent, of the income per head, representing 0.13 per
cent, of the average income per economically active person. An increase of
40 per cent, to cover practice expenses would bring the gross income per person
protected to 0.21 per cent, of the average income per economically active
person as compared with the average of 0.20 per cent, found in Chapter II.
France.
In France the number of consultations and visits and the corresponding
expenditure are known.
The amount reimbursed to the insured person for a consultation or a
visit by a general practitioner is doubled in the case of a specialist. Consequently the figures for the average expenditure of the scheme per consultation
or visit cannot be used to estimate the income of a general practitioner from
persons protected. However, this estimate has been made with the aid of the
average numbers of consultations and visits, the average insurance fees and
the results of a private inquiry into medical fees.
The gross income of a general practitioner giving 3,600 consultations and
paying 2,400 visits a year to persons protected by social security would have
been Frs. 3,141,600 per year in 1953, or 5.76 times the average income per
economically active person. 1 Of this amount the patient would have paid
23.30 per cent. The sickness insurance scheme would then have been paying
4.42 times the average income for 6,000 items of care, or 76.70 per cent, of the
cost.
On the assumption that the 6,000 items of care were spread over 2,000 protected persons, the gross income of the practitioner per person protected
would have been 0.29 per cent, of the average income per economically active
person. If the number of persons protected had been 2,500 the practitioner's
income per person would have been 0.23 per cent, of the average income per
economically active person 2 , sickness insurance paying 0.18 per cent.
Federal Republic of Germany.
In the Federal Republic of Germany the cost of medical practitioner care
outside hospitals, per person protected, was found to be 1.02 per cent, of the
income per head, or 0.50 per cent, of the average income per economically
active person, in 1953. It has not been found possible to estimate the general
practitioner's share.
1

For an explanation of the calculations on which these estimates are based see
p. 172.
8
A recent estimate of the gross income required by a medical practitioner to cover
his expenses and permit of a reasonable standard of living gave a total of Frs. 4
million. This amount is equivalent to 12.5 times the income per head in 1956
(Frs. 320,500) or 5.6 times the average income per economically active person. If the
doctor were in charge of 2,500 persons, his gross income per person would have been
0.22 per cent, of that average income—a figure practically the same as that arrived at
earlier for the year 1953. (See: " Die Berechnung des Konsultationshonorars ", in
Schweizerische Ärztezeitung (Berne), 39th Year, No. 5, 31 Jan. 1958, pp. 45-46).
The plan of the National Federation of Social Security Bodies for Health Centres
provides for a remuneration, for a doctor engaged full-time, of Frs. 250,000 to
Frs. 300,000 per month, or Frs. 3 million to Frs. 3,600,000 per year. (See Revue de la
Sécurité sociale, No. 89, Apr. 1958).

138

THE COST OF MEDICAL CARE

Mexico.
The statistics for Mexico show only the sum total of the salaries and wages
(including expenses) of the staff providing medical care at dispensaries. However, according to official information received from the social security institution, the average salary of a practitioner in general medicine under the scheme
was 867.35 pesos a month (making 10,408 pesos a year) in December 1953. The
number of hours worked by medical practitioners for the institution is generally
four a day. The average number of persons protected in 1953 was 1,286,481 ;
the number of practitioners in general medicine working for the institution
was 805. The number of persons protected per general practitioner was
therefore 1,598.
A practitioner's annual salary per person protected would thus have been
6.51 pesos, that is, 0.36 per cent, of the income per head (1,789 pesos) or
0.12 per cent, of the average income per economically active person. However,
the data available for other countries generally include practice expenses
(usually about 40 per cent, of the gross income). If the figures are increased
by two-thirds to allow for this factor a cost per person of 10.85 pesos, or 0.20
per cent, of the average income per economically active person, is obtained, a
value which corresponds to the average found in Chapter II. However, in
1954—a year of currency depreciation—the average salary was doubled, and
the net income per person protected was 0.19 per cent, of the average income
per economically active person, which would give a notional gross income of
about 0.31 per cent.
Switzerland.
The Swiss funds reporting expenditure on medical care do not give separate
figures for general practitioner and specialist care.
In order to estimate the gross income of a general practitioner assumed to
be giving 6,000 items of care (of which 3,600 are consultations) per year, the
fees paid in 1954 by the Swiss employment injury insurance institution have
been used. On this basis a general practitioner's gross income would have been
Frs. 46,200 per year. This represents 10.23 times the income per head or
4.65 times the average income per economically active person. 1 On the assumption that the 6,000 items of care were distributed among 2,500 protected persons,
his gross income per person would have been 0.19 per cent, of the average
income per economically active person.
On the other hand, according to the agreement concluded between the
Geneva Medical Association and the Geneva Federation of Sickness Funds
in 1955, the gross income for 6,000 items of service under the sickness insurance
would have been Frs. 36,000 per year, that is, 7.69 times the income per head
or 3.50 times the average income per economically active person. This, however, does not include fees for special items nor the extra fees charged to
well-to-do patients.
United States.
No separate figures are available for private expenditure on general practitioner care on the one hand and on specialist care on the other in the United
States. However, inquiries into doctors' incomes undertaken for various years
show the average gross income of general practitioners in 1951 to have been
$23,766 and the net income S 14,098; the former figure represents 13.24 times
the income per head and 5.28 times the average income per economically
1
For an explanation of the calculations on which these estimates are based see
p. 182.

THE INCOMES OF MEDICAL PRACTITIONERS

139

active person. 1 The average number of persons in the care of general practitioners covered by the inquiry is not given. However, the average net income
of all doctors covered who had seen 20 to 29 patients daily (or roughly 6,000 a
year) was $14,250 in 1951, or about the average net income of a general practitioner. In 1955 the average net earnings of a general practitioner were found
to be $14,817. If practice expenses are assumed to be 36 per cent, of the gross
income 2 the latter was then $23,152. This represents 11.8 times the income
per head in 1955 or 4.7 times the average income per economically active
person. The net earnings of all independent physicians seeing 20 to 29 patients
daily was $16,047, or rather more than the average net income of general
practitioners and about the same as the average net earnings of all physicians
covered, viz. $16,017 ($25,016 gross). The number of patients attended daily
by general practitioners was 25.
On the other hand, some 4 per cent, of the patients seen by general practitioners may have been hospital cases.3 A corresponding reduction in the
practitioner's gross income would leave an income from care of non-hospitalised patients of $22,815 in 1951, representing about five times the average
income per economically active person, and to $22,226 in 1955, representing
about 4.5 times that income.
Had the general practitioner been responsible for a population of 2,000
persons, then his gross income per person would have been 0.25 per cent, of the
average income per economically active person in 1951 and 0.23 per cent, in
1955. Had he been responsible for 2,500 persons, then his gross income per
person would have been 0.20 per cent, of that income in 1951 and 0.18 per
cent, in 1955.
According to a sampling survey made for the Health Information Foundation by the National Opinion Research Center of the University of Chicago
in the summer of 1955, the average net income of a family doctor was $15,000.*
If practice expenses (assumed to be 40 per cent, of the gross income) are
added the gross income works out at $25,000. This represents 12.76 times
the income per head ($1,960) or 5.09 times the average income per economically active person. The net income is stated to be for home and office calls.
The average number of patients seen per day was 26, which would make about
6,000 a year. The most frequent charge was $3 for a consultation and $5 for
a visit.
1
See Medical Economics (New York, Lansing Chapman), Vol. 30, Nos. 1-3
(Oct. 1952-Dec. 1952) and 8 (May 1953), Vol. 33, No. 10 (Oct. 1956) and Vol. 34,
No. 2 (Feb. 1957). According to these inquiries the net incomes of medical practitioners in 1951 were considerably higher than those shown in official statistics (see
Building America's Health, Vol. 4: Financing a Health Program for America, op. cit.,
p. 247), in which the average net income of general practitioners (including parttime specialists) in 1949 was estimated at $9,294 and that of full-time specialist
$14,033. The income of a general practitioner was 6.41 times the income per head
(81,449) or 2.56 times the average income per economically active person. If this
amount is adjusted to allow for practice expenses the gross income works out at
4.27 times the average income per economically active person.
2
This is the average found for all independent practitioners in 1955.
3
See Building America's Health, Vol. 3: A Statistical Appendix, op. cit., p. 149.
This estimate is based on statistics of the average weekly patient-load of 157 white
male general practitioners. In the District of Columbia the average number of patients
seen by a doctor was 78 per week (64 at the doctor's surgery, 11 at the patients' homes
and three in hospital). In Baltimore six out of 110 cases were hospital cases in 1942;
corresponding proportions were seven out of 132 in Maryland (except Baltimore) in
1942, 11 out of 112 in the urban districts of Georgia in 1942, six out of 111 in the
rural areas of Georgia in 1949, and eight out of 115 in 1942 and seven out of 133 in
1945 in the District of Columbia.
4
See Public Health Economics, Vol. 15, No. 8, Aug. 1958, pp. 416-417.

140

THE COST OF MEDICAL CARE

General Remarks.
The gross income of a general practitioner assumed to be attending
to a population of 2,500 persons protected by social security or, alternatively, to be giving 6,000 items of care per year, or the average number
of items where this is known, has been either computed or estimated for
12 of the countries covered by the present survey. They include:
(1) the gross income per person protected—(a) from social security,
and (b) from all sources, and from private payments in the United
States, in terms of the average income per economically active person ;
and
(2) the estimated gross income from all sources in terms of that
average income.
It will be seen that the estimated results are of the same order of
magnitude as those arrived at in Chapter II by the aid of recorded data.
The average gross income of practitioners per person protected in the
12 countries was 0.20 per cent, of the average income per economically
active person, i.e. the same as that found for 1953, for the five countries
TABLE 46. ESTIMATED GROSS INCOMES OF GENERAL
PRACTITIONERS FROM PERSONS PROTECTED BY SOCIAL SECURITY
(AND FROM PRIVATE AND VOLUNTARY INSURANCE PRACTICE
IN THE UNITED STATES) IN TERMS OF AVERAGE INCOME
PER ECONOMICALLY ACTIVE PERSON
Gross income of general practitioner
as a percentage of the average income
per economically active person
Country and year

Belgium, 19541
Canada, 1952 (Swift Current region) '
Chile, 1953 1
Denmark, 1953
England and Wales, 1953-54 . .
France, 1953 l
Italy, 1953
Mexico, 1953 l
Netherlands, 1955
New Zealand, 1953-54
Switzerland, 1954 l
United States, 1955 *

Per person protected
For 2,500 protected
persons or for 6,000
items of care

From
social security

From
all sources

0.12

0.22

550»

0.17
0.21 2
0.20
0.18
0.18 *
0.23
0.20
0.19
0.16

0.17
0.21 2
0.20
0.18
0.23 2
0.23
0.20
0.19
0.23
0.19 2
0.18 2

425
520
500
450
575
575
500
475
575
465
450

1
1.L.O. estimate. ' Estimated on assumption that 6,000 items of care are given to a population at
risk of 2,500. 'Estimated average number of consultations and visits: 2.12 consultations and 2.06
visits per person protected.

THE INCOMES OF MEDICAL PRACTITIONERS

141

for which the expenditure is recorded. The median figure for the 12
countries is 0.20 per cent. The average gross income for 2,500 persons
protected or 6,000 items of care a year was 505 per cent, of the average
national income per economically active person and the median figure
500. If the estimates of 635 and 509 per cent, for Canada and the United
States are substituted for those shown in table 46, the average becomes
527 per cent, and the medians are 509 and 520 per cent.

Specialists
The data given in Chapter II and supplementary estimates have
shown that the average incomes, per person protected, of general practitioners are remarkably similar in the countries studied.
Far less material is available concerning the incomes of specialists
for the care of patients outside hospital wards. The two exceptions are
Italy and the Netherlands ; these two countries will therefore be taken
first.
Italy.
In Italy, under the general sickness insurance scheme, the cost of treatment
by specialists, whether at the scheme's polyclinics or otherwise, was 0.36 per
cent, of the income per head per person protected in 1953, or 0.16 per cent.
of thè average income per economically active person. This cost includes
general expenses of the polyclinics. By 1955 the cost had risen to 0.37 per
cent, of the income per head but was still 0.16 per cent, of the average income
per economically active person.
A specialist employed at the clinic has been paid, for one hour a week,
from 6,660 to 7,992 lire a month, according to grade, since 1 April 1955.
A specialist in the intermediate or second grade earns 7,326 lire per month or
87,912 lire per year. If employed full time (assumed to be 30 hours a week)
he should thus earn 2,637,360 lire per year, which is about 12 times the income
per head or 5.30 times the average income per economically active person.
However, an addition must be made for practice expenses, since these
are paid by the polyclinic. If they are assumed to be 40 per cent, of the gross
income the latter would be 8.80 times the average income, as against 6.25 times
found for the general practitioner.
Netherlands.
For the Netherlands, on the other hand, the cost of specialist care outside
hospital wards in 1953 per person protected was 0.27 per cent, of the income
per head x or 0.11 per cent, of the average income per economically active person, as against the 0.14 per cent, earned by general practitioners—a proportion
1
This figure is based on statistics supplied to the International Social Security
Association. If the cost of general practitioner care (0.14 per cent.) is deducted from
that of all medical practitioner care (0.23 per cent.) the remainder (the cost of specialist care) is only 0.09 per cent. The difference is probably due to the fact that
special payments for surgery, etc., outside hospital wards are included in the LS.S.A.
figures but are not included in thefigureson p. 21.

142

THE COST OF MEDICAL CARE

of 100 to 127. In 1955 the cost of specialist care was 0.13 per cent, of that
income as against 0.19 per cent, for general practitioner care—a proportion
of 100 to 146. However, the income of a specialist cannot be estimated from
these data, since specialists also have private practices.
Belgium.
In Belgium, fees for consultation by specialists in 1953 were Frs. 25 under
the sickness insurance tariff as against Frs. 80 under the proposed national
practitioners' service. The latter fee was therefore 313 per cent, of the former
and the insured patient would have been paying 69 per cent, of the cost.
However, the sickness insurance scheme paid special fees for all interventions
which went beyond the ordinary care given in the course of a consultation. The
patient would then be paying 25 per cent, of the fee stipulated in the insurance
tariff unless the item of care received was one coming under the heading of
special care. The portion of the fee exceeding that fixed in the insurance
tariff would be paid by the patient, but the amount he pays in this way is not
known.
The aggregate income of specialists for care outside hospital wards can
be estimated by deducting from the cost of medical practitioner care as
calculated earlier (0.34 per cent, of the average income per economically
active person) the 0.22 per cent, found for general practitioners; this leaves
0.12 per cent for such specialist care.
Canada (Swift Current Region,

Saskatchewan).

The income per person protected of a general practitioner in the Swift
Current region of Saskatchewan was estimated at 0.17 per cent, of the average
income per economically active person 1 in 1952. Since the total cost per
person protected of medical practitioner care outside hospital wards was
found to be 0.22 per cent, of that income, this leaves only 0.05 per cent, for
specialist care given outside hospital wards. If income from hospital work
(which brought in $4.03 2, or 0.12 per cent, of the average income per economically active person) is included the specialists collectively (and those general
practitioners who did some specialist work) would have received 0.17 per cent.
of that income per person protected.
England and Wales.
For England and Wales, the assumption made in Chapter II that onetenth of the cost of hospital and specialist services is for treatment of outpatients by specialists and auxiliary staff, the cost of such treatment would,
in 1953-54, have been 0.09 per cent, of the average income per economically
active person. This figure included general expenses for out-patient care at
hospitals and thus represents the equivalent of a specialist's gross income
per head of the population for care of out-patients. 3 However, some deduction should be made on account of the inclusion of the cost of care given by
allied professions such as physiotherapy.
A specialist of the rank of consultant earned from £2,100 to £3,100 a year
under the National Health Service if employed full time unless he was granted
a special award. This may be deemed net income. However, other specialists,
1
2
8

See above, p. 136.
See appendix, p. 162.
See above, p. 28.

THE INCOMES OF MEDICAL PRACTITIONERS

143

such as senior hospital medical officers who earn less than consultants, also
give out-patient as well as in-patient treatment.
If the consultant's salary is assumed to be £2,600 a year and is notionally
increased to take account of general expenses (corresponding to practice
expenses in private practice, although probably higher) by two-thirds (on the
assumption that such expenses take up 40 per cent, of the gross income) the
gross income of a specialist would be £4,333. This would represent, in 1954,
14.02 times the income per head or 6.48 times the average income per economically active person.
However, there are many grades of specialists on hospital staffs other than
that of consultant.
Another estimate of the income of a " specialist " may be made by relating
the total amount paid in salaries to the medical staff of the hospital and
specialist service in England and Wales, including all grades, to the wholetime equivalent of such staff. The whole-time equivalent in 1953 of the rredical
staff was 15.040.1 In 1953-54 the salaries amounted to £27,217,231; this sum
may be doubled to account for the " general expenses " of the medical care
given by the hospital and specialist service to both in-patients and out-patients.
The " gross income " thus obtained is £3,619, representing 12.44 times the
income per head or 5.75 times the average income per economically active
person. The population per whole-time unit is 2,932. Per head the " gross
income " (including fees for the care of in-patients and of out-patients) would
thus be 0.20 per cent, of the average income per economically active person. 2
France.
The income of specialists in France from treatment given outside hospital
wards may be very roughly estimated by deducting from the cost of medical
practitioner care as estimated in Chapter II (namely 0.39 per cent, of the
average income per economically active person in 1953) the cost of general
practitioner care (0.23 per cent, of that income). This would leave 0.16 per
cent, per person protected for specialist care, including treatment in private
hospitals covered by social insurance.
Mexico.
The average salary of specialists working for the Mexican sickness insurance
institution in December 1953 was 818.76 pesos per month or 9,825 pesos per
year. If it is assumed that they worked three hours a day for the institute, a
six-hour day would have given them a salary of 19,650 pesos a year, representing 10.98 times the income per head or 3.56 times the average income per
economically active person. If this figure is increased by two-thirds to allow
for practice expenses the gross income works out at 5.93 times that income,
or 20 per cent, more than the estimated gross income of a practitioner in general
medicine with 2,500 patients.
New Zealand.
It was estimated in Chapter II that the cost of all medical practitioner care
per head (including the share of general practitioner fees paid by the patient)
was 0.28 per cent, of the average income per economically active person in
1953-54. If 0.23 per cent, is deducted for general practitioner care, the
1
2

The Cost of the National Health Service in England and Wales, op. cit., p. 118.
See also p. 146.

144

THE COST OF MEDICAL CARE

specialist's share is 0.05 per cent, per person protected. This, however, does not
include the patient's contribution to the fees charged by the specialist at his
own surgery. Since the social security fund paid the same amount for treatment by specialists as for treatment by general practitioners, and as, furthermore, that payment only covered 71 per cent, of the general practitioner's
average fees, the cost of specialist care outside hospital wards may easily be
twice as much as the figure of 0.05 per cent., which represents mainly the cost
of out-patient care at hospitals. This would mean that specialist care outside
hospital wards per head of the population cost 0.10 per cent, of the income per
economically active person.
Switzerland.
For Switzerland the estimated cost of general practitioner care per person
protected (0.19 per cent, of the average income per economically active person)
would leave 0.18 per cent, for specialist care given outside hospital wards, the
total cost of medical practitioner care in 1953 having been estimated at 0.37 per
cent. This does not appear to include the cost of hospital care. Since there are
about as many specialists in Switzerland as there are general practitioners, the
average income from patients not hospitalised would be roughly the same.
However, specialists would in addition receive the greater part of the income
from patients in private hospital wards and from hospitals.
United States.
In the United States, where specialist care is obtained on a private basis,
the average income of a full-time specialist in 1951, according to the inquiries
already referred to 1, was estimated at 826,495 gross or 517,112 net. The gross
income is 14.76 times the income per head or 5.89 times the average income
per economically active person. The greater part of this amount would appear
to come from hospitalised patients. In 1955 the average net earnings of
specialists ware $18,010. If gross earnings are assumed to be $28,141 (assuming
that the proportion of net to gross income was the same as that shown in the
inquiry mentioned above) this would represent 14.43 times the income per head
or 5.76 times the average income per economically active person.
In Chapter II the cost, per head of the population, of medical practitioner
care given outside hospital wards was estimated at 0.22 per cent, of the average
income per economically active person in 1951. If the gross income of a general
practitioner—estimated earlier at 0.20 per cent, of that income—is deducted
from this figure, only 0.02 per cent, remains for care by specialists outside
hospital. This seems very low.

General Remarks.
It is difficult to estimate the income of specialists from care given
outside hospital wards, since the cost of such care is not always clearly
distinguishable from the cost of specialist care given in hospital wards
on the one hand or from that of general practitioner care on the other.
Per person protected and in terms of the average income per economically
active person, the estimated cost of specialist care outside hospital wards
1

Medical Economics, Vol. 30, No. 2, Nov. 1952, p. 91.

THE INCOMES OF MEDICAL PRACTITIONERS

145

in 1953 ranged from 0.02 per cent, to 0.18 per cent, in the following eight
countries :
Country

Percentage

United States
0.02
England and Wales
0.09
New Zealand
0.10
Netherlands
0.11
Belgium
0.12
France
0.16
Italy
0.16
Switzerland
0.18
The average for these eight countries is 0.12 per cent. ; the medians are
0.11 and 0.12 per cent.
Since these amounts go to remunerate members of all specialities,
of which there are more than 20, it is impossible to draw conclusions
concerning the specialist's optimal income in general.
The estimate of 0.10 to 0.15 per cent, of the average income per
economically active person arrived at in Chapter II is therefore no more
than an approximation based in most cases on the difference between
the average total cost of medical practitioner care and the cost of general
practitioner care.
Such tentative estimates as can be made show the gross average
income of a full specialist from all sources to have been 5.75 times the
average income per economically active person in England and Wales
(1954), 5.93 times in Mexico (1953) and 5.76 times in the United States
(1955). Their values are quite comparable, so far as order of magnitude
is concerned.
The Incomes of Medical Practitioners from All Sources
In order to obtain an idea of the total gross income of medical
practitioners per person protected, income from care of hospitalised
patients must be added to what was found in the preceding sections.
Canada (Swift Current Region, Saskatchewan).
In Canada the cost of medical practitioner care for hospitalised patients
has been estimated, on the basis of the experience under the Swift Current
scheme in Saskatchewan, at 0.32 per cent, of the income per head in 1952 or
0.12 per cent, of the average income per economically active person.1
The total gross income of medical practitioners in the Swift Current region
per head of the population protected (including fees for hospital care paid to
private practitioners and the cost of out-patient care at hospitals) was SI 1.06
in 1952 ', representing 0.88 per cent, of the income per head or 0.33 per cent.
of the average income per economically active person.
1

See appendix, p. 162.

146

THE COST OF MEDICAL CARE

England and Wales.
Of the total hospital expenditure of the National Health Service in England
and Wales only about one-tenth goes to pay the salaries of the medical staff.
In 1953-54 these amounted to £27,217,231 \ or £0.62 per head of the population, representing 0.21 per cent, of the income per head. If this percentage is
doubled in order to account for general expenses involved in the provision of
medical care at hospitals, the expenditure on such medical care, including outpatient treatment, works out at 0.42 per cent, of the income per head. If this
figure is added to the cost of general practitioner care outside hospital wards
(0.40 per cent.) a total gross expenditure per person on medical practitioner care,
both for in-patients and out-patients, of 0.82 per cent, of the income per head
is arrived at. This is equivalent to 0.38 per cent, of the average income per
economically active person and may tentatively be taken as representing the
average gross income from social security of medical practitioners, including
the share of the patient but not income from private practice.
France.
In France the expenditure of the general social security scheme on medical
fees in public hospitals accounted in 1953 for only 5.4 per cent, of the total
expenditure on hospital care, that is to say, Frs. 3,791 million out of a total of
Frs. 70,219 million.2 This amount does not include medical fees reimbursed
for treatment in private hospitals, which are shown in table C. It represents
much the same proportion of the total hospital cost as doctors' salaries
under the English hospital service, assuming that one-half of these salaries is
for out-patient care. In terms of income per head, 5.4 per cent, of the expenditure shown in table E (1.58 per cent, of the income per head) would be 0.085
per cent, of that income, or 0.04 per cent, of the average income per economically active person. Since medical care in hospital was given largely
by specialists or general practitioners established in private practice, the
medical fees paid for care in public hospitals may be assumed to cover practice
expenses. For 1951, the sum of Frs. 3,291 million estimated to have been
paid in fees for such treatment represented Frs. 184.89 per person protected. 3
This is 0.09 per cent, of the income per head, or 0.04 per cent, of the average
income per economically active person.
If 0.C4 per cent, is added to the estimates, made in Chapter II, of expenditure
per person protected by sickness insurance on medical practitioner care in
France in 1951 and 1953 (0.35 and 0.39 per cent, respectively), the over-all
expenditure on medical practitioner care for those two years works out at
0.39 and 0.43 per cent, of the average income per economically active person. 4
According to the estimates made by the National Institute of Statistics
and Economic Studies, referred to earlier 6 , the gross income of medical
practitioners per head of the population was 0.80 per cent, of the income per
head in 1951 and 0.87 per cent, in 1952 6 , or 0.36 per cent, of the average
income per economically active person in 1951 and 0.39 per cent, in 1953.
1
Report of the Ministry of Health for the Year Ended 31st December 1955, Part I,
op. cit., p. 193. The expenditure and revenue account of hospitals does not contain
values identical with those used in table E which is based on the expenditure accounts
of the Exchequer. Nevertheless, the order of magnitude is the same.
2
Revised figures.
3
See appendix, p. 172.
4
If the cost of medical care for employment injury is added the total was 0.43
per cent, for 1951 and 0.47 per cent, for 1953.
6
Rapport sur les dépenses de santé, op. cit.
• See appendix, pp. 167-168.

THE INCOMES OF MEDICAL PRACTITIONERS

147

These figures, which cover the whole population, are slightly lower than the
estimated expenditure for the persons protected by the general sickness insurance scheme.
Federal Republic of Germany.
In the Federal Republic of Germany a break-down of the operating costs
of a municipal hospital in Solingen in the Ruhr industrial area shows that the
cost of medical treatment was DM 1.94 per patient-day out of a total gross
cost of DM 21.29—a little over 9 per cent. If this were taken to be typical of
other hospitals, doctors would have received about 0.10 per cent, of the average
income per economically active person from hospital activities, per head of
population in 1953, the total estimated cost of hospital care being 1.10 per
cent. Added to the 0.50 per cent, found to represent their income from
persons protected for care outside hospital wards, a total income per person
protected for medical practitioners of 0.60 per cent, is arrived at. 1
Italy.
In Italy, out of a total of 2,005 lire paid by the sickness insurance institution
per patient-day in 1953, 281 lire—or 14 per cent.—were for medical treatment.
Since the expenditure per head was 0.69 per cent, of the income per head in
1952, medical costs in hospitals would have represented about 0.10 per cent.
of that income or 0.04 per cent, of the average income per economically active
person.
The share of medical costs in the total expenditure of the tuberculosis
insurance scheme on care in sanatoria (0.35 per cent, of the average income per
economically active person) is not known. If it were also 14 per cent, the
incorre of medical practitioners from the two insurance schemes would be
further increased hy 0.05 per cent, of that income.
If the estimated average income of medical practitioners from hospital
care under general sickness and tuberculosis insurance (0.09 per cent, of the
average income per economically active person) is added to the 0.37 per cent.
representing the cost of medical practitioner care outside hospitals 2 the gross
incorre of medical practitioners per person protected in 1952 works out at
0.46 per cent, of that income.
Netherlands.
The expenditure on hospital care in the Netherlands shown in table E
includes 30 per cent, of the cost of specialist treatment in hospitals. 3 In 1953
the expenditure on specialist care in hospitals not covered by inclusive fees,
1
According to an estimate published by Dr. Thieding, the total net income of
doctors in 1953 was about DM 1,000 million. This represented 0.96 per cent, of the
national income, or, per head of the population, 0.48 per cent, of the average income
per economically active person. If practice expenses are assumed to be 40 per cent.
of gross income, then the latter would be 0.80 per cent, of the average income per
economically active person. Whether or not this estimate includes the income of
doctors in employment is not stated. See F. THIEDING : Das soziale Mosaik (Hamburg,
Hamburger Ärzte Verlag, 1956), p. 142.
2
Expenditure on medical practitioner care in 1952 per person protected amounted
to 0.86 per cent, of the income per head (see table C) which represents 0.37 per cent.
of the average income per economically active person, the proportion of economically
active persons being 43.1 per cent, of the total population.
3
See appendix, p. 209.

148

THE COST OF MEDICAL CARE

and therefore included not in table E but in table C, was 2.36 florins per
person protected, or 0.13 per cent, of the income per head. As this represents
70 per cent, of the expenditure on specialist care in hospitals, to obtain the
total cost in terms of the income per head a further 0.06 per cent, must be
added to the figure of 0.70 per cent, shown in table C. The total expenditure
on medical practitioner care, both for in-patients and for out-patients, then
works out at 0.76 per cent, of the income psr head or 0.31 per cent, of the
average income per economically active person.
Wen» Zealand.
In New Zealand the salaries of the medical staff of public hospitals, whether
part time or whole time, accounted in 1953-54 for £804,504 \ or only 5.70 per
cent, of the over-all hospital operating expenditure of £14,120,000. These
medical costs represented 0.11 per cent, of the national income. If this amount
is doubled to take into account general expenses, the cost works out at 0.22
per cent, of the income per head; if this percentage is added to the 0.60 per
cent, given in Chapter II for general practitioner care 2 the gross average
income of medical practitioners works out at 0.82 per cent, of the income per
head or 0.31 per cent, of the average income per economically active person.
To this total an unknown amount should be added for private payments to
specialists.
Switzerland.
Medical treatment in public hospital wards in Switzerland is usually given
by doctors attached to the hospital, on a full-time or part-time basis. Treatment in private hospitals is given by the doctor of the patient's choice; this is
to some extent also true for treatment given in private wards of public hospitals.
In 1953, 8.0 per cent, of the total expenditure of reporting hospitals was for
" medical needs ". 3 This would constitute, per head, about 0.06 per cent, of the
average income per economically active person, since the total estimated cost of
hospitals per head is 0.77 per cent, of that income. 4 If 0.06 per cent, is added to
the estimated cost of medical practitioner care outside hospitals (0.37 per cent.
of that income) 6, the aggregate income of medical practitioners for the care
of persons protected by sickness insurance would work out at 0.43 per cent.
of the average income per economically active person.
It is interesting to compare these findings with those of an inquiry into the
incomes of independent practitioners in 1944 based on the statistics of the
national defence tax.6
The average net income from medical practice of 3,322 independent
doctors covered by the survey was found to be Frs. 17,222. If this amount
is increased by two-thirds to arrive at the gross income, the latter works out
at Frs. 28,703. Such income would represent 10 times the income per head
1
New Zealand, Department of Health: Annual Report of the Director-General
of Health for the year 1955 (Wellington, Government Printer, 1956), p. 41.
2
See table 1.
3
Revue Vesica (Aarau, Association des établissements suisses pour malades),
19th Year, No. 11, Nov. 1955, p. 690.
* See above, p. 59.
6
See above, p. 31.
* R. STUPNICKI: Die soziale Stellung des Arztes in der Schweiz, Berner rechts- und
wirtschaftswissenschaftliche Abhandlungen, Heft 65 (Berne, Verlag Paul Haupt,
1953), pp. Ill ff.

THE INCOMES OF MEDICAL PRACTITIONERS

149

of 1944 or 4.55 times the average income per economically active person.1
It may be recalled that the estimated gross income of a general practitioner
in 1954 was 4.73 times the average income per economically active person;
The population per doctor, including salaried doctors, was 1,227 in 1945 a ;
this would mean that a medical practitioner received a gross income, per
head of the population, of 0.37 per cent, of the average income in 1944 and
0.43 per cent, in 1953.
United States.
In the United States hospital expenditure does not include payments by
patients to private independent practitioners attending them in hospital.
These payments were estimated in Chapter II to represent 40 per cent, of the
cost of medical practitioner care shown in table C, which, for 1953, was
calculated to be equivalent to 0.38 per cent, of the national income, or about
one-fifth of the total operating cost of hospitals (1.56 per cent, of the national
income, or, per head, 0.15 per cent, of the average income per economically
active person). The total income of independent medical practitioners, whether
from out-patient or in-patient care, but not including care given by doctors
employed by hospitals, is shown in table C. In 1953, it amounted to 0.94 per
cent, of the national income or, per head of the population, 0.38 per cent.
of the average income per economically active person. It is not known what
proportion of the hospital expenditure shown in table E goes on out-patient
care, which is largely given by specialists.
The incomes of medical practitioners per person protected in 1955, as
shown in table C, were 0.96 per cent, of the income per head and 0.38 per
cent, of the average income per economically active person. This year is
used for comparison subsequently because the available estimates of the
incomes of general practitioners and specialists are for 1955.
General Remarks.
The average gross income of a medical practitioner (general or
specialist) from all sources, including the care of hospitalised patients,
expressed in terms of the average income per economically active person
in the country concerned, in those countries in which that income
could be estimated, was as follows:
Country

[Percentage

Netherlands (1953)
0.31
Canada (1952)
0.33
England and Wales (1953-54)
0.38
United States (1955)
0.38
France (1953)
0.43
Switzerland (1953)
0.43
Italy (1952)
0.46
Germany (Federal Republic) (1953)
0.60
The average is 0.41 per cent, and the medians 0.38 and 0.43 per cent.
Income
from medical practitioner care given outside hospital wards takes
1
In 1944 the national incorni was Frs. 12,524 million and ths population 4,364,000 .
The income per head was therefore Frs. 2,870.
s
" Ärztestatistik 1956 ", in Schweizerische Ärztezeitung (Berne), 37th Year,
No. 34, 24 Aug. 1956, p. 357.

150

THE COST OF MEDICAL CARE

about 0.30 per cent., leaving roughly 0.10 per cent, for the care of
hospitalised patients.
The share of the general practitioner per person protected was found
to represent about 0.20 per cent, of the average income per economically
active person.
If the estimated average income of the general practitioner (which
is also shown) is deducted from the income of all medical practitioners
per person protected, there remains the income of the specialist for care
both of out-patients and of in-patients. In seven of the countries mentioned above these incomes, expressed as a percentage of the ave'rage
income per economically active person, were as follows:
Income of
specialist

Country

Netherlands (1953)
Canada (1952)
England and Wales (1953-54)
United States (1955)
France (1953)
Switzerland (1953 or 1954)
Italy (1952) »

0.17
0.16
0.20
0.20
0.20 »
0.24
0.25

1
See above, pp. 143 and 146.
• See table C and p. 147.

Income of general
practitioner

0.14
0.17
0.18
0.18
0.23
0.19
0.21

For specialists the average and the median are 0.20 per cent., while
for general practitioners the average is 0.19 per cent, and the median
0.18 per cent.
These figures show the incomes of specialists and general practitioners per person protected to have been in the neighbourhood of 0.20
per cent, of the average income per economically active person in the
country concerned. Specialists appear to have derived about one-half
of their incomes from hospital care.
However, the estimated total income of specialists per person protected varied, from one country to the other, just as much as the cost
of specialist care outside hospital wards. The same countries are at the
lower and higher ends of the scale.
Dentists
Dentists' incomes are difficult to estimate from social security
statistics, since most services provide only limited benefits, at least as
regards dentures.
England and Wales.
Serre idea of a dentist's gross income in England and Wales can be gained
from the number of dentists working for the National Health Service outside

THE INCOMES OF MEDICAL PRACTITIONERS

151

hospitals (at the end of 1953 there were 9,473). Expenditure per head on dental
care was 0.10 per cent, of the average income per economically active person.
The population per dentist working for the Service was thus 4,655. In fact
it was lower, since not everybody made use of the dental service. However,
if that figure is taken as a basis for calculation, the average income per dentist
per person works out at 4.66 times the average income per economically
active person.
On the other hand, according to the Memorandum submitted by the
Ministry of Health to the Royal Commission on Doctors' and Dîtitists'
Remuneration1, the average gross earnings from National Health Sîrvice
work of a dentist working as a principal was £3,200 in 1953-54 and £4,100 in
1955-56. This would represent 5.08 times the average income per economically
active person in 1953-54 and 5.82 times that income in 1955-56. These figures
do not include government contributions to the superannuation scheme.
Assistants are not counted as dentists, but their income from National Health
Service work is included in the total income of principals.
United States.
In the United States the average gross income of independent dentists
was $22,093 in 1955 2, that is to say, 11.27 times the income per head ($1,960)
or 4.50 times the average income per economically active person.
General Remarks.
These figures may be compared with the estimated gross income of a
general practitioner, who earns five times the average income per economically active person. It is true that the dentist's income is an average,
whereas the general practitioner's income has been calculated for a
practitioner caring for 2,500 persons. Nevertheless, the estimates of
average gross dental income, being based on the whole population
of the countries concerned, are probably a fair approximation to the
actual income of a dentist with a normal workload.
On the other hand, the average cost per person protected of dental
care (including the cost of dentures) was found to be 0.15-0.20 per cent.
of the average income per economically active person. If 0.10 per cent.
were for dentists' work, a dentist with an income of five times the average
income per economically active person would have about 5,000 protected
persons in his care; if 0.15 per cent, were for dental treatment, the dentist
would be in charge of 3,300 persons.
However tentative these results may be, it is interesting to observe
how close the dentists' average income in the two countries was to the
average for general practitioners attending 2,500 persons protected.

See above, p. 127 (note under table 43).
'"The 1956 Survey of Dental Practice. II. Income of Dentists by Location,
Age and Other Factors ", in The Journal of the American Dental Association (Atlantic
City, N.J.), Vol. 53, No. 6, Dec. 1956, pp. 719 ft".

CHAPTER V
CONCLUSIONS
COST OF MEDICAL CARE IN TERMS OF THE AVERAGE INCOME
PER ECONOMICALLY ACTIVE PERSON

1. The cost of medical care per head of the population tended, during
the period under review, to be of the order of 1.75 to 2 per cent, of the
average national income at factor cost per economically active person,
whatever the country or the method of providing medical care.
2. Slightly over one-tenth of this (0.20 to 0.25 per cent, of the average
income per economically active person) represented the cost of general
practitioner care.
3. The cost of hospital care per head of the population, including
both treatment and capital outlay, represented approximately one-half
of the total cost of medical care (0.9 to 1 per cent, of the average income
per economically active person).
4. The share of the specialist varied considerably. For care of nonhospitalised patients it is estimated at between 0.10 and 0.15 per cent.
of the average income per economically active person, but the figures
for individual countries vary greatly. If care of hospitalised patients is
included, the cost of specialist care was probably around 0.20 per cent.
of the income per economically active person.
5. If the cost of general practitioner care is added to this figure,
the cost of all medical practitioner care works out at 0.40 to 0.45 per cent.
of the average income per economically active person, or about onefifth of the cost of medical care in general.
6. The cost of pharmaceutical supplies per head of the population
also varies greatly, but this is partly due to differences in the scope of
this item. Under social security schemes providing fairly comprehensive
pharmaceutical care in the form of drugs, preparations and minor
appliances it has proved possible to keep the cost for supplies outside
hospital wards within a range of 0.15 to 0.20 per cent, of the average
income per economically active person.

CONCLUSIONS

153

7. The cost of conservative dental care may amount to something
like 0.10 to 0.15 per cent, of the average income per economically active
person, although this is only a very tentative figure. After there has been
a reasonable period of conservative care for children, the cost of dentures
is likely not to exceed 0.05 per cent.
8. Of the total cost of medical care, the share borne by social security
schemes ranged from as little as 25 per cent, to as much as 95 per cent.
These differences reflect not only the varying range of medical benefits
and differences in the proportion paid by the patient himself of the
cost of the care he received under the social security scheme, but also,
and perhaps primarily, the greater or lesser participation of public
authorities in the financing of hospital care.
9. It appears that the main variations in total cost, expressed in terms
of the income per economically active person in the country concerned,
were principally due to differences in the cost of pharmaceutical supplies
and of specialist care. Medical practice may differ considerably from
country to country as regards preference for certain types of care l ; there
seems to be a direct relationship between the amount of specialist care
and the amount of pharmaceutical supplies provided, but differences
in the definition of " pharmaceutical supplies " may have a considerable
effect on the comparability of the relevant figures.
10. A closer control of the prices of pharmaceutical supplies and
some check on consumption might result in savings. On the other hand,
the prescription of expensive medicines may avert much greater expenditure on hospital and other care. Thus, any restrictive measures should
not be introduced without considerable thought. More particularly, the
widely held belief that proprietary medicines are excessively dear may
prove to be unfounded.
TRENDS IN EXPENDITURE OF SOCIAL SECURITY SCHEMES

11. The expenditure, per person protected, of social security services
on medical care, expressed in terms of the income per head and the
reference wage, rose appreciably only in the following cases:
(a)

In France, where the coverage of the schemes has gradually been
extended to cover more and more of the full range of medical
benefits (the general social insurance scheme for non-agricultural

. ' Local custom has been shown to have a considerable effect on the relative
frequency of prescribing in different regions. See J. P. MARTIN: Social Aspects of
Prescribing (Melbourne, London, Toronto, Heinemann, 1957).

154

THE COST OF MEDICAL CARE

employees now covers practically all types of care; the patient pays
part of the cost, but the public authorities make no contribution,
not even towards the cost of hospital care); in 1954 the cost of the
French scheme per person protected was the same as that of the
National Health Service in England and Wales, even if allowance
is made for the fact that the percentages for England and Wales are
calculated on the basis of the gross national product.
(b) In Italy, where the remuneration for medical services and payments
for hospital care made by the social security scheme gradually
caught up with inflation.
12. In all the other countries (except England and Wales, where
there was a marked decline) the expenditure per person protected of
the social security services, expressed in terms of the national income or
the reference wage, remained fairly stable. There was a slight tendency
(which, in view of the great technical developments that have taken
place in medical science and practice, may be regarded as normal),
in some of the countries concerned, for this expenditure to rise during
the latter part of the period under review; on the other hand, in certain
other countries expenditure seems to have declined since 1953.
13. The ratio between expenditure in the country where it was
highest and in the country where it was lowest decreased from 4.6 to
1 in 1949 to 3.7 to 1 in 1954.
14. The expenditure per person protected of the social security
schemes on medical practitioner care given outside hospital wards rose
substantially only in those countries where total expenditure also
increased considerably (France and Italy). In France, however, it rose
much less than total expenditure. In two of the other countries the
medical practitioner's income from social security patients (and, in
the United States, the medical practitioner's income from private practice
and voluntary insurance schemes) just about kept pace with the general
increase in the income per head; in five countries it fell slightly and in
three others it rose somewhat from 1945 onwards over the whole of the
period under review. In terms of the reference wage the tendency was
usually the same, although the variations were smaller. However, in one
country (the Federal Republic of Germany) the expenditure increased in
terms of the reference wage but declined in terms of the income per head.
15. Pharmaceutical expenditure under social security schemes,
like that on medical practitioner care, rose considerably (in terms
of the national income or the reference wage) only in those countries
where over-all social security expenditure also rose considerably
(France and Italy). In France it rose more than the total expendi-

CONCLUSIONS

155

ture since 1947. In Italy, between 1947 and 1955, the increase in pharmaceutical expenditure was greater than that in over-all expenditure;
but the opposite is the case if the reference period taken is 1948 to 1955.
Otherwise there was not any general rise in the expenditure on
pharmaceutical benefits per person protected; there was even a slight
decline, especially since 1949. The disquieting fact about expenditure
on pharmaceutical supplies is not therefore its increase in terms of
national income or reference wages but the great disparity between
the expenditure under different social security systems, even when
expressed in terms of the average income per economically active person.
However, since 1953 certain fairly clearly defined tendencies have been
appearing; in five schemes the pharmaceutical expenditure became
fairly steady at between 0.3 and 0.5 per cent, of the income per head,
while in three other schemes it ranged between 0.7 and 0.8 per cent, of
that income.
16. The stationary or declining trend of dental expenditure is
surprising in view of the widely held opinion that dental needs are not
adequately met because of a shortage of dentists. The inference that
demand is kept below the desirable level owing to the fact that social
security often covers only a relatively small part of the cost cannot be
rejected out of hand. However, if dental care is provided regularly
the demand for it tends to fall ; the reduction, as might be expected, is
particularly marked in the demand for dentures. The preventive effect
of medical care provided at the proper time is best illustrated by the
case of dental care. The gradual introduction of free dental care, first
for children and subsequently for adults when the children who have
received the free care grow up, might be the most rational method of
providing dental care for the population.
17. In the countries where expenditure on social security has risen,
this rise is chiefly due to an increase in hospital expenditure, which in
turn would appear to be due to an increase in the amount of care provided
and possibly to the introduction of more expensive equipment and
methods of treatment. It has not, however, occurred in all schemes,
although it is especially liable to occur in one particular sector, namely
over-all expenditure on hospital care, including payments by patients
and expenditure of public authorities. To judge from the data available
for the United States and Saskatchewan, it is the cost of maintaining and
nursing the patient in hospital that has risen rather than the cost of
medical treatment in hospital. This is confirmed by the fact that in most
cases during the period under review the cost of medical practitioner care
outside hospitals did not rise in terms of either the income per head

156

THE COST OF MEDICAL CARE

or the reference wage and in some actually fell. However, by the end
of the period even hospital maintenance costs seemed to have reached
a peak they were unlikely to climb beyond in the United States.
18. Accordingly, where hospital costs have risen the problem is
mainly one of preventing a further rise. This can be done by improving
domiciliary care, shortening periods of treatment and keeping a close
check on the use of auxiliary services and on the length of stays in hospital.
19. Hence the present study does not bear out the commonly held
belief that there is a general tendency for all medical costs to rise—or
it rather indicates that they have not risen any faster than national
income or reference wages, although hospital costs show a certain
tendency to outstrip the rest.

20. The payments made by sickness or medical care insurance
under most of the social security schemes dealt with in this study do not
cover the full cost of medical care. Payments are made by private persons
(particularly for pharmaceutical supplies and dental care) ; contributions
are also received from public funds (especially for hospital care). Where
hospital costs are paid almost entirely out of contributions under schemes
of limited scope (and particularly under schemes for employees only) the
burden may well become too heavy for a contributory scheme to bear.
21. Social security tends to enable the persons protected to obtain
something approaching comprehensive care. This care, however, while
no doubt more evenly distributed, does not appear, during the period
under review, to have been more expensive, in terms of the average
income per economically active person, than care privately obtained,
or provided at the expense of public funds, in the United States.

APPENDIX

A. EXPLANATIONS O F CALCULATIONS
Belgium
MEDICAL PRACTITIONER CARE

Table C shows the expenditure of the scheme on consultations and visits
by general practitioners and specialists, for which the benefits paid to persons
protected in 1953 were Frs. 25 per consultation, Frs. 30 per visit, and an average
of Frs. 57.50 for special visits (i.e., urgent, night and Sunday visits). This
scale of fees was still in use in 1956. Higher benefits were only paid for consultations by physicians (médecins internistes) who drew up written reports.
The expenditure on this item was Frs. 0.51 per person protected.
Under the National Practitioners' Service, planned by the medical profession in 1954, persons whose incomes did not exceed Frs. 100,000 a year, with
an extra Frs. 25,000 for a spouse and Frs. 10,000 for each other dependant,
were to be treated by medical practitioners belonging to the service at rates
fixed by it. The lowest rates were Frs. 40 for a consultation, Frs. 60 for a visit
and Frs. 90, Frs. 180 and Frs. 120 respectively for the three kinds of " special "
visits. The average for these special items is estimated at Frs. 130.1
The number of items of service rendered per 100 persons protected under
the scheme was 472, of which 269 were consultations, 198 ordinary visits and
5 special visits. On the basis of an inquiry into the number of items of service
of each kind provided in 1948 it is assumed that 13 per cent, of the services
(that is 61 items per 100 persons) were rendered by specialists 2 ; these are
assumed to have been consultations, for which the fee chargeable under the
National Practitioners' Service is Frs. 80, the insurance scheme refunding
Frs. 25. The number of consultations per 100 persons given by general practitioners would then have been 208.
In the light of the above assumptions, the cost to patients qualifying for
treatment at the lowest rates under the National Practitioners' Service of the
472 items of service per 100 persons protected would then have been Frs. 257.30
per person protected, of which the insurance scheme would have reimbursed
Frs. 130, or 50.5 per cent. The patient would thus have borne 49.5 per cent.
of the cost.
Expenditure on special treatment other than payments to médecins internistes for written reports is not included in table C but in table G. No breakdown of the expenditure on special treatment according to whether it is given
in hospital or not is available. An adjustment of the percentages in table C
has tentatively been trade by including the expenditure per person protected
on neuro-psychiatry (Frs. 1.79), dermatology (Frs. 1.44) and radiology (Frs.
1
See Industry and Labour (Geneva, I.L.O.), Vol. XII, No. 11,1 Dec. 1954, p. 532.
At first only one scale of fees was laid down for the service. Subsequently, however,
a second scale of fees was established, the participating practitioner being allowed
to choose which he would apply. The fees in the second scale are 50 per cent, higher
than those in the first one. 1 he fees quoted in the present study are those of the lower
scale.
8
Although substantial amendments have been made in the regulations concerning
reimbursement since 1948, the results of the inquiry are used by way of approximation.

160

THE COST OF MEDICAL CARE

55.01) The addition of these items to the cost of medical practitioner care
would bring the total up from Frs. 257.30 to Frs. 315.54, representing
0.83 per cent, of the income per head (Frs. 38,129) and 0.70 per cent, of the
reference wage (Frs. 44,778). The expenditure of the scheme in 1953 was
Frs. 188, that is to say, 0.49 per cent, of the income per head and 0.42 per cent.
of the reference wage.
In 1951 the expenditure of the scheme on consultations and visits (including
some fees paid to dispensing doctors) was Frs. 136.54 per person protected.
The total expenditure, including that on neuro-psychiatry (Frs. 1.32), dermatology (Frs. 1.36) and radiology (Frs. 49.88), was Frs. 189, representing
0.52 per cent, of the income per head (Frs. 36,241) and 0.43 per cent, of the
reference wage (Frs. 43,680).
PHARMACEUTICAL SUPPLIES

(a)

1951.
The insurance scheme paid out Frs. 794,779,044 for pharmaceutical
benefits. To this amount have been added Frs. 100,994,593, representing the
beneficiaries' share of the cost of 14,427,799 prescriptions of non-proprietary
drugs or preparations at Frs. 7 each; Frs. 27,264,753, representing the
beneficiaries' share of the cost of indispensable proprietary medicines, on
the assumption that, since the insurance scheme normally pays 70 per cent.
of the cost but may pay up to 100 per cent, the beneficiaries pay 25 per
cent, of the total (Frs. 81,794,260 are paid by the insurance scheme); and
Frs. 354,217,220, representing the beneficiaries' share (50 per cent.) of the cost
of other reimbursable proprietary medicines (Frs. 354,217,220 are paid by
the insurance scheme). The total is thus Frs. 1,277,255,610, of which Frs.
482,476,566, or 37.8 per cent., were paid by the beneficiaries. Both the total
spent and the proportion paid by the beneficiaries should, however, be increased
to take account of ceilings on the amounts payable (for ordinary proprietary
medicines, Frs. 20 per item and, where several are prescribed on a single prescription, Frs. 50 per prescription). This means that the beneficiary pays more
than 50 per cent, of the cost of proprietary medicines priced at over Frs. 40.
Data on the actual proportion of the cost of ordinary proprietary medicines
paid by the beneficiary are not available. It has therefore been assumed that
the actual amount paid by the beneficiaries would bring the share of the total
cost of reimbursable pharmaceutical supplies paid by them to approximately
40 per cent.
(b)

1953.
The insurance scheme paid out Frs. 732,883,866 for pharmaceutical
benefits. To this amount have been added the sum of Frs. 136,964,632,
representing the beneficiaries' share of the cost of 17,120,579 prescriptions
of non-proprietary medicines at Frs. 8 each, and Frs. 139,942,964, representing
the beneficiaries' share of the cost of reimbursable proprietary medicines
(42 per cent, of the total). 1 Thus the total cost of reimbursable pharmaceutical
supplies appears to have been Frs. 1,009,791,462, of which the beneficiaries
paid Frs. 276,107,596, or 27.3 per cent.
HOSPITAL CARE

1. Estimated Cost of Hospital Care per Day
1951.
According to estimates made by the Belgian Ministry of Public Health,
the cost of hospital care per day and per patient, in 38 hospitals
(a)

" La spécialité pharmaceutique ", in L'Effort, No. 3, 1955, p. 61.

APPENDIX: EXPLANATIONS OF CALCULATIONS

161

depending on the public assistance commissions (including six maternity
hospitals), ranged from Frs. 78 to Frs. 721.10. These figures include the cost
of maintenance and nursing, medical fees, the cost of medicines and depreciation of equipment. The average for the 38 hospitals was Frs. 247.15 per day;
the medians were Frs. 222 and Frs. 230. Official estimates suggest that the
average cost per day is about Frs. 200.
(b)

1953.

In the civilian hospital at Charleroi the cost per patient-day, excluding
capital outlay, was Frs. 250.30.1 This figure is taken as a basis for calculation.
2. Cost of Hospital Care Received under Sickness and
Invalidity Insurance
(a)

1951.

The number of days of hospital care of all types received by persons
protected was 145.75 per 100 persons protected. If the average cost
per hospital-day is assumed to be Frs. 200, the cost per person protected
(for 1.46 days) would be Frs. 292 per year. This represented 0.81 per cent.
of the income per head (Frs. 36,241) or 0.67 per cent, of the reference wage
(Frs. 43,640), the expenditure of the insurance scheme amounting to 0.63 per
cent, of the income per head or 0.52 per cent, of the reference wage. On
these assumptions the scheme would cover 78 per cent, of the cost.
If the average of the expenditure in the 38 hospitals of Frs. 247 a day
is taken as the basis of the estimate, the cost of hospital care per person
protected would be Frs. 360.62, or 1.00 per cent, of the income per head,
and 0.83 per cent, of the reference wage. On this hypothesis the scheme
would be paying about 63 per cent, of the cost.
(b)

1953.

The number of days of hospital care received by the persons protected was
148.78 per 100 persons protected. At an average cost of Frs. 250.30 per
patient-day the cost per person protected would be Frs. 372.40 a year. This
represents 0.98 per cent, of the income per head (Frs. 38,129) and 0.83 per
cent, of the reference wage (Frs. 44,778). The insurance scheme, which paid,
per person protected, 0.64 per cent, of the income per head and 0.55 per cent.
of the reference wage, thus paid 65 per cent, of the cost.
INCOMES OF MEDICAL PRACTITIONERS

1. The number of consultations given by all doctors under the sickness
insurance scheme in 1954 was 2.74 per person protected, the number of visits
2.01 and that of special visits 0.05.
2. The estimates of the number of items of service given by general
practitioners, of the cost of these items to the patient and of the corresponding expenditure of the scheme, were made in the same way as for 1953
(see p. 159). The average fee paid by the insurance scheme for special visits
was Frs. 57.59.
1
" Problèmes et institutions hospitalières en Belgique ", in Revue de l'Assistance
publique à Paris (Paris, Service de la documentation de l'Assistance publique), No. 32,
Nov.-Dec. 1954, p. 720.

162

THE COST OF MEDICAL CARE

Canada
MEDICAL PRACTITIONER CARE (SWIFT CURRENT REGION)

(a) 1951.
The expenditure of the scheme on medical practitioner services in the
Swift Current region was S9.36 per person protected. Of this $4.05 was
spent on visits to hospitals, major surgical operations, surgical assistance and
the services of anaesthetists, leaving a remainder of $5.31. Expenditure on
out-patient services was $1.04 per head and payments for treatment outside
the region, other than treatment of hospitalised patients, amounted to $0.10.
The total expenditure on medical practitioner care outside hospital wards was
therefore S6.45 per person protected. This represents 0.53 per cent, of the
income per head ($1,223) or 0.28 per cent, of the reference wage ($2,265).
(b) 1952.
The expenditure of the service for practitioner services in the region was
$9.54 per person protected. Of this $4.03 was spent on visits to hospitals,
major surgical operations, surgical assistance and the services of anaesthetists.
leaving a remainder of $5.51. Expenditure on out-patient services at hospitals
was $1.52 per protected person and payments for treatment outside the
region other than treatment of hospitalised patients amounted to $0.16.
The total expenditure on medical practitioner care outside hospital wards was
therefore $7.19. This represents 0.57 per cent, of the income per head ($1,263)
or 0.29 per cent, of the reference wage ($2,443).1
HOSPITAL CARE

Province of Saskatchewan
(a) 1951.
(1) Expenditure of hospitals. Expenditure of public hospitals, mental
hospitals and tuberculosis hospitals was $22,149,722 representing $26.63 per
head of population (831,728). This represented 2.18 per cent, of the income per
head ($1,223) or 1.18 per cent, of the reference wage ($2,265).
(2) Expenditure on medical practitioner care (Swift Current region only).
The expenditure of the medical practitioner service within the region, for
physicians' services, was $9.36 per head; $4.05 was for treatment of patients in
hospitals. 2 The latter amount represented 0.33 per cent, of the income per
head or 0.18 per cent, of the reference wage.
(3) Cost of out-patient treatment. The expenditure of public hospitals on
out-patient treatment was $523,284, or $0.63 per head of the population,
representing 0.05 per cent, of the income per head or 0.03 per cent, of the
reference wage.
(4) Total estimated cost of hospital care, not including operating expenditure
of private hospitals. The total cost of hospital care for in-patients may be
estimated by adding to the operating expenditure of $26 per head for the whole
province ($26.63 minus $0.63), the estimated expenditure for treatment by
medical practitioners of hospitalised patients in the Swift Current region, viz.
1
Province of Saskatchewan, Department of Fublic Health: Public Health, annual
report for the fiscal year 1 April 1951 to 31 March 1952 (Regina, 1952). See also
idem, annual report for the fiscal year 1 April 1952 to 31 March 1953 (Regina, 1954).
• See above.

APPENDIX: EXPLANATIONS OF CALCULATIONS

163

$4.05. The total would then be $30.05, representing 2.46 per cent, of the
income per head or 1.33 per cent, of the reference wage.1
(¿>) 1953.
(1) Expenditure of hospitals. The expenditure of hospitals in Saskatchewan
was $25,986,456, or $30.18 per head of the population (861,000). Of this
expenditure $5,020,124 was for mental hospitals, representing $5.83 per head of
population or 0.45 per cent, of the income per head ($1,288) and 0.23 per cent.
of the reference wage ($2,556).
(2) Expenditure on medical practitioner care (Swift Current region only).
The expenditure of the medical practitioner service within the region, for
physicians' services, was $9.71 per head. Of this, $4.93 per head of the population (representing 0.38 per cent, of the income per head or 0.19 per cent, of
the reference wage) was estimated to be for treatment in hospital.
(3) Cost of out-patient treatment. No allowance can be made for outpatient treatment.
(4) Total estimated cost of hospital care. The total cost of hospital care for
in-patients may be estimated by adding the estimated expenditure for treatment
by medical practitioners of hospitalised patients in the Swift Current region
($4.93) to the operating expenditure ($30.18 per head) for the whole province.
The total would then be $35.11, representing 2.73 per cent, of the income per
head or 1.39 per cent, of the reference wage. It should be noted that these
percentages are not strictly comparable with those for 1951 since the latter do
not include the expenditure of private hospitals or expenditure on out-patient
care. 2
Whole of Canada (1953)
(1) Expenditure of Hospitals.
(a) Net operating expenditure. The net operating expenditure was $402,776,769,
or $27.25 per head of the population (14,781,000). This represents 2.12
per cent, of the national income ($19,043 million) or, per head of the
population, 1.07 per cent, of the reference wage ($2,556).
(b) Capital expenditure. Capital expenditure on hospitals amounted to
$118,300,000, or $8 per head of the population. This represents 0.62
per cent, of the national income or, per head of the population, 0.32 per
cent, of the reference wage.
(c) Total expenditure of hospitals. The total expenditure of hospitals per
head of the population was therefore 2.74 per cent, of the national income
or 1.39 per cent, of the reference wage.
(2) Expenditure on Medical Practitioner Care.
The expenditure on hospital treatment by medical practitioners in the
Swift Current region (0.38 per cent, of the income per head or 0.19 per cent.
of the reference wage) has been taken as representative of the expenditure of
patients for treatment by private practitioners in Canadian hospitals.
'Government of Canada: Annual Report of Hospitals, 1951 (Ottawa, 1953),
pp. 86-87. See also Province of Saskatchewan, Department of Public Health :
Public Health, annual report for the fiscal year 1 April 1952 to 31 March 1953,
op. cit., pp. 26-27.
2
Department of National Health and Welfare, Research Division: Hospitals in
Canada, General Series, Memorandum No. 10 (Ottawa, Sep. 1955), p. 75; and
Province of Saskatchewan, Department of Public Health : Public Health, annual report
for the fiscal year 1 April 1953 to 31 March 1954 (Regina, 1955), pp. 28 and 29.

164

THE COST OF MEDICAL CARE

(3) Total Estimated Hospital

Expenditure.

(a) Operating expenditure. To the operating expenditure of hospitals per
head (2.12 per cent, of the national income or 1.07 per cent, of the
reference wage) are added 0.38 per cent, of the income per head or 0.19
per cent, of the reference wage for payments to medical practitioners not
on the staff of the hospital. The total per head thus obtained is 2.50 per
cent, of the national income or 1.26 per cent, of the reference wage.
(b) Total expenditure of hospitals. By adding to the above percentages the
cost of construction, representing 0.62 per cent, of the national income
and, per head, 0.32 per cent, of the reference wage a total cost of 3.12 per
cent, of the first unit and 1.58 per cent, of the second is obtained.
(4) Mental Hospitals.
The expenditure of mental hospitals, included under (1) above, was
$57,229,007, representing 0.30 per cent, of the national income or, per head of
the population, S3.87 (0.15 per cent, of the reference wage). 1

Denmark
MEDICAL PRACTITIONER CARE

(a) 1951.
In 1951 expenditure by the sickness insurance scheme on out-patient care
in public district hospitals amounted to 5,058,000 crowns, or 24 per cent, of
the total expenditure on care provided in district hospitals (21,092,000 crowns).
The total expenditure on care in district hospitals per member of the fund
was 8.74 crowns.
Twenty-four per cent, of this amount is 2.10 crowns per member, or 1.50
crowns per person protected (on the basis of 40 children for 100 members).
This amount is equivalent to 0.03 per cent, of the income per head (4,776
crowns) or 0.02 per cent, of the reference wage (9,385 crowns).
(b) 1953.
In 1953 expenditure on out-patient care in public district hospitals amounted
to 6,009,000 crowns, or 24.1 per cent, of total hospital expenditure (24,968,000
crowns). The total expenditure of district hospitals per member was 10.25
crowns, of which out-patient care took up 2.48 crowns per member or 1.77
crowns per person protected. This represents 0.03 per cent, of the income per
head (5,152 crowns) or 0.02 per cent, of the reference wage (9,934 crowns).
HOSPITAL CARE

1. Cost of All Hospitals
(a) 1951.
The number of patient-days per head of the population in 1951 was 1.85
in general hospitals, 0.04 in maternity hospitals, 0.30 in tuberculosis hospitals
and sanatoria and 0.90 in mental hospitals, making a total of 3.09 days per
head of the population.
1
Hospitals in Canada, op. cit., pp. 69 and 75. See also Province of Saskatchewan
Department of Public Health: Public Health, annual report for thefiscalyear 1 April
1953 to 31 March 1954, op. cit.

APPENDIX: EXPLANATIONS OF CALCULATIONS

165

The average cost per day, excluding depreciation and interest, was 33 crowns
for general hospitals, 26 crowns for maternity hospitals, 17 crowns for mental
hospitals, 28 crowns for tuberculosis hospitals and 21 crowns for tuberculosis
sanatoria. Assuming the average cost of the 0.30 patient-days per person
spent in tuberculosis institutions to have been 24.50 crowns a day, then the
total cost of the 3.09 days per head of the population spent in hospital each
year would have been 84.74 crowns—an average of 27.42 crowns per day.
The total cost represented 1.77 per cent, of the income per head (4,776 crowns)
or 0.90 per cent, of the reference wage (9,385 crowns).
(b) 1953.
In 1953 the number of patient-days per head of the population spent in
hospital was 1.89 in general hospitals, 0.04 in maternity hospitals, 0.90 in
mental hospitals, and 0.29 in tuberculosis hospitals, per head of population.
The average cost per day was 37 crowns for general hospitals, 30 crowns
for maternity hospitals, 19 crowns for mental hospitals and 31 crowns for
tuberculosis hospitals (27 crowns for tuberculosis sanatoria). If it is assumed
that the 0.29 days of tuberculosis care provided per head cost on the average
29 crowns a day, then the cost of the 3.12 days of hospital care per head
of population would have averaged 96.64 crowns, or 30.97 crowns per day.
The total cost represented 1.88 per cent, of the income per head (5,152 crowns)
or 0.97 per cent, of the reference wage (9,934 crowns).
2. Expenditure of Sickness Insurance Scheme
(a) 1951.
The expenditure of the social security scheme on hospital care (excluding
convalescent home care) was 10.83 crowns per member, of which 8.74 crowns
was taken up by care provided in general public hospitals. Of the latter
amount 24 per cent. (2.10 crowns) was spent on out-patient care. This leaves
8.73 crowns per member for in-patient care.
The number of days of hospital benefit provided per member of the
scheme was 3.10. The expenditure of the scheme per day would thus have
been 2.82 crowns per member, while the average expenditure of all hospitals
amounted to 27.42 crowns per day. If these assumptions are correct the
insurance scheme paid 10.28 per cent, of the cost of the care received by the
persons protected.
At the average cost for all hospitals, the 3.10 days of care provided per
member would have cost 85 crowns. Per person protected (40 children per 100
members) the real cost was thus 60.71 crowns, representing 1.27 per cent.
of the income per head or 0.65 per cent, of the reference wage.
(b) 1953.
The expenditure of the scheme on hospital care amounted to 12.56 crowns
per member, of which 10.27 crowns were for care in general public hospitals.
Of the latter amount, 24.1 per cent. (2.48 crowns) was expended on out-patient
care. This leaves 10.08 crowns per member for in-patient care. The number
of hospital benefit days per member was 3.19. The expenditure of the scheme
per bed-day would then have been 3.16 crowns out of a total average expenditure of all hospitals of 30.97 crowns per day. The insurance scheme would
thus have paid 10.20 per cent, of the cost of the care received by the persons
protected.
If the average cost of care in all hospitals is taken as a basis for calculation,
the cost of the 3.19 days per member works out at 98.79 crowns. Per person
protected, the real cost was 70.56 crowns, representing 1.37 per cent, of the
income per head or 0.71 per cent, of the reference wage.

166

THE COST OF MEDICAL CARE

England and Wales
HOSPITAL CARE

1. According to'the hospital costing returns for the year ended 31 March
1953 ', the percentage of the total inclusive net cost of maintaining a patient
that was estimated to have been expended on out-patient care ranged on an
average from 41 for eye hospitals to 0 for chronic, convalescent, isolation,
tuberculosis and mental hospitals; it was 22 per cent, for general hospitals.
The notional isolation of expenditure on out-patient care was achieved
by apportioning the total expenditure between in-patients and out-patients on
the basis, adopted for the Emergency Hospital Scheme during the Second
World War, that five out-patient attendances represented the equivalent in
expenditure of one in-patient day.
The cost of out-patient care is estimated at roughly one-tenth of the total
cost of the hospital service shown in table E. In 1951-52 it represented 0.22
per cent, of the income per head or 0.22 per cent, of the reference wage; the
corresponding percentages for 1953-54 were 0.20 and 0.19. This leaves 2.01 per
cent, of the income per head, or 1.93 per cent, of the reference wagî, for
in-patient hospital cost in 1951-52, and 1.84 per cent, of the income per head,
or 1.74 per cent, of the reference wage, in 1953-54.
2. Expenditure on doctors' salaries for both in-patient and out-patient
care amounted to £27,217,231 (including contributions for superannuation) or
£0.6172 per head of the population, or 0.21 per cent, of the income per head,
in 1953-54. If one-half of doctors' salaries are assumed to be for out-patient
care, and this amount is doubled to allow for general expenses, the expenditure
works out at 0.21 per cent, of the income per head. This is similar to the
percentage of 0.20 found by applying the method described above.
3. Capital expenditure amounted to £10,817,750 in 1951-52 and £9,290,258
in 1953-54.
France
MEDICAL PRACTITIONER CARE

1. Cost of Medical Practitioner Care Provided under
the Social Security Schemes
According to an inquiry into the fees charged by doctors, referred to later 2 ,
the proportion of the cost of medical practitioner care received under the
general sickness insurance scheme paid by the patient is estimated at 25 per cent.
for short-term illness and 5 per cent, for long-term illness. The inquiry would
appear to relate to the year 1953, but it is assumed that cost-sharing took place
on the same basis in 1951.
(a) 1951.
In 1951 the expenditure of the sickness insurance scheme on medical practitioner care (but not including expenditure on care by allied professions) was
Frs. 20,945 million for short-term illness and Frs. 2,131 million for long-term
illness, making a total of Frs. 23,076 million. This represented, per head of the
1
Ministry of Health, National Health Service: Hospital Costing Returns for
the year ended 31 March 1954 (London, H.M. Stationery Office, 1955) p. 123.
2
See below, p. 172.

APPENDIX: EXPLANATIONS OF CALCULATIONS

167

17.8 million persons protected, Frs. 1,296.40, that is to say, 0.60 per cent, of
the income per head of the population (Frs. 216,866) or 0.53 per cent, of the
reference wage (Frs. 243,776). On the assumption that 25 per cent, of the cost
of short-term illness and 5 per cent, of that of long-term illness is paid by the
patient, the total cost of medical practitioner care was Frs. 6,982 million (onethird) higher than the expenditure of the scheme on short-term illness
(Frs. 20,945 million) and Frs. 112 million (one-nineteenth) higher than its
expenditure on long-term illness (Frs. 2,131 million). The total estimated cost
of the care received under the sickness insurance scheme would thus be
Frs. 30,170 million, or Frs. 1,695 per person protected. This represents 0.78
per cent, of the income per head or 0.70 per cent, of the reference wage.
Expenditure under the employment injury insurance scheme on medical
practitioner care, including care by allied professions, amounted to Frs. 2,841
million, representing Frs. 159.61 per person protected by the general sickness
insurance scheme. This is 0.07 per cent, of the income per head or 0.07 per
cent, of the reference wage.
The total expenditure of the sickness and employment injury insurance
schemes thus amounted to Frs. 25,917 million, or Frs. 1,456 per person protected, representing 0.67 per cent, of the income per head or 0.60 per cent, of
the reference wage.
The estimated cost of the medical care received under sickness and employment injury insurance (including the patient's share) thus works out at
Frs. 33,011 million, or Frs. 1,855 per person protected. This represents 0.86
per cent, of the income per head or 0.76 per cent, of the reference wage.
(b) 1953.
The expenditure of the sickness insurance scheme on medical practitioner
care amounted to Frs. 29,624 million, or Frs. 1,627.69 per head of the 18.2 million persons protected. The latter figure represents 0.67 per cent, of the income
per head (Frs. 244,284) or 0.62 per cent, of the reference wage (Frs. 262,080).
It is estimated that the patients paid out Frs. 8,946 million in respect of shortterm illness (as against expenditure by the scheme of Frs. 26,837 million) and
Frs. 147 million for long-term illness (as against expenditure of Frs. 2,787 million); the total cost was therefore Frs. 38,717 million, or Frs. 2,127 per head of
the 18.2 million persons protected. This represents 0.87 per cent, of the income
per head or 0.81 per cent, of the reference wage.
Employment injury insurance expenditure on medical treatment amounted
to Frs. 3,786.5 million, or Frs. 208.05 per person protected, that is to say,
0.09 per cent, of the income per head or 0.08 per cent, of the reference wage.
The combined expenditure of the sickness and employment injury insurance
schemes therefore amounted to Frs. 33,411 million, or Frs. 1,836 per person
protected. This represents 0.75 per cent, of the income per head or 0.70 per
cent, of the reference wage.
The estimated cost of care received under sickness and employment injury
insurance was therefore Frs. 42,504 million, or Frs. 2,335 per person protected,
representing 0.96 per cent, of the income per head or 0.89 per cent, of the
reference wage.
2. Aggregate Gross Income of Medical Practitioners
An inquiry into the national expenditure on health, published in 1954 by
the National Institute of Statistics and Economic Research \ contained the
following estimates of the aggregate income (including medical fees for treat1

Rapport sur les dépenses de santé, op. cit.

168

THE COST OF MEDICAL CARE

ment in public hospitals and those for treatment in private hospitals) of medical
practitioners liable to income tax. These estimates were made on the basis of
income-tax returns, increased by 50 per cent, to account for income-tax evasion.
(a) 1951.
The gross aggregate earnings of medical practitioners were estimated at
Frs. 73,128 million, or Frs. 1,731 per head of the population (42,238,000). This
is equivalent to 0.80 per cent, of the national income (Frs. 9,160,000 million)
or, per head of the population, 0.71 per cent, of the reference wage.
(b) 1952.
The gross aggregate earnings of medical practitioners were estimated at
Frs. 90,000 million, or Frs. 2,115.40 per head of the population (42,545,000).
This is equivalent to 0.87 per cent, of the national income (Frs. 10,310,000
million) or, per head of the population, 0.82 per cent, of the reference wage
(Fr. 258,752).
3. Cost of Medical Care Given in Hospitals under Sickness Insurance
(a) 1951.
Under short-term sickness insurance Frs. 2,343 million were spent on medical fees for treatment in public hospitals. If it is assumed that the patient paid
20 per cent, of the cost, Frs. 586 million should be added, making a total of
Frs. 2,929 million. Expenditure on long-term insurance was Frs. 362 million.
The total was thus Frs. 3,291 million, or Frs. 184.89 per head of the 17.8 million
persons protected. The latter figure represents 0.09 per cent, of the income per
head, or 0.08 per cent, of the reference wage.
(b) 1952.
Under short-term sickness insurance Frs. 2,913 million were spent on
medical fees in public hospitals. If it is assumed that the patient paid 20 per
cent, of the cost, the addition of one-quarter (20 per cent, of the total) makes a
total of Frs. 3,641 million. If the Frs. 519 million spent on long-term treatment are added, a total of Frs. 4,160 million, or Frs. 229.83 per person protected (18.1 million) is obtained. The latter figure represents 0.09 per cent, of
the income per head (Frs. 242,332) or 0.09 per cent, of the reference wage.
PHARMACEUTICAL SUPPLIES

1. Cost of Pharmaceutical Products Supplied under Insurance Schemes
(a) 1951.
The expenditure on drugs and preparations prescribed under short-term
sickness insurance was Frs. 23,954 million. To this amount one-quarter
(Frs. 5,989 million) is added to allow for the part of the cost borne by the
patient. If the expenditure under long-term sickness insurance is added
(Frs. 2,350 million) the total cost works out at Frs. 32,293 million, or
Frs. 1,814.21 per person protected (17.8 million), which represents 0.84 per cent.
of the income per head (Frs. 216,866) or 0.74 per cent, of the reference wage
(Frs. 243,776). Expenditure amounted to Frs. 26,304 million, or Frs. 1,477.75
per person protected, which represents 0.68 per cent, of the income per head or
0.61 per cent, of the reference wage.
The expenditure on drugs and preparations under the employment injury
insurance scheme amounted to Frs. 1,275 million.

APPENDIX: EXPLANATIONS OF CALCULATIONS

169

The cost of all pharmaceutical supplies was therefore Frs. 33,568 million.
This amount is equal to Frs. 1,885.84, viz. 0.87 per cent, of the income per head
or 0.77 per cent, of the reference wage, per person protected by the sickness
insurance scheme (including dependants and pensioners). The combined
expenditure of the sickness and employment injury insurance schemes per
person protected amounted to Frs. 1,549.38, that is to say, 0.71 per cent, of
the income per head and 0.64 per cent, of the reference wage.
(b) 1952.
Expenditure on drugs and preparations under short-term insurance
amounted to Frs. 31,155 million. If one-quarter is added to allow for costsharing the cost works out at Frs. 38,944 million. Expenditure under longterm sickness insurance was Frs. 3,099 million, bringing the total to Frs. 42,043
million, or Frs. 2,323 per perscn protected (18.1 million). The latter figure is
equivalent to 0.96 per cent, of the income per head (Frs. 242,332) or 0.90 per
cent, of the reference wage.
(c) 1953.
Expenditure on drugs and preparations under short-term sickness insurance
amounted to Frs. 35,069 million. To this amount one-quarter (Frs. 8,767
million) may be added as before to allow for cost-sharing. Expenditure under
long-term insurance was Frs. 3,283 million, bringing the total cost under
sickness insurance to Frs. 47,119 million. This represents Frs. 2,588.96 per
person protected (18.2 million) or 1.06 per cent, of the income per head
(Frs. 244,284), or 0.99 per cent, of the reference wage (Frs. 262,080). The
total expenditure of sickness insurance was Frs. 38,352 million, or Frs. 2,107.25
per person protected, which represents 0.86 per cent, of the income per head
and 0.80 per cent, of the reference wage.
Expenditure on drugs and preparations under the employment injury
insurance scheme amounted to Frs. 1,656 million.
The cost of all pharmaceutical supplies was therefore Frs. 48,775 million,
or Frs. 2,679.95 per person protected by the sickness insurance scheme. The
total cost of the supplies received under the two schemes was therefore 1.10
per cent, of the income per head and 1.02 per cent, of the reference wage.
The expenditure of the two schemes amounted to Frs. 2,198.24 per person protected, which represents 0.90 per cent, of the income per head and 0.84 per
cent, of the reference wage.
2. Pharmaceutical Expenditure in General1
(a) 1951.
On the basis of sales by wholesale firms and manufacturers of proprietary
medicines to pharmacies, and taking into account local taxes, the total turnover of pharmacies is estimated at Frs. 97,632 million. This is Frs. 2,311 per
head of the population (42,238,000), and represents 1.07 per cent, of the
national income (Frs. 9,160,000 million) or, per head, 0.95 per cent, of the
reference wage.
(b) 1952.
On the basis of income-tax assessment the turnover of pharmacies is estimated at Frs. 121,958 million, or Frs. 2,867 per head of the population
1

Rapport sur les dépenses de santé, op. cit. pp. 10 ff.

170

THE COST OF MEDICAL CARE

(42,545,000). The latter figure is equivalent to 1.18 per cent, of the national
income (Frs. 10,310,000 million) or, per head, 1.11 per cent, of the reference
wage (Frs. 258,752).
HOSPITAL CARE

1. Sickness Insurance
(a) 1951.
Expenditure on short-term hospital care (not including care at spas)
amounted to Frs. 33,480 million. Cost-sharing by the patient accounted for
Frs. 8,370 million, or 20 per cent, of the total. Expenditure on long-term
hospital care amounted to Frs. 14,013 million. The total cost was therefore
Frs. 55,863 million or Frs. 3,138.37 per person protected (17.8 million); the
latter figure is equivalent to 1.45 per cent, of the income per head (Frs. 216,866)
or 1.29 per cent, of the reference wage (Frs. 243,776).
(b) 1953.
Expenditure on short-term hospital care amounted to Frs. 47,885 million;
the share of the cost borne by the patient is estimated at Frs. 11,971 million.
Expenditure on long-term hospital care amounted to Frs. 22,446 million.
The total cost was therefore Frs. 82,302 million or Frs. 4,522.20 per person
protected (18.2 million); the latter figure is equivalent to 1.85 per cent, of the
income per head (Frs. 244,284) or 1.73 per cent, of the reference wage (Frs.
262,080).
2. Employment Injury Insurance
(a) 1951.
The expenditure of the employment injury insurance scheme on hospital
care was Frs. 2,303 million, or Frs. 129.38 per person protected, including all
persons protected under the sickness insurance scheme (whether insured
persons or dependants, etc.). The latter figure is equivalent to 0.06 per cent.
of the income per head or 0.05 per cent, of the reference wage.
(b) 1953.
Expenditure was Frs. 3,165.1 million, or Frs. 173.91 per person protected
by sickness insurance. The latter figure is equivalent to 0.07 per cent, of the
income per head and 0.07 per cent, of the reference wage.
3. Sickness and Employment Injury Insurance Combined
(a) 1951.
The cost of hospital care received being Frs. 55,863 million under sickness
insurance and Frs. 2,303 million under employment injury insurance, the
grand total was Frs. 58,166 million, or Frs. 3,267.75 per person protected.
The latter figure is equivalent to 1.51 per cent, of the income per head or 1.34
per cent, of the reference wage.
(b) 1953.
If the expenditure on hospital care in case of employment injury (Frs. 3,165.1
million) is added to the cost of hospital care received under sickness insurance
(Frs. 82,302 million) a total cost of Frs. 85,467.1 million, or Frs. 4,696 per
person protected, is arrived at. The latter figure is equivalent to 1.92 per cent.
of the income per head or 1.79 per cent, of the reference wage.

APPENDIX: EXPLANATIONS OF CALCULATIONS

171

4. Total Hospital Expenditure, Not Including Medical Fees Liable to Income Tax
(a) 1951.
Expenditure, both public and private, on treatment in hospitals was
estimated in the report of the National Institute of Statistics and Economic
Research 1 already referred to by adding to the receipts of public hospitals,
including hospital medical fees other than those liable to the tax on profits
made in non-commercial professions (Frs. 83,265 million), the estimated
income of private hospitals (Frs. 35,000 million) and expenditure in spas
(Frs. 2,691 million). The total thus computed comes to Frs. 120,956 million,
or Frs. 2,864 per head of the population (42,238,000). This amount represented 1.32 per cent, of the national income (Frs. 9,160,000 million) or, per
head, 1.17 per cent, of the reference wage.
(b) 1952.
Expenditure on care in public hospitals was estimated at Frs. 127,735
million, private hospital income at Frs. 40,000 million and expenditure on
care in spas at Frs. 3,303 million. The total was thus Frs. 171,038 million,
representing 1.66 per cent, of the national income (Frs. 10,310,000) or
Frs. 4,020 per head of the population (42,545,000), making, per head, 1.55 per
cent, of the reference wage (Frs. 258,752).
5. Cost of Hospital Care Provided under Sickness Insurance Schemes (Including
the Cost of Care in Spas)
(a) 1951.
The expenditure on care in spas under short-term sickness insurance was
Frs. 898 million; an addition of one-quarter (Frs. 225 million) to allow for
cost-sharing brings this amount up to Frs. 1,123 million.2 Expenditure on
spas under long-term sickness insurance was Frs. 205 million. The total cost
of spas was therefore Frs. 1,328 million. If this is added to the estimated cost
of hospital care (Frs. 55,863 million) a total of Frs. 57,191 million is arrived
at. This represents Frs. 3,213 per person protected, which is equivalent to
1.48 per cent, of the income per head or 1.32 per cent, of the reference wage.
(b) 1952.
Expenditure on short-term hospital care, including treatment at spas,
amounted to Frs. 43,909 million. If one-quarter (Frs. 10,977 million) is added
to allow for cost-sharing, a total of Frs. 54,886 million is arrived at. Expenditure
on long-term hospital care, including the cost of care in spas, amounted to
Frs. 20,029 million. The total cost was therefore Frs. 74,915 million. This
represents Frs. 4,139 per person protected, which is equivalent to 1.71 per
cent, of the income per head (Frs. 242,332) or 1.60 per cent, of the reference
wage.
6. Medical Fees for Treatment in Public Hospitals Payable under
Sickness Insurance
(a) 1951.
The fees paid to doctors under short-term sickness insurance in respect of
treatment given in public hospitals in 1951 amounted to Frs. 2,343 million.
1

Rapport sur les dépenses de santé, op. cit., pp. 13 ff.
* The actual cost is probably considerably higher, since insurance does not in
fact cover 80 per cent, of the real cost.

172

THE COST OF MEDICAL CARE

This sum may be increased by one-quarter (i.e. Frs. 586 million) to allow for
cost-sharing. The fees paid in respect of long-term sickness amounted to
Frs. 362 million. The total was therefore Frs. 3,291 million. This represents
Frs. 184.89 per head of the 17.8 million persons protected, which is equivalent to 0.09 per cent, of the income per head and to 0.08 per cent, of the
reference wage.
(b) 1952.
The fees paid to doctors under short-term sickness insurance in respect of
treatment given in public hospitals in 1952 amounted to Frs. 2,913 million.
This sum may be increased by one-quarter (i.e. Frs. 728 million) to allow for
cost-sharing. The fees paid in respect of long-term sickness amounted to
Frs. 519 million. The total was therefore Frs. 4,160 million, or Frs. 229.83
per head of the 18.1 million persons protected. The latter figure is equivalent
to 0.09 per cent, of the income per head and of the reference wage.
INCOMES OF MEDICAL PRACTITIONERS

1. The estimates are based on the assumption that the average number of
visits and consultations effected of a general practitioner is 6,000 a year, of
which 3,600 are consultations and 2,400 are visits.1
2. The weighted average of the insurance tariffs for 1953 was Frs. 322 per
consultation and Frs. 417 per visit for a general practitioner. 2 From these
amounts, 20 per cent, is deducted as representing the payment made by the
insured person. This leaves Frs. 258 for a consultation and Frs. 334 for a visit.
3. To the fee per consultation paid by the insurance scheme may be added
expenditure for minor surgery, amounting on an average to Frs. 134 per
consultation. To the fee for a visit by a general practitioner may be added an
average of Frs. 82 per visit for mileage costs. The total amount thus obtained is
Frs. 392 per consultation and Frs. 416 per visit for care by a general practitioner,
specialists being paid higher fees for both consultations and visits.
4. For the 3,600 consultations estimated to be given in a year, the sickness
insurance fund would thus have paid out Frs. 1,411,200, and for 2,400 visits
Frs. 998,400. The total expenditure for 6,000 consultations and visits would
have been Frs. 2,409,600. This is equivalent to 9.9 times the income per head
(Frs. 244,284), or 4.44 times the average income per economically active person.
5. On the other hand, a sample inquiry into the fees paid by patients to
general practitioners reveals that the average fee paid for a consultation was
Frs. 474 and that for a visit Frs. 598.3
6. These fees are assumed to include mileage costs and minor surgery. For
an average of 3,600 consultations and 2,400 visits per year, they would add up
to 3,141,600 francs a year, which is equivalent to 12.86 times the income per
head or 5.76 times the average income per economically active person.
7. On these assumptions the patient paid 23.30 per cent, of the cost.
1

This hypothesis has been adopted for France and Switzerland after consultation with the World Medical Association. It does not correspond to conditions in
Belgium or in England and Wales, where the average number of items of service per
person on the doctor's list is about five per year.
2
Bulletin de la Fédération nationale de la Mutualité française (Paris), No. 29,
Mar. 1954, p. 7.
3
See " Le Français face à la maladie ", in Semaine professionnelle et médicosociale (Supplement to La Semaine des hôpitaux (Paris)), 30th Year, No. 1,2 Jan. 1954.

APPENDIX: EXPLANATIONS OF CALCULATIONS

173

Federal Republic of Germany
PHARMACEUTICAL SUPPLIES

(a) 1951.
Expenditure on drugs, preparations and appliances amounted to D M
324.42 million, or 78.24 per cent, of the total expenditure (DM 414.64
million) shown in table D. Dentures accounted for DM 90.22 million. The
expenditure per insured person on pharmaceutical supplies only was D M 20.08
(16,155,940) and that per person protected (assuming there were 0.80 dependant per insured person) D M 11.16. The latter figure is equivalent to 0.60 per
cent, of the income per head (DM 1,870) and 0.40 per cent, of the reference
wage (DM 2,774). The expenditure per person protected on dentures amounted
to 0.17 per cent. oftheincomeperheadandO.il percent, of the reference wage.
(b) 1953.
Expenditure on drugs, preparations and appliances amounted to D M
425.82 million, viz. DM 25 per insured person (17,032,338) or, per person
protected (assuming there were 0.77 dependant per insured person), D M 14.12.
The latter figure is equivalent to 0.67 per cent, of the income per head and
0.48 per cent, of the reference wage. Dentures accounted for DM 103.32
million, viz. D M 6.07 per insured person or DM 3.43 per person protected.
This latter figure is equivalent to 0.16 per cent, of the income per head or
0.12 per cent, of the reference wage.
HOSPITAL CARE

1. Cost of Hospital Care (1953)
The total number of patient-days spent in all hospitals of the Federal
Republic of Germany in 1953 was 167.3 million. 1 This is equivalent to 3.41
days per head of the population (49,005,000).
The average cost per patient-day in a public hospital was DM 23.26 for
university hospitals, DM 14.36 for ordinary hospitals, and D M 8.29 for mental
institutions. 2 The number of beds in each of the three categories was 24,009,
192,456 and 59,251 respectively. If the cost per day is weighted according to
the number of beds in each category the average is D M 13.83 per day. For 3.41
days per head of the population, the cost would then be D M 47.16 per head per
year, representing 2.23 per cent, of the income per head (DM 2,117) or 1.60
per cent, of the reference wage (DM 2,945).3
2. Sickness Insurance (1953)
The number of patient-days of care per insured person provided in 1953
under the general sickness insurance scheme was as follows: 1.986 for insured
1
Wirtscheft und Statistik (Stuttgart, Statistisches Bundesamt), 7th Year, No. 1,
Jan. 1955, p. 24.
2
Ibid., 8th Year, No. 2, Feb. 1956, p. 92.
3
In 1956 the number of patient-days spent in all hospitals except those in West
Berlin was 176 million, making 3.466 days per head of the population (50,786,000).
The average cost was DM 15 per day. Expenditure per person was thus DM 52, that is
to say, 1.875 per cent, of the income per head for the whole of the Federal Republic,
including West Berlin (DM 2,773) or 0.93 per cent, of the average income per economically active person. These figures do not appear to include capital outlay. See
ibid., 9th Year, No. 12, Dec. 1957, p. 678.

174

THE COST OF MEDICAL CARE

persons in hospitals and 0.0755 for insured persons in convalescent homes and
similar institutions. For dependants the number of days in all institutions was
1.575 per insured person. The total number of days in medical establishments
was, therefore, 3.637 per insured person or 2.055 days per person protected
(assuming that there were 0.77 dependant per insured person).
On the assumption, made above, that the cost of hospital care for persons
protected by the sickness insurance scheme averaged D M 13.83 per day, the
cost of the 2.055 hospital days per person protected would have been DM 28.42.
This is equivalent to 1.34 per cent, of the income per head or 0.97 per cent, of
the reference wage. Of this, the sickness insurance schemes paid DM 17.20,
which is equivalent to 0.81 per cent, of the income per head or 0.58 per cent, of
the reference wage. Sickness insurance, therefore, would have covered 60.52
per cent, of the total cost of the hospital care received by the persons protected.
3. Cost of Mental Hospitals (1953)
The number of beds in all mental institutions was 85,630 1 which, if in use
365 days a year, would represent 31,254,950 bed-days. At a cost of DM 8.29
per bed-day, the total cost for all beds would be DM 259,103,536 a year or
D M 5.29 per head of the population. The latter figure is equivalent to 0.25 per
cent, of the income per head or 0.18 per cent, of the reference wage.

Italy
PHARMACEUTICAL SUPPLIES

(a) 1951.
The number of persons protected who were entitled to pharmaceutical
benefits was 9,483,336. Expenditure on such benefits amounted to 13,030.9
million lire, or 1,374.08 lire per person protected, which represented 0.82 per
cent, of the income per head (167,873 lire).
(b) 1953.
The number of persons protected who were entitled to pharmaceutical
benefit was 11,806,316. Expenditure on such benefits amounted to 21,657.8
million lire, or 1,834.42 lire per person protected, representing 0.95 per cent.
of the income per head (193,876 lire).
HOSPITAL CARE

1. Care Provided under Sickness and Tuberculosis Insurance
(a) 1952.
Expenditure on hospital care by the general sickness insurance scheme
amounted to 1,234 lire per person protected. The expenditure of the tuberculosis insurance scheme on treatment in its own sanatoria or in other institutions was 28,989 million lire or 1,449 lire per person protected (20 million).2
1

Wirtschaft und Statistik, 7th Year, No. 12, Dec. 1955, p. 604.
Istituto Centrale di Statistica: Annuario Statistico Italiano, 1954 (Rome), Series V,
Vol. 6, p. 333.
8

APPENDIX: EXPLANATIONS OF CALCULATIONS

175

If the persons protected by sickness insurance were also protected by tuberculosis insurance, the total expenditure was 2,683 lire per person protected
by the sickness insurance scheme. This amount represented 1.52 per cent.
of the income per head (176,228 lire) and 0.90 per cent, of the reference wage
(299,520 lire).
(b) 1953.
The expenditure of the general sickness insurance scheme was 1,340 lire
per person protected. The expenditure on sanatorium care of the tuberculosis
scheme amounted to 28,708 million lire, or 1,435.40 per person protected
against tuberculosis. The total expenditure was thus 2,775.40 lire, or 1.43 per
cent, of the income per head (193,876 lire), per person protected by the sickness insurance scheme.
2. Hospital Care in Generai
(a) 1952.
The expenditure of public hospitals (excluding outlay on construction)
totalled 115,464.9 million lire and that of sanatoria owned by tuberculosis
insurance was 15,942.8 million. The expenditure of private hospitals was
estimated at between one-third and one-fourth of that of public hospitals,
34,639.5 million lire if one assumes that it is 30 per cent. The total expenditure
on hospitals was thus 166,047.2 million lire, representing 1.99 per cent, of the
national income (8,340,000 million lire) ; per head of the population (47,325,000)
it was 3,508.66 lire or 1.17 per cent, of the reference wage (299,520 lire).
(b) 1954.
The expenditure of public hospitals (excluding outlay on construction) as
above was 122,196.3 million lire and that of the sanatoria owned by tuberculosis insurance 16,872.2 million. The expenditure of private hospitals is
estimated in the same way as for 1952 at 36,658.9 million lire. The total expenditure was thus 175,727.4 million lire, representing 1.81 percent, of the national
income (9,718,000 million lire); per head of population (47,785,000) it was
3,677.46 lire, representing 1.10 per cent, of the reference wage (335,764 lire).

Netherlands
MEDICAL PRACTITIONER CARE

(a) 1951.
The amount paid to specialists for hospital treatment not covered by
inclusive fees was 2.06 florins per person protected, the equivalent of 0.12
per cent, of the income per head (1,661 florins) and0.09 percent, of the reference wage (2,321 florins). The deduction of these percentages from those
shown in table C brings the expenditure down from 0.65 to 0.53 per cent.
of the income per head and from 0.46 to 0.37 per cent, of the reference
wage.
(b) 1953.
The amount paid to specialists for hospital treatment not covered by
inclusive fees was 2.36 florins per person protected, the equivalent of 0.13 per
cent, of the income per head (1,845 florins) and 0.10 per cent, of the reference

176

THE COST OF MEDICAL CARE

wage (2,471 florins). The deduction of these percentages from those shown in
table C brings the expenditure down from 0.70 to 0.57 per cent, of the income
per head and from 0.52 to 0.42 per cent, of the reference wage.

HOSPITAL CARE

(a) 1951.
The expenditure of the medical care insurance scheme on hospital care
shown in table E was 12.16 florins per person protected. Expenditure on
specialist care for hospitalised patients not included in the inclusive hospital
fees paid by the insurance scheme to the hospitals amounted to approximately
2.06 florins per person protected for compulsorily insured persons. 1 This
fee, however, appears to include some payments for surgery performed outside
hospital wards.
Under the supplementary hospital insurance scheme the funds reporting
spent 1.83 florins per person protected, including insurance for sanatorium
treatment, specialist care and hospitalisation. 2
This amount is added for every compulsorily protected person—although
not all of these had taken out supplementary insurance for hospital care—on
the assumption that it represents the average of the supplementary cost of
hospital care extending beyond the maximum benefit period. The total cost
of the care received by persons protected would then have been 16.05 florins
per person, representing 0.97 per cent, of the income per head (1,661 florins)
or 0.69 per cent, of the reference wage (2,321 florins).
(b) 1953.
The expenditure on hospital care under the sickness insurance scheme as
shown in table E was 14.12 florins per person protected; expenditure on specialist care in hospital not covered by the scheme amounted to 2.36 florins, and
the cost of supplementary insurance was 2.21 florins, per person protected.
If the assumptions taken as a basis for the calculations for 1951 are taken as
holding good for 1953 the total expenditure would therefore be 18.69 florins
per person protected. This represented 1.01 per cent, of the income per head
(1,845 florins) or 0.76 per cent, of the reference wage (2,471 florins).
INCOMES OF MEDICAL PRACTITIONERS

1. In 1953 the capitation fee was 5.46 florins between 1 January and 30 June
and 7 florins during the rest of the year. Extra charges were payable for persons
in isolated areas (these amounted to 0.14 florin per person protected), and
for persons aged over 65 years (amounting, per person protected, to 0.09
florin). The average for 1953 was therefore 6.46 florins, representing 0.35
per cent, of the income per head (1,845 florins).
2. In 1955, as from 1 October, the capitation fee was 10.20 florins for the
first 2,000 persons and 7.50 florins for each additional person on the doctor's
list. The former represented 0.49 per cent, of the income per head in 1955
(2,094 florins). The fee of 7.50 florins represents 0.36 per cent, of the income
per head. The percentages would probably be somewhat lower if calculated
in terms of the income per head in 1956.
1

Verslagen en Mededelingen betreffende de Volksgezondheid (The Hague, Staatsdrukkerij- en Uitgeverijbedrijf), year 1953, No. 11-12, Nov.-Dec. 1953, p. 778.
2
Ibid., p. 770.

APPENDIX: EXPLANATIONS OF CALCULATIONS

177

New Zealand
HOSPITAL CARE

1. Total Hospital Expenditure
(a) 1951-52.
The expenditure of hospital boards, including capital outlay (£13,763,000),
the expenditure, including capital outlay, of the institutions under the authority
of the Department of Health (£484,000), the expenditure, not including capital
outlay, of mental institutions (£2,289,000) and the payments of the social
security fund to private hospitals and approved institutions (£318,000)
amounted altogether to £16,854,000. Per head of the population this represented £8.66, that is to say, 2.73 per cent, of the income per head (£317) and
2.09 per cent, of the reference wage (£414). The expenditure per head of the
population on mental hospitals amounted to 0.37 per cent, of the income
per head or 0.28 per cent, of the reference wage. The capital outlay of hospitals
other than mental hospitals amounted, per head of the population, to 0.41 per
cent, of the income per head or 0.32 per cent, of the reference wage.
(b) 1953-54.
The expenditure of hospital boards amounted to £16,960,000; that of the
institutions under the authority of the Department of Health amounted to
£505,000; the expenditure of mental institutions totalled £2,511,000; and the
payments of the social security fund to private hospitals and approved institutions came to £298,000. The total expenditure was thus £20,274,000. This
represented £9.90 per head of the population (2,047,000); this amount represented 2.79 per cent, of the income per head (£355) or 2 per cent, of the
reference wage (£496). The expenditure on mental hospitals per head of the
population amounted to 0.35 per cent, of the income per head or 0.25 per cent.
of the reference wage, while the capital expenditure of hospitals other than
mental hospitals, per head of the population, amounted to 0.46 per cent, of the
income per head or 0.33 per cent, of the reference wage.

2. Out-Patient Care
(a) 1951-52.
The total number of out-patients treated at hospitals administered by
hospital boards or by the Department of Health was 585,921. The average
maintenance cost per out-patient was £1 5s. 7d. The expenditure on these
out-patients amounted to £749,491, representing per head of the population,
0.12 per cent, of the income per head or 0.09 per cent, of the reference wage.
(b) 1953-54.
The total number of out-patients treated at the same hospitals was 679,641
and the average maintenance cost per patient was £1 9s. lOd. The total expenditure was therefore £1,013,798 or, per head of the population, 0.14 per cent.
of the income per head or 0.10 per cent, of the reference wage.
3. Sources of Hospital Income (1953-54)
To the total expenditure of £20,274,000 the social security fund contributed £2,087,101, of which £175,338 was for out-patient care. Another
£61,434 was paid in respect of pharmaceutical benefits supplied by institutions.

178

THE COST OF MEDICAL CARE

The contribution of £97,138 to the consolidated revenue fund to be used for the
provision of subsidies for private hospitals is not included in this total.
The State contributed £10,269,000 over and above the expenditure of the
Department of Health on hospitals (£505,000) and on mental hospitals
(£2,511,000). The State also subsidised the social security fund to the extend
of about one-third of its income.
Hospital levies raised from local authorities brought in £1,660,000. These
levies are being gradually reduced and will be abolished in a few years' time.
Loans were also raised to finance capital expenditure.
DENTAL CARE

(a) 1951-52.
The dental hygiene division of the Department of Health spent £533,495 in
1951-52. If the expenditure of the social security scheme on dental benefits
(£469,989) is added, the total expenditure on dental benefits was £1,003,484,
or £0.515 per head of the population (1,947,000). The latter figure represented
0.16 per cent, of the national income (£617,400,000), or, per head of the
population, 0.12 per cent, of the reference wage (£414). If this expenditure is
related to the number of children under 16 years of age (these being the only
persons who are entitled to dental benefits)—who in 1951 constituted roughly
30 per cent, of the population—the expenditure per child works out at 0.53 per
cent, of the income per head or 0.40 per cent, of the reference wage.
(b) 1953-54.
The dental hygiene division of the Department of Health spent £538,942.
If this amount is added to the £663,950 spent on treatment by private dental
practitioners for persons enrolled under the social security dental benefit
regulations the total comes to £1,202,892 or £0.59 per head of the population
(2,047,000). The latter figure represented 0.17 per cent, of the income per head
(£355) and 0.12 per cent, of the reference wage (£496) spent on dental care for
children under 16 years of age. If the expenditure is related to the number of
children under 16 years of age (who, in 1953, constituted roughly 32 per cent.
of the population), the expenditure per child works out at 0.53 per cent, of the
income per head and at 0.38 per cent, of the reference wage.

Norway
HOSPITAL CARE

1. Operating Cost of Hospitals
(a) 1949.
The average cost per patient-day of care provided in public hospitals was
18 crowns for general hospitals, 12 crowns for tuberculosis institutions and
11 crowns for mental institutions. The three categories of institutions provided
respectively 5,102,000, 1,951,000 and 2,850,000 patient-days of treatment. 1 The
number of patient-days provided by all these institutions thus works out at
3.06 per head of the population (3,233,000). The total cost would thus have
been 146,598,000 crowns, or 1.22 per cent, of the national income (12,026 mil1
Samordning av de Nordiske Lands Statistikk, vedrorende den Sostale Lovgivning, op. cit., pp. 47-48.

APPENDIX: EXPLANATIONS OF CALCULATIONS

179

lion crowns) or, per head of the population, 45.34 crowns, that is to say,
0.96 per cent, of the reference wage (4,717 crowns). The average cost per
patient-day (not including interest, depreciation or capital expenditure) was
14.80 crowns.
(b) 1952-53.
The average cost per patient-day of care provided in public hospitals in 1953
was roughly 33 crowns for general hospitals, 20 crowns for tuberculosis institutions and similar establishments and 18 crowns for mental institutions.
In 1952 a total of 5,503,000 patient-days of care, or 1.654 days per head of
the population (3,327,000) were provided by general hospitals, 1,491,000 (or
0.448 per head of the population) at tuberculosis institutions and 2,953,000 (or
0.888 day per head of the population) by mental institutions.1 Thus a total
of 2.99 days of hospital care was supplied per head of the population.
If the average cost of care per patient-day in 1953 is taken as being valid for
1952, the total cost of these 2.99 days works out at 79.52 crowns. This amount
represents 1.59 per cent, of the income per head (4,988 crowns) or 1.10 per cent.
of the reference wage (7,227 crowns). These figures do not include care provided by maternity hospitals.
2. Cost of Hospital Care Provided Under Sickness Insurance
(a) 1949.
The sickness insurance scheme provided 4.09 days of hospital care (including care of dependants) per insured person. The number of days provided per
person protected was 2.17. The expenditure of the scheme amounted to 43.90
crowns per insured person or 10.73 crowns per patient-day. It is assumed that
days in mental institutions are not included in thesefiguresand that the number
of days spent in general hospitals and in tuberculosis hospitals respectively was
in the same proportion, for the persons protected by sickness insurance, as for
the whole country, that is 72.34 per cent, for general hospitals and 27.66 per
cent, for tuberculosis hospitals. On these assumptions 2.96 days per member
would have bejn spent in general hospitals and 1.13 days in tuberculosis
hospitals. The cost of these days at the average rates shown under 1 (a) above
would thus have been 53.28 and 13.56 crowns respectively for each of the two
types of institution, making a total cost per insured person of 66.84 crowns.
The expenditure of the sickness funds per patient-day amounted to 43.90
crowns. Thus the funds paid on the average 66 per cent, of the total cost of
providing hospital care for persons protected. Per person protected the full
cost of hospital care received under sickness insurance was 35.43 crowns, that
is to say, 0.95 per cent, of the income per head or 0.75 per cent, of the reference
wage. If the estimated cost, per head of the population, of treatment given in
mental hospitals (0.26 per cent, of the income per head) is added, the total is
1.21 per cent, of the income per head, i.e. a percentage similar to that for
hospital operating costs in general as estimated in 1 {a).
(b) 1952.
The sickness insurance scheme provided 3.45 days of hospital care (including care of dependants) per insured person or 1.82 days per person protected.
Expenditure on hospital care amounted to 71.44 crowns per insured person or
20.71 crowns per patient-day.
1
Statistical Reports of the Northern Countries: 2. Co-ordination of Social Welfare
Statistics in the Northern Countries, op. cit., pp. 56-57.

180

THE COST OF MEDICAL CARE

On the basis of the assumptions accepted in 2 '(a)' above, it is estimated
that 78.68 per cent, of the patient-days were spent in general hospitals and
21.32 per cent, in tuberculosis hospitals. On this assumption 2.71 days would
have been spent in general hospitals and, at a cost of 33 crowns a day, would
have cost 89.43 crowns per insured person; 0.74 day would have been spent
in tuberculosis institutions at a cost of 20 crowns a day and would have cost
14.80 crowns per insured person. The total cost would then be 104.23 crowns
per insured person. The expenditure of the sickness insurance scheme amounted to 71.44 crowns. Thus the scheme paid 68.54 per cent, of the cost of hospital
Care received by protected persons. The full cost of the hospital care received
by such persons would be 55.24 crowns per person protected (including
dependants), that is to say, 1.11 per cent, of the income per head or 0.76 per
cent, of the reference wage. If 0.32 per cent, of the income per head is
added to allow for the cost of treatment per head in mental institutions
(see under 1 (b)), the total is 1.43 per cent, of the income per head. This
may be compared to the total cost found for the whole country and all institutions (1.59 per cent, per head of the population).

TOTAL COST OF MEDICAL CARE

1. Private Expenditure

(1952)

The medical care insurance scheme covered about 80 per cent, of the
population during the period under review. The cost per person protected
of medical practitioner care in 1952 (including the share of the patient, estimated at 30 per cent.) was 0.56 per cent, of the income per head (see table C).
For the remaining 20 per cent, of the population it would then be 0.14 per
cent, of the income per head or 0.06 per cent, of the average income per economically active person.
Pharmaceutical costs are estimated, on the basis of the average cost as
calculated in Chapter II, at 0.25 per cent.; dental costs at 0.15 per cent, from
which 0.04 per cent, is deducted as being included in the public expenditure
on dental care for children, leaving 0.11 per cent. The total would then be
0.42 per cent, of the average income per economically active person.
Private expenditure on medical care in Norway may also be estimated on
the basis of the private expenditure of a family of four insured persons in Oslo. 1
This was 192 crowns in 1952 or 48 crowns per person. The cost per person
represented 0.96 per cent, of the income per head or 0.41 per cent, of the
average income per economically active person. The latter percentage is
practically the same as that found by the first method. It is somewhat overstated in that it relates to the capital city, but possibly understated in that
it assumes three dependants for each economically active person.

2. Cash Sickness Benefit

(1952)

The expenditure of public funds on cash sickness benefit was 55,352,000
crowns and that on family cash benefit 3,775,000 crowns. The total was
59,127,000 crowns, representing 0.36 per cent, of the national income (16,596
million crowns).
1

Statistical Reports of the Northern Countries: 1. Cost of Living and Real Wages
in the Capitals of the Northern Countries, op. cit., p. 61.

APPENDIX: EXPLANATIONS OF CALCULATIONS

181

Switzerland
HOSPITAL CARE

1. Operating Cost of Hospitals
(a) 1950.
The total number of days of hospital care provided in Switzerland in 1951
was 20,853,000, or 4.44 per head of the population (4,694,000).» The average
cost of care per patient-day in the hospitals covered by the statistics published
was Frs. 13.64.2 The cost of hospital care per head of the population (not
including capital expenditure for contruction purposes) would thus have
been Frs. 60.56. The latter figure represents 1.57 per cent, of the income per
head (Frs. 3,869) or 1.16 per cent, of the reference wage (Frs. 5,208).
(b) 1953.
The total number of days of hospital care provided in 1953 was 21,060,000,
or 4.32 per head of the population (4,877,000). The average cost of care per
patient-day in the reporting hospitals was Frs. 16.81. 3 The cost of hospital
care per head of the population would thus have been Frs. 72.62. The latter
figure represents 1.70 per cent, of the income per head (Frs. 4,271) or 1.27
per cent, of the reference wage (Frs. 5,700).
2. Social Insurance Expenditure on and Cost of Hospital Care for Persons
Protected by Sickness Insurance

(a) mo.
The total number of days of hospital care provided under the 555 reporting
schemes was 2.317 per person protected, of which 0.817 were given in tuberculosis establishments and 1.50 in other institutions. The average cost per
patient-day of care given in tuberculosis establishments reporting their costs
was Frs. 12.06, and that of care given in general hospitals with more than 75
beds Frs. 16.13.2 If these figures are taken as a basis for estimating the full
cost per person protected of the hospital care received under sickness insurance,
this cost works out at Frs. 9.85 for tuberculosis hospitals and Frs. 24.20 for
other hospitals, making a total of Frs. 34.05. This is 0.88 per cent, of the
income per head and 0.65 per cent, of the reference wage.
If the average cost per day of all hospitals reporting (viz. Frs. 13.64) is
taken as the basis for calculation the cost of hospital care per person protected
works out at Frs. 31.60, which represents 0.82 per cent, of the income per
head and 0.61 per cent, of the reference wage.
(b) 1953.
The total number of days of hospital care provided per person protected
was 2.106 of which 0.615 were given in tuberculosis sanatoria and 1.491 in
other institutions. The cost of care in reporting hospitals was Frs. 13.46
per day for tuberculosis sanatoria and Frs. 18.82 for general hospitals with
more than 75 beds. The cost of Fr. 0.615 per day in a sanatorium would thus have
been Frs. 8.28 per person protected and the cost of 1.491 days in other
establishments Frs. 28.06; the total cost of hospital care would have been
Frs. 36.34 per person protected. This figure represented 0.85 per cent, of
1

Annuaire statistique de la Suisse, 1954 (Berne, Bureau fédéral de statistique), p. 487.
* Revue Veska, 16th Year, No. 11, Nov. 1952, p. 560.
8
Ibid., 19th Year, No. 11, Nov. 1955, p. 690.

182

THE COST OF MEDICAL CARE

the income per head and 0.64 per cent, of the reference wage. Calculated on
the basis of the average cost per day of all reporting hospitals (Frs. 16.81) the
cost of the days received under sickness insurance would have been Frs. 35.40,
which is 0.83 per cent, of the income per head or 0.62 per cent, of the
reference wage.
INCOMES OF MEDICAL PRACTITIONERS

1. Tariff of Swiss Employment Injury Insurance Institution (1954)
The institution paid Frs. 7.25 for the first consultation and Frs. 5.80 for
each subsequent consultation, and Frs. 10.15 for the first visit and Frs. 8.70
for each subsequent visit. The average fees are estimated by the I.L.O. to be
Frs. 6.50 per consultation and Frs. 9.50 per visit. For 6,000 items of care,
of which 3,600 would be consultations, the gross income would then be
Frs. 23,400 for consultations and Frs. 22,800 for visits, or altogether Frs. 46,200
a year, representing Frs. 10.23 times the income per head (Frs. 4,516).
2. Tariff of Geneva Sickness Funds (1955)
The agreement of 1955 with the medical association provides for a fee of
Frs. 5 per consultation and Frs. 7.50 for a visit, plus extra payments for special
treatments. The medical practitioner may charge a supplementary fee to the
well-to-do patient. At the above fees, the gross income for 6,000 items of care,
of which 3,600 were consultations, would amount to Frs. 36,000, representing
7.69 times the income per head (Frs. 4,680).

United States
HOSPITAL CARE

1. Private Expenditure of In-Patients on Treatment
According to data published in the report of the President's Commission
on the Health Needs of the Nation1, the private expenditure which a family
of four persons (including two children) would incur, were it to make the average
use of the medical services experienced under the Kaiser " Permanent "
Health Plan in 1949-50, would be $34.65 for physicians' care in hospital, as
compared to other hospital expenditure of S53.22. On the other hand, estimated expenditure on physicians' services in hospitals constituted 40 per cent.
of the total cost of physicians' services, which was $86.79 for a family of four
persons. (It may be recalled that the same proportion was found for Saskatchewan.) Forty per cent, of private expenditure on physicians' services (shown
in table C) for 1951—0.92 per cent, of the income per head or 0.57 per cent.
of the reference wage—is 0.37 per cent, and 0.23 per cent, respectively.
For the purposes of the estimates which follow it is assumed that 40 per
cent, of the private expenditure on physicians' services shown in table C is
for hospital treatment, and that amount is added to the expenditure of all
hospitals. The cost of medical treatment given in hospital by medical staff
is included in the total expenditure (shown in table E), a considerable proportion of the medical men working for hospitals being employed full time.
1
Building America's Health, Vol. IV: Financing a Health Program for America,
op. cit., pp. 363 ff.

APPENDIX: EXPLANATIONS OF CALCULATIONS

183

2. Operating Expenditure of Hospitals
(a) 1951.
The total operating expenditure of all hospitals in 1951 was 53,912,596,000,
or 1.41 per cent, of the national income ($277,000 million). Per head of the
population (154,360,000) the expenditure was $25.35, or 0.87 per cent, of the
reference wage ($2,912).
(b) 1953.
The total operating expenditure of all hospitals in 1953 was $4,765,063,000,
or 1.56 per cent, of the national income ($305,000 million). Per head of the
population (159,629,000) the expenditure was $29.85, or 0.93 per cent, of the
reference wage ($3,203).
3. Operating Cost of Hospitals
(a) 1951.
Private expenditure on physicians' services amounted to $2,562 million.
If 40 per cent, of this is assumed to represent expenditure by patients on
doctors' fees for care in hospitals (see 1 above) an amount of $1,024,800,000
must be added to the operating expenditure of hospitals ($3,912,596,000) as
estimated in 2 (a) above, making a total of $4,937,396,000, or 1.78 per cent.
of the national income. This amount is equivalent, per head of the population,
to $31.99, or 1.10 per cent, of the reference wage.
(b) 1953.
Private expenditure on physicians' services amounted to $2,859 million.
If 40 per cent, of this amount ($1,143,600,000) is added to the operating
expenditure of hospitals as estimated in 2 (b) above ($4,765,063,000) a total
of $5,908,663,000, or 1.94 per cent, of the national income, is obtained. Per
head of the population the cost was thus $37.01, or 1.16 per cent, of the
reference wage.
4. Total Cost of Hospital Care
(a) 1951.
The sum of $917 million, or 0.33 per cent, of the national income, was
spent on construction. 1 This is equivalent to $5.94, or 0.20 per cent, of the
reference wage, per head of the population. The total cost of hospitals was
thus $5,854,396,000, or 2.11 per cent, of the national income, or, per head
of the population, $37.93, which is 1.30 per cent, of the reference wage. The
cost of out-patient care is included in these figures.
(b) 1953.
In 1953-54 expenditure on hospital construction amounted to $682 million,2
or 0.22 per cent, of the national income. This is equivalent to $4.27, or 0.13
per cent, of the reference wage, per head of the population. The over-all cost
of hospitals was thus $6,590,663,000, or 2.16 per cent, of the national income,
or, per head of the population, $41.29, which is equivalent to 1.29 per cent.
of the reference wage.

1
Building America's Health, Vol. IV: Financing a Health Program for America,
op. cit., pp. 274 ff. The American Hospital Association estimated that the amount
involved was 8947 million.
- Information obtained from the American Hospital Association.

184

B. NATIONAL
BELGIUM
POPULATION, NATIONAL INCOME, AND EXPENDITURE OF SICKNESS AND
Expenditure of sickness and invalidity
Year

1950
1951
1952
1953
1954
1955

Medical practitioner 1

Pharmaceutical '

Hospital 3

564,364,882
616,268,562
613,972,651
605,343,177
620,190,929
646,380,798

662,943,300
794,779,044
750,027,654
732,883,866
785,079,406
902,953,864

887,457,515
1,025,176,839
1,194,051,793
1,140,467,770
1,230,319,895
1,266,971,204

Sources: Expenditure: Ministère du Travail et de la Prévoyance sociale, Fonds National d'Assurance MaladieInvalidité: Rapport général sur l'année sociale (years 1951 to 1955). Part 4: Rapport statistique. Population and
national income: United Nations: Monthly Bulletin of Statistics, op. cit., Oct. 1957.
1
a
Expenditure on consultations, visits, etc.
* Not including medicines for hospitalised patients.
Expenditure
on maintenance, nursing, pharmaceutical supplies, surgery and other medical treatment, also treatment for cancer,
tuberculosis, poliomyelitis, etc. * Expenditure on consultations of dentists, dental prostheses and other dental care. . 5 Includes
special therapies.

185

STATISTICS
BELGIUM
INVALIDITY INSURANCE ON MEDICAL BENEFITS, BY TYPE OF CARE, 1950-55
insurance scheme on benefits (in francs)
Dental *

Other '

Total

164,839,600
158,058,104
147,020,560
146,054,357
159,317,150
174,310,018

702,094,703
726,417,451
810,927,342
801,850,830
877,883,675
976,912,304

2,981,700,000
3,320,700,000
3,516,000,000
3,426,600,000
3,672,791,055
3,967,528,188

Population
(in
thousands)

National
income
(in millions
of francs)

Year

8,639
8,678
8,730
8,778
8,819
8,868

275,800
314,500
323,900
334,700
348,900
368,300

1950
1951
1952
1953
1954
1955

186
CANADA
EXPENDITURE OF SWIFT CURRENT REGION MEDICAL CARE SCHEME AND OF
SASKATCHEWAN HOSPITAL SERVICE PLAN ON MEDICAL BENEFITS PER PERSON
PROTECTED, AND POPULATION AND NATIONAL INCOME OF CANADA, 1947-55
Expenditure, per person protected, of services listed
on medical benefits (in dollars)

Population and
national income
(Canada)

Swift Current region scheme
Year
Physicians' services
Within
region

Outside
region

1947
1948
1949
1950
1951
1952
1953
1954
1955

8.85
8.87
9.32
9.36
9.54
9.71
9.73
9.82

Out-patient
services

—
1.78
0.78
0.73
0.78
0.86
0.90
0.80

Saskatchewan
Hospital
Services
Plan

Population
(in
thousands)

National
income
(in millions
of Ss)

12,888
13,167
13,447
13,712
14,009
14,430
14,781
15,195
15,601

10,985
12,560
13,194
14,550
17,138
18,221
19,043
18,845
20,535

8.92
11.11
13.30
15.27
17.22
18.42
19.69
20.42
23.14

0.92
0.91
1.02
1.04
1.52
1.51
1.46
1.38

Sources: Expenditure: Swift Current region, Province of Saskatchewan: annual reports of the Department os
Public Health. Saskatchewan hospital services: Province of Saskatchewan, Department of Health: annual reportf
of the Saskatcbewan Hospital Services Plan. Population and national income: United Nations: Monthly Bulletin of
Statistics, Nov. 1954 and Jan. 1957.

CHILE
EXPENDITURE OF WORKERS' SICKNESS AND MATERNITY INSURANCE
SCHEME ON MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION AND
NATIONAL INCOME, 1943-51
Year

1943
1944
1945
1946
1947
1948
1949
1950
1951

. . . .

Expenditure of insurance
scheme on medical
benefits
(in millions of pesos)

231.5
266 4
308 1
370.6
490.4
526.4
607.2
864.4
1,093.2

Population
(in thousands)

5,199
5,273
5,349
5,430
5,526
5,621
5,712
5,809
5,912

National income
(in millions of pesos) *

32,035
36,975
42,470
49,070
62,605
76,561
93,800
110,758
145,100

Year

1943
1944
1945
1946
1947
1948
1949
1950
1951

Sources: Expenditure: República de Chile, Caja de Seguro Obligatorio: Anuario Estadístico 1951. Population:
United Nations: Monthly Bulletin of Statistics, Jan. 1955. National income: Idem, Statistical Papers, Series H, No. 6;
Monthly Bulletin of Statistics, June 1956.
'Population: 1952: 5,931,000; 1953: 6,072,000; 1954: 6,597,000; 1955: 6,761,000. ! National income: 1952: 190,500
million pesos; 1953; 266,600 million; 1954: 456,900 million; 1955: 739,400 million.

187

DENMARK
EXPENDITURE OF SUBSIDISED VOLUNTARY SICKNESS INSURANCE
ON MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION AND NATIONAL
INCOME, 1938 AND 1945-55
Expenditure of subsidised voluntary sickness insurance scheme on medical benefits
(in thousands of crowns)
Year
General
practitioner Specialist

1938
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

.
.
.
.
.
.
.
.
.
.
.
.

19,879
28,714
32,156
38,460
39,584
42,513
43,989
50,297
57,641
72,887
73,645
75,917

2,967
4,902
5,511
6,675
7,153
8,296
8,840
10,375
11,087
10,831
12,501
14,406

Pharmaceutical

Hospital

Dental

Other

Total

9,066
14,160
14,996
15,215
16,835 .
18,311
19,987
19,359
18,874
21,950
24,070
26,319

14,198
20,352
20,911
21,177
22,460
24,385
25,808
27,790
30,503
32,413
34,043
35,529

1,207
6,072
6,154
7,177
7,717
8,259
8,235
11,435
12,412
13,016
14,897
16,930

7,714
13,920
16,578
16,287
17,104
17,847
18,945
19,797
22,419
23,421
23,653
27,746

55,031
88,120
96,306
104,991
110,853
119,611
125,804
139,053
152,936
174,518
182,809
196,847

Popula- National
income
tion
(in
(in
thousands) millions of
crowns)

3,777
4,045
4,101
4,146
4,190
4,231
4,270
4,304
4,334
4,364
4,406
4,439

6,385
11,968
13,260
14,580
15,809
16,678
18,854
20,558
21,652
22,484
22,879
23,600

Sources: Expenditure: (1) Beretning fra Direkteren for Sygekassevaesenet i Henhold til Folkeforsikringslovens § 29,
stk. 4 om Statens Tilsyn med anerkendte Sygekasser og Fortsaettelsessygekasser (statskontrolerede Sygeforeninger) m.v.
samt om Bestyrelsen af Invalideforsikringsfonden i Aret (Copenhagen, 1946, 1952, 1953, and 1954-55); (2) Sociali Tidsskrift,
30th Year, Nos. 1-9, Jan.-Feb. 1954, pp. 31 to 43. Sygeforsikringen, 1938, 1945, 1947 to 1951. Population: United Nations:
Monthly Bulletin of Statistics, June 1954, Jan. 1955 and Jan. 1957. National income: Idem: Statistical Papers, Series H ,
Nos. 5, 6 and 10.

188

ENGLAND
EXPENDITURE OF NATIONAL HEALTH SERVICE, AND
UNITED KINGDOM: POPULATION, GROSS NATIONAL PRODUCT
England and Wales: expenditure of National
(in thousands
Year

1949-50
1950-51
1951-52
1952-53
1953-54
1954-55
1955-56

. . .
.
.
.
.
.
.

Pharmaceutical

Hospital

Dental

General
practitioner
(=cost)

Expenditure

Cost

Expenditure

Cost

Expenditure

Cost

41,643
42,072
42,123
75,631
51,719
52,598
54,978

31,515
34,810
45,330
42,887
39,826
42,979
44,678

31,515
34,810
45,330
47,637
46,226
48,979
51,478

210,240
226,196
241,725
252,467
258,586
274,175
300,632

213,240
229,196
244,669
255,926
262,288
278,023
304,564

42,628
40,337
31,434
22,089
21,479
23,618
28,888

42,628
40,337
33,000
27,589
27,979
30,518
36,188

Sources: Expenditure and cost: Ministry of Health: annual reports of the Ministry of Health, Part I. 1. The National
Health Service (London, H.M. Stationery Office). Population and gross national product: United Nations: Monthly
Bulletin of Statistics, Jan. 1955 and Aug. 1956. National income: Idem, Jan. 1957.
1
Calendar year corresponding to fìrst year of financial period.

189

AND WALES
COST OF CARE RECEIVED, BY TYPE OF CARE, 1949-55
AT FACTOR COST AND NATIONAL INCOME, 1949-55
Health Service and cost of care received

United Kingdom

of£s)

Other

Total

Expenditure

Cost

Expenditure

Cost

Population
(in
thousands)

72,974
67,585
64,388
72,926
77,326
81,659
79,879

72,974
67,585
68,878
79,217
84,788
84,882
87,792

399,000
411,000
425,000
466,000
448,936
475,029
509,055

402,000
414,000
434,000
486,000
473,000
495,000
535,000

50,363
50,616
50,557
50,722
50,857
50,785
50,968

Gross
national
product at
factor cost
(in millions
of£s)

National
Income
(in
millions of
£s)

10,970
11,545
12,715
13,738
14,796
15,769
16,634

10,110
10,626
11,630
12,627
13,490
14,482
15,226

Year

1949-50
1950-51
1951-52
1952-53
1953-54
1954-55
1955-56

190

FRANCE
EXPENDITURE OF SICKNESS INSURANCE SCHEME FOR NON-AGRICULTURAL
EMPLOYEES ON MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION
AND NATIONAL INCOME, 1947-55
Expenditure of sickness insurance scheme on medical benefits
(in millions of francs)
Year

1947
1948
1949
1950
1951
1952
1953
1954
1955

.
.
.
.
.
.
.
.
.

Medical
practitioner

Pharmaceutical

Hospital

Dental

Other

6,766
11,221
15,144
17,817
25,089
29,288
32,312
35,617
39,754

4,982
8,990
14,233
19,655
28,492
36,812
40,984
46,050
53,767

7,149
16,200
30,031
39,406
47,495
62,614
70,331
78,355
85,502

3,145
4,772
5,427
6,570
8,677
10,612
10,901
11,897
12,983

1,878
3,454
5,113
6,749
8,349
10,160
10,896
11,630
12,885

Total

23,920
44,637
69,948
90,197
118,102
149,486
165,424
183,529
204,891

National
Population
income
(in
(in 000 milthousands) lion francs)

41,617
42,115
41,602
41,944
42,238
42,545
42,860
42,844
43,300

3,303
5,430
6,539
7,117
9,160
10,310
10,470
11,510
12,440

Sources: Expenditure: Ministère du Travail et de la Sécurité sociale: Rapport sur l'Application de la Législation de
Sécurité sociale (published yearly in Journal officiel de la République française) ; International Social Security Association,
Xllth General Meeting (Mexico City, Nov.-Dec. 1955), Report II: Sickness Insurance (Geneva, 1956). Population and
national income: United Nations: Monthly Bulletin of Statistics, Jan. 1955 and June 1956.

191

FEDERAL REPUBLIC OF GERMANY
EXPENDITURE OF GENERAL SICKNESS INSURANCE SCHEME ON MEDICAL
BENEFITS PER INSURED PERSON BY TYPE OF CARE, AND POPULATION AND
NATIONAL INCOME, 1937 AND 1949-55
Expenditure of sickness insurance scheme on medical benefits,
per insured person
(in DM)
Year

Medical
practitioner

Pharmaceutical
and
dentures

Hospital

Dental
(conservative)

Other

Total

National
Population
income
(in
(in
milthousands) lions000
of DM)

1937 1

17.25

8.39

12.06

4.82

0.65

43.17

67,831

79.8 a

1949

23.47

23.97

19.74

5.97

0.91

74.06

46,778

63.1

1950

26.19

22.21

22.48

6.38

1.09

78.35

47,519

71.5

1951

30.13

25.66

24.84

7.56

1.33

89.52

48,079

89.9

1952

34.63

28.96

27.75

8.44

1.58

101.36

48,478

98.1

1953

38.17

31.07

30.44

9.10

1.71

103.7

40.92

31.01

31.31

10.44

1.84

110.49
115.52

48,994

1954

49,516

1955

44.82

32.81

32.98

11.56

1.99

124.16

49,995

112.3
126.2

Sources : Expenditure : Bundesministerium für Arbeit : Die soziale Krankenversicherung im Jahre.... (Bonn). Population :
United" Nations : Monthly Bulletin of Statistics, Jan. 1957. National income: United Nations, Statistical Papers, Series H,
Nos. 9 and 10.
1
German Reich; figures in Reichsmarks.
* 1938.

192
ITALY
EXPENDITURE OF GENERAL SICKNESS INSURANCE SCHEME ON
MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION AND
NATIONAL INCOME, 1946-55
Expenditure of general sickness insurance scheme on medical benefits
(in millions of lire)
Year
Specialist
General
practitioner (¡nel. dental)

1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

.
.
.
.
.
.
.
.
.
.

916.7
2,548.2
5,093.1
7,234.9
7,620.9
10,744.2
13,095.2
16,977.5
19,848.2
23,632.6

1,000.9
4,279.5
5,664.7
6,468.7
7,635.8
8,645.4
9,723.9
11,432.1
12,867.3
13,944.6

Pharmaceutical

Hospital

Other

Total

1,779.1
3,741.1
11,544.9
10,442.6
9,855.6
13,030.9
17,646.3
21,657.8
23,707.9
27,544.6

2,381.0
6,548.6
12,079.3
13,910.7
14,401.2
16,630.9
18,621.4
22,226.3
24,825.0
28,458.4

365.7
1,193.5
1,936.3
1,886.2
2,049.2
2,593.5
2,689.1
3,050.3
3,287.7
3,375.9

6,443.4
18,310.9
36,318.3
39,943.1
41,562.7
51,644.9
61,775.9
75,344.0
84,536.1
96,956.1

Popula- National
income
tion
(in 000
(in
thousands) million
lire)

45,287
45,664
46,004
46,307
46,603
46,988
47,325
47,551
47,785
48,001

5,178
5,943
6,227
6,866
7,888
8,340
9,219
9,718
10,600

Sources: Expenditure: Istituto nazionale per l'Assicurazione contro le Malattie: Annuario statistico for the years
1949-54 (Rome, Istituto poligrafico dello Stato); Bilancio consuntivo and Bollettino Statistico for the same years;
International Social Security Association, Sickness Insurance, op. cit. Population: United Nations, Monthly Bulletin of
Statistics, June 1956. National income: Ibid., June 1956 and Jan. 1957.

MEXICO
EXPENDITURE OF SICKNESS AND MATERNITY INSURANCE SCHEME ON
MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION AND
NATIONAL INCOME, 1950-53
Expenditure of sickness and maternity insurance scheme on
medical benefits
(in pesos)
Year

1950.
1951 .
1952.
1953.

.
.
.
.

Medical care
(other than
pharmaceutical
and hospital)

Pharmaceutical
(incl. hospital
supplies)

Hospital (incl.
transport of
sick)

Total

45,924,158
60,116,773
69,838,978
71,763,797

43,151,695
58,330,370
74,281,153
69,292,657

12,753,751
16,189,817
19,730,843
22,624,075

101,829,603
134,636,960
163,850,973
163,680,529

Population
(in
thousands) 1

National
income *
(in millions
of pesos)

25,791
26,332
26,922
28,053

37,816
46,800
52,000
50,200

Sources: Expenditure: figures supplied by the Mexican Social Insurance Institute. Population: United Nations:
Monthly Bulletin of Statistics, Jan. 1955. National income: Idem: Statistical Papers, Series H, Nos. 6 and 9.
1
1954: 28,853,000 inhabitants; 1955: 29,679,000 inhabitants.
» 1954: 59,180 million; 1955: 74,760 million pesos.

193

NETHERLANDS
EXPENDITURE OF COMPULSORY MEDICAL CARE INSURANCE
SCHEME PER PERSON PROTECTED BY TYPE OF CARE, AND
POPULATION AND NATIONAL INCOME, 1943 AND 1945-55
Expenditure of compulsory medical care insurance scheme on
medical benefits per person protected
(in florins)
Year

1943.
1945.
1946.
1947.
1948.
1949.
1950.
1951 .
1952.
1953.
1954.
1955.

General
practitioner

Specialist
(incl.
part of
hospital
care)

Pharmaceutical

Hospital
(incl.
sanatoria)

Dental

Other

Total

3.24
4.01
4.74
4.70
4.73
5.01
5.21
5.56
5.70
6.41
7.13
9.19

1.73
1.83
2.69
3.03
3.35
4.07
4.86
5.24
5.53
6.43
6.82
8.63

2.83
3.05
3.78
4.16
4.72
5.09
5.51
6.26
6.35
6.41
6.62
7.74

3.36
3.27
4.79
6.28
7.49
8.32
10.06
12.16
13.16
14.12
15.30
16.69

1.12
0.68
0.99
1.55
1.76
2.00
2.23
2.53
2.64
2.88
3.13
3.58

0.85
0.84
1.40
1.50
1.78
1.95
1.89
1.91
1.48
1.64
1.79
2.67

13.13
13.68
18.39
21.22
23.83
26.44
29.76
33.66
34.86
37.89
40.79
51.48

Population
(in thousands)

National
Income
(in
millions
of
florins)

9,102
9,262
9,423
9,629
9,800
9,956
10,114
10,264
10,382
10,493
10,615
10,751

5,635
4,170
9,326
11,251
12,887
14,112
15,624
17,050
17,700
19,360
21,360
23,780

Sources: Expenditure: Verslagen en Mededelingen Betreffende de Volksgezondheid (Staatsdrukkerii en Uitgeverijbedrijf). Nos. 10, 11 and 12, 1954 (table 9); Nos. 10, 11, 12, 1955; Nos. I, 2 and 12, 1957. Population: United Nations:
Monthly Bulletin of Statistics, Nov. 1954 and Jan. 1957. National income: Idem: Statistical Papers, Series H, No. 5;
Monthly Bulletin of Statistics, Nov. 1954 and Jan. 1957.

194
NEW ZEALAND
EXPENDITURE OF THE SOCIAL SECURITY FUND ON MEDICAL BENEFITS BY
TYPE OF CARE, TOTAL HOSPITAL EXPENDITURE AND POPULATION AND
NATIONAL INCOME, 1943 AND 1945-55
(Expenditure of the social security fund on medical benefits

(in is)

Year

General
practitioner Pharmaceutical
and some
specialist

1943-44
1945-46
1946-47
1947-48
1948-49
1949-50
1950-51
1951-52
1952-53
1953-54
1954-55
1955-56

1,179,331
1,427,309
1,760,574
2,167,826
2,306,881
2,524,290
2,661,166
2,760,583
3,047,202
3,085,749
3,350,180
3,548,080

762,198
1,133,366
1,439,686
1,558,350
1,793,159
2,043,843
2,097,000
2,428,216
3,015,833
2,919,620
3,047,331
4,039,145

Hospital
incl. outpatient

Dental (for
children^

2,158,146
2,173,460
1,986,288
1,949,489
1,997,375
2,011,649
2,018,963
2,112,494
2,135,218
2,184,239
3,411,040
4,764,666

105,109
223,186
324,933
385,612
469,989
545,002
659,570
716,251
798,756

Total social
security
expenditure
(net)

4,726,680
5,536,564
6,191,196
6,973,858
7,843,634
8,425,698
8,692,193
9,363,777
10,424,564
10,601,761
12,584,435
15,541,588

Total
hospital
expenditure
(in thow
sands of
£s)

8,152
8,656
9,668
11,389
12,185
13,810
16,854
18,863
20,274
22,117
24,023

Population x
(in thousands)

National
income
(in
millions
of is)

1,633
1,688
1,759
1,797
1,833
1,871
1,908
1,947
1,995
2,047
2,093
2,136

324.6
346.2
365.9
410.2
419.4
481.0
607.4
617.4
646.4
727.0
802.0
846.0

Sources: Expenditure: New Zealand, Department of Health: Annual Reports of the Director-General of Health
(Wellington). Population: United Nations: Monthly Bulletin of Statistics, Jan. 1955 and Jan. 1957. National income:
Idem: Statistical Papers, Series H, Nos. 6, 7, 8 and 10.
1
Calendar year (first of financial period).

NORWAY
EXPENDITURE OF PUBLIC SICKNESS INSURANCE FUNDS ON MEDICAL
BENEFITS BY TYPE OF CARE PER INSURED PERSON, AND POPULATION AND
NATIONAL INCOME, 1939 AND 1945-55
Expenditure of public sickness insurance funds on medical benefits
per insured person
(in crowns)
Year

1939.
1945.
1946.
1947.
1948.
1949.
1950.
1951 .
1952.
1953.
1954.
1955.

.
.
.
.
.
.
.
.
.
.
.
.

Medical
practitioner

Physiotherapy,
Pharmaceutical

Hospital

Transport
of doctors
and patients

15.51
21.16
22.60
23.80
24.03
28.58
30.60
31.20
36.61
43.06
44.53
46.19

2.38
3.59
4.35
4.90
5.62
5.56
5.74
5.60
6.11
6.50
8.46
9.06

19.48
24.25
27.38
35.83
43.19
43.90
50.56
61.12
71.44
82.09
87.25
89.85

3.52
7.77
9.02
9.79
10.19
11.21
12.28
13.13
15.09
16.18
17.11
17.93

Other
(dental)

Total

1.78
0.86

42.67
57.63
63.35 1
75.16
83.91
90.17
100.13
112.07
130.32
149.45
159.60
165.34

0.84.
0.88
0.92
0.95
1.02
1.07
1.62
2.25
2.31

Population
(in
thousands)

National
income
(in millions
of crowns)

2,954
3,088
3,124
3,163
3,200
3,233
3,265
3,296
3,327
3,359
3,392
3,425

4,975
8,612
10,237
11,296
12,026
13,183
15,695
16,596
16,871
18,370
19,507

Sources: Expenditure: Norges Offisielle Statistikk (Series X and XI), Table 16 B (to 1952) and 15 B (1953 to 1955).
Population: United Nations: Monthly Bulletin of Statistics, June 1954 and Jan. 1957. National income: Idem: Statistical
Papers, Series H, Nos. 5 and 10.
1
Does not include dental care.

195
SWITZERLAND
EXPENDITURE OF 555 SICKNESS FUNDS ON MEDICAL BENEFITS \ BY TYPE OF
CARE, PER INSURED PERSON 2 , AND POPULATION AND NATIONAL INCOME, 1946-55
Expenditure of 555 sickness funds on medical benefits
per insured person
(in francs)
Year

1946
1947
1948
1949
1950
1951
1952
1952
1954
1955

Medical
practitioner

Pharmaceutical
(incl.
appliances)

Hospital

Other

Total

23.15
24.94
26.56
28.47
30.02
31.87
33.55
34.82
36.10
37.44

10.31
10.80
11.37
12.25
12.43
13.40
14.04
14.62
15.11
16.21

10.22
10.60
12.35
13.50
13.70
13.65
14.01
13.99
14.48
14.56

0.49
0.49
0.50
0.51
0.54
0.56
0.60
0.63
0.63
0.62

44.17
46.83
50.78
54.73
56.69
59.48
62.20
64.06
66.32
68.83

Population
(in
thousands)

National
income
(in millions of
francs)

4,467
4,524
4,582
4,640
4,694
4,749
4,815
4,877
4,927
4,977

15,033
16,842
17,646
17,360
18,160
19,500
20,360
20,830
22,250
23,290

Sources: Expenditure: Office fédéral des assurances sociales: Statistique relative aux caisses-maladie et aux caisses
d'assurance contre la tuberculose reconnues par la Confédération (published annually), Part II: Assurance des soins médicopharmaceutiques (accouchement non compris) dans 555 caisses. Population and national income: United Nations:
Monthly Bulletin of Statistics, Jan. 1955 and Jan. 1957.
1
Including share payable by patient to sickness fund for care received.
' Wives, children and other dependants
are insured in their own right.

VENEZUELA
EXPENDITURE OF SICKNESS AND MATERNITY INSURANCE SCHEME ON
MEDICAL BENEFITS BY TYPE OF CARE, AND POPULATION
AND NATIONAL INCOME, 1946-53
Expenditure of sickness and maternity insurance scheme on medical benefits
(in bolivars)
Year

1946-47
1947-48
1948-49
1949-50
1950-51
1951-52
1952-53
1953-54

Wages and
salaries
(excl. surgical
and obstetrical
fees)

Pharmaceutical and
optical
(incl.
hospital)

Hospital
(excl.
surgical and
obstetrical
fees)

Other
(incl.
surgical and
obstetrical
fees)

Total

4,664,334
5,748,801
7,415,513
9,013,306
12,886,429
14,533,572
15,194,250
15,761,336

2,177,052
2,266,847
2,977,366
4,269,705
5,455,814
6,951,425
6,393,732
7,117,038

2,147,489
3,000,538
3,384,313
3,545,758
4,847,804
4,727,579
4,285,750
4,337,682

1,601,192
1,780,588
1,252,226
3,214,993
3,942,617
6,174,789
5,165,434
5,954,434

10,590,067
12,796,774
15,029,418
20,043,762
27,132,664
32,387,365
31,039,166
33,170,490

National
Population income
(in mil(in
thou- lions of
sands) 1 bolivars)

2
4,391
2
4,548
2
4,686
2
4,828
2
4,974
2
5,125
5,280 9,158
5,440 9,893

Sources: Expenditure: Instituto Venezolano de los Seguros Sociales, División de Estadística y Actuariado: Notas
Estadísticas, annual report for 1953 and monthly issues (Caracas). Population and national income: United Nations:
Monthly Bulletin of Statistics, Jan. 1955 and Aug. 1956.
1
Excluding Indian jungle population.
* National income not fully assessed until 1952.

196

UNITED
PRIVATE (AND VOLUNTARY INSURANCE)
OF CARE; EXPENDITURE ON MAINTENANCE AND CONSTRUCTION OF
Private (and voluntary insurance) expenditure on medical care
(in millions of dollars)
Year

1946 . . .
1947
1948
1949
1950
1951
1952
1953
1954
1955

Medical
Pharmaceutical
practitioner
(¡nel. appliances)
(¡nel. hospital)

Hospital
(maintenance,
etc.)

Dental

Other

Total

—

2,233
2,342
2,467
2,562
2,718
2,859
2,963
3,123

1,785
1,798
1,885
2,048
2,130
2,192
2,197
2,319

1,663
1,858
2,121
2,283
2,561
2,825
2,970
3,365

833
857
869
888
906
943
975
1,017

679
697
775
805
921
1,047
1,160
1,374

7,193
7,552
8,117
8,586
9,236
9,866
10,265
11,198

Sources- Expenditure: (1) Social Security Bulletin (Washington, U.C., United States Department of Health, Education
and Welfare Social Security Administration). Dec. 1954, Dec. 1955 and Dec. 1956; (2) American Hospital Association:
Hospitals (Administrators' Guide Issue), Part II; (3) The President's Commission on the Health Needs of the Nation:
Building America's Health. Vol. IV. Financing a Health Program for America, p. 274. Population: United Nations:
Monthly Bulletin of Statistics, Jan. 1955 and Jan. 1957. National Income: Idem: Statistical Papers, Series H, Nos. 7
and 8; Monthly Bulletin of Statistics, Jan. 1957.

197

STATES
EXPENDITURE ON MEDICAL CARE BY TYPE
HOSPITALS; AND POPULATION AND NATIONAL INCOME, 1946-55
Total hospital expenditure
(in thousands of dollars)
Maintenance, etc.

Construction

1,963,355
2,354,344
2,875,478
3,486,109
3,650,691
3,912,596
4,456,160
4,765,063
5,229,040
5,594,304

170,000
195,000
349,000
679,000
812,000
917,000
867,000
682,000
702,000
680,000

Population
(in thousands)

National income
(in millions of dollars)

Year

141,389
144,126
146,631
149,188
151,683
154,360
157,022
159,629
162,414
165,271

179,600
197,200
221,600
216,200
240,000
277,000
291,000
305,000
300,000
324,000

1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

199

C. COMPARATIVE TABLES
PRESENTATION OF MATERIAL

The expenditure on medical benefits per person protected by the social
security services covered (in the United States, the expenditure on medical
care per head of population") is shown in tables B to G—
(i) as a percentage of the income per head in the country concerned, and
(ii) as a percentage of the reference wage.
The expenditure shown, apart from some minor exceptions, is that incurred
for medical benefits only and does not include administrative expenses save
in the cases of hospital expenditure in England and Wales, New Zealand
and the United States.
The breakdowns of expenditure into expenditure on medical practitioner
care, pharmaceutical supplies, hospital care, dental care and residual care
(given in tables C to G) are based, as a rule, on the corresponding categories
of expenditure as given in the official statistics. However, where the subdivisions in the latter differed substantially from those used in the tables,
some tentative adjustments have been made. The data for Belgium have been
rearranged to correspond fairly closely to the pattern adopted in this study,
the necessary detailed analyses being available. Total hospital expenditure
in New Zealand has been computed from official sources.
Table H shows the income per head and the reference wage in the countries
covered.
Table J shows the proportion of economically active persons in the populations concerned.
Expenditure figures relating to a financial year beginning in April or June
are included under the first of the two calendar years concerned and are
compared with the income per head and the reference wage for that year.

200
TABLE A
NUMBER OF PERSONS PROTECTED (a) OR PERSONS INSURED (b) UNDER
POPULATION OF
Canada (Saskatchewan) (a)
Year

Belgium (a)

_
—
—
—
—

Hospital service
(Saskatchewan)

_
—
—

Prior to 1945
1945 . . .
1946 .
1947 .
1948 .
1949 .
1950 .
1951 .
1952 .
1953 .
1954 .
1955 .

4,401,185
4,407,188
4,513,639
4,615,542
4,659,152
4,690,709
4,749,877

780,445
776,478
766,304
766,785
779,470
786,497
803,941
810,246
822,956

Year

Italy (a) «

Mexico (a)

—

Prior to 1945
1945 . . .
1946 .
1947 .
1948 .
1949 .
1950 .
1951 .
1952 .
1953 .
1954 .
1955 .

13,245,045
14,227,699
14,248,588
14,015,263
13,881,203
14,282,138
15,096,188
16,586,722
17,060,156
16,887,638

•

—

—
—
—
974,105
1,046,195
1,140,883
1,286,481
1,387,915

Medical practitioner
service (Swift
Current region)

984,700 l
984,700 »
984,700 l
984,700 »
984,700 1
984,700 »
984,700
1,048,000

—
—
—
—
48,193
48,000
47,640
45,730
47,538
47,262
48,380

Netherlands (a)

_
—
—
3,991,742
4,218,863
4,340,867
4,548,554
5,338,091
5,470,438
5,679,345
5,788,900
5,920,089

Chile (b)

—
—
—

New Zealand (a)

1,633,000
1,688,000
1,759,000
1,797,000
1,833,000
1,871,000
1,908,000
1,947,000
1,995,000
2,047,000
2,093,000
2,136,000

1
Estimated.
"Persons over 15 years3 of age at end of year. Children under 15 years (estimated to number 40 per
100 members over 15) are not included.
The number of dependants (not included in this table) is estimated at about
80 per 100 insured persons (see p. 8).
• Persons protected who are entitled to medical and dental practitioner care.
About two-thirds of these are entitled to pharmaceutical benefits and the majority to hospital benefit.
* The average
number of persons protected under the compulsory scheme prior to 1947 is not known, although the expenditure per
person protected, by type of care, can be obtained from statistics covering the whole period in recent publications.
• Persons insured by public funds only. The number of dependants (not included in this table) is estimated at 89 to 94
(according to the year) per 100 insured persons.

201
TABLE Ä
THE SOCIAL SECURITY
THE UNITED STATES

Denmark (b) '

2,173,000
2,366,513
2,360,166
2,344,836
2,351,498
2,373,328
2,410,899
2,416,979
2,426,155
2,436,449
2,456,147
2,466,197

Norway (b) •

1,218,514
1,263,594
1,300,327
1,324,249
1,349,278
1,379,784
1,412,003
1,438,656
1,470,304
1,510,239
1,541,940

MEDICAL

England and Wales (a)

CARE SCHEMES COVERED,

France (a)

Germany
(Federal Republic) (b)'

AND

Year

43,800,000
43,800,000
43,800,000
43,900,000
44,100,000
44,300,000
44,400,000

16,400,000
16,500,000
17,100,000
17,500,000
17,800,000
18,100,000
18,200,000
18,300,000
18,800,000

15,108,058
15,709,305
16,155,940
16,530,547
17,032,338
17,632,859
18,330,243

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Switzerland (a}

Venezuela (a}

United States (a)

Year

141,389,000
144,126,000
146,631,000
149,188,000
151,683,000
154,360,000
157,022,000
159,629,000
162,409,000
165,248,000

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

1,653,512
1,743,290
1,816,861
1,869,947
1,937,291
2,028,125
2,125,616
2,223,262
2,324,008
2,438,091

195,829
206,209
225,414
244,172
279,690
313,737
290,722
303,846
342,214

202
TABLE B
TOTAL EXPENDITURE PER PERSON PROTECTED ON MEDICAL
EXPENDITURE ON MEDICAL CARE IN THE UNITED STATES, IN
England and Wales
Year

Belgium

Chile

Denmark

Without
costsharing

With
costsharing

France

Germany
(Federal
Republic)

Italy

Percentage of income per head
Prior to
1945 .
1945 .
1946 .
1947 .
1948 .
1949 .
1950 .
1951 .
1952 .
1953 .
1954 .
1955 .

.
.
.
.
.
.
.
.
.
.
.
.

—
—
—
—
—
2.10
2.12
2.03
2.05
1.93
1.98
2.01

3.81 1
3.94
4.16
4.40
3.93
3.76
4.60
4.25

—
—
—
—

1.07 2
0.90
0.90
0.91
0.89
0.91
0.84
0.86
0.90
0.99
1.02
1.07

—
—
—
—
—

—
—
—
—

4.18
4.11
3.86
3.92
3.50
3.45
3.52

4.21
4.14
3.95
4.08
3.69
3.60
3.70

•

—

—
—
—
1.84
2.10
2.60
3.04
3.06
3.41
3.72
3.73
3.79

2.04 3

—
—
—
—
3.05
2.89
2.66
2.78
2.95
2.89
2.78

—
—
—
1.13
1.97
2.11
2.03
2.15
2.32
2.34
2.44
2.60

Percentage of reference wage
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1

.
.
.
.
.
.
.
.
.
.
.

—
—
—

1.63
1.76
1.68
1.70
1.64
1.75
1.67

2.47
2.93
2.79

1943 or 1943-44.

—
—
—
—
• 1938.

0.48
0.44
0.45

—
0.46

—
0.44

—
0.52
0.52
0.53

—
—
—

3.81
3.92
3.73
3.69
3.31
3.30
3.32

3.84
3.95
3.81
3.84
3.48
3.44
3.49

' 1937 (German Reich).

' 1939.

—
1.55

—
2.75
2.78
2.72
3.19
3.47
3.60

—

—
—
—
—
—
1.79
2.03
2.12
2.23
2.38

• Excluding dental care.

_
—
0.36

—
0.99

—
—
1.37

—
1.48
1.69

203
TABLE B
BENEFITS UNDER 13 SOCIAL SECURITY SERVICES, AND PRIVATE
TERMS OF THE INCOME PER HEAD AND OF THE REFERENCE WAGE

Mexico

Netherlands New Zealand

Norway

Switzerland

Venezuela

United States
(private and
voluntaryinsurance
expenditure)

Year

Percentage of income per head

7.13
7.24
7.43
7.11

2.12 !
3.04
1.85
1.82
1.81
1.86
1.97
2.03
2.04
2.05
2.03
2.33

1.46 1
1.60
1.69
1.70
1.87
1.75
1.43
1.52
1.61
1.46
1.57
1.84

1.34*
1.22 6
1.23
1.26
1.28
1.31
1.25
1.38
1.54
1.52
1.50

1.31
1.26
1.32
1.46
1.47
1.45
1.47
1.50
1.47
1.47

6.16
6.00

3.25
3.49
3.38
3.10
3.17
3.23
3.42
3.46

Prior to
1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Percentage of reference wage

7.40

0.98
0.87
1.04

1.08
1.18

1.28
1.31
1.45
1.41
1.53
1.47
1.86

1.25
1.21
1.16
1.16
1.04
1.21
1.43

1.14 5
0.87
1.01
0.99
0.95

0.98
0.98
1.01
1.08
1.09
1.08
1.10
1.12
1.13
1.13

2.19
2.49

2.57
2.70
2.80

2.03
1.92
2.04
1.94

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

204
TABLE C
EXPENDITURE PER PERSON PROTECTED O N MEDICAL PRACTITIONER (OR
A N D PRIVATE EXPENDITURE ON SUCH CARE I N T H E UNITED STATES, IN

Year

Belgium

Canada *

Denmark

England
and
Wales

France

Germany
(Federal
Republic)

Italy

Percentage of income per head
ior to 1945
1945. . .
1946.
1947.
1948.
1949.
1950.
1951 .
1952.
1953.
1954.
1955.

—
—
—
—
—
0.40
0.38
0.36
0.34
0.33
0.33

—
—
—
0.93
0.90
0.88
0.77
0.76
0.75
0.78
0.75

0.44
0.34
0.35
0.39
0.38
0.38
0.35
0.37
0.41
0.48
0.48
0.49

(0.38) <
(0.29)
(0.30)
(0.33)
(0.32)
(0.32)
(0.29)
(0.31)
(0.34)
(0.41)
(0.41)
(0.41)

0.81

(0.42)
(0.42)
(0.38)
(0.63)
(0.40)
(0.38)
(0.38)

0.52
0.53
0.56
0.60
0.65
0.67
0.73
0.72
0.74

0.97
0.97
0.90
0.95
1.02
1.03
1.00

0.43
0.59
0.72
0.74
0.81
0.86
0.89
0.94
1.00

(0.16)
(0.28)
(0.38)
(0.37)
(0.45)
(0.49)
(0.53)
(0.57)
(0.63)

Percentage of reference wage
1945.
1946.
1947.
1948.
1949.
1950.
1951 .
1952.
1953.
1954.
1955.

0.19 (0.16)
0.18 (0.15)
0.19 (0.16)

0.33
0.31
0.30
0.29
0.30
0.27

0.46
0.45
0.41
0.39
0.38
0.36
0.36

0.20 (0.17)
0.19 (0.16)
0.24 (0.21)
0.24 (0.21)
0.24 (0.20)

(0.40)
(0.40)
(0.37)
(0.60)
(0.38)
(0.37)
(0.36)

0.44

0.13 (0.05)

0.59
0.55
0.58
0.63
0.68
0.70

0.34 (0.18)
0.60
0.69
0.73
0.79
0.86

0.51 (0.29)
0.57 (0.35)
0.65 (0.41)

1
Cost of general practioner care shown in brackets; included in other value.
* Swift Current region, Saskatchewan;
5
care in region only.
* Including other staff.
* 1938.
1937 (German Reich).
« 1943 or 1943-44.
' 1939.

205
TABLE C
GENERAL PRACTITIONER) CARE UNDER THIRTEEN SOCIAL SECURITY SERVICES,
TERMS OF THE INCOME PER HEAD AND OF THE REFERENCE WAGE 1

Mexico •

Netherlands

New
Zealand

Norway

Switzerland Venezuela •

United
States

Year

_
—
—
—

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Percentage of income per head

—
—
—
—
—
3.22
3.23
3.17
3.12

—
—

0.80
1.30
0.75
0.66
0.61
0.64
0.65
0.65
0.65
0.70
0.69
0.81

(0.52)8
(0.89)
(0.48)
(0.40)
(0.36)
(0.35)
(0.34)
(0.33)
(0.33)
(0.35)
(0.35)
(0.42)

(0.36)6
(0.41)
(0.48)
(0.53)
(0.55)
(0.53)
(0.44)
(0.45)
(0.47)
(0.43)
(0.42)
(0.42)

—

_
—

0.43
0.39
0.36
0.41
0.40
0.35
0.39
0.44
0.42
0.42

0.69
0.67
0.69
0.76
0.78
0.78
0.79
0.82
0.80
0.80

0.49 7

_
—
—
—
—
—
—
—
3.01
2.85

—
—

1.01
1.08
1.03
0.92
0.93
0.94
0.99
0.96

Percentage of reference wage

_
—
—
—
—
—
—
3.15

—
—
—

0.42 (0.29)
0.35 (0.22)
0.38 (0.23)

—
0.44
0.44
0.46
0.45
0.52
0.50
0.64

(0.24)
(0.23)
(0.24)
(0.23)
(0.26)
(0.26)
(0.33)

(0.28)

—

0.41
0.28

0.51
0.52
0.53
0.56
0.58
0.58
0.59
0.61
0.62
0.61

0.96
1.12

(0.37)

—

•—

(0.38)
(0.37)
(0.34)
(0.34)
(0.30)
(0.32)
(0.33)

0.34

—
0.28
0.27

—
—

—
—
1.22
1.21
1.37

—
—
•

_
—
—
—
—
0.61
0.57
0.60
0.56

—
—

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

206
TABLE D
EXPENDITURE PER PERSON PROTECTED ON PHARMACEUTICAL SUPPLIES
ON SUCH SUPPLIES IN THE UNITED STATES, IN TERMS OF
England and Wales
Year

Belgium

Denmark

Without
With
cost-sharing cost-sharing

France 1

Germany
(Federal
Republic) > •

Italy

Percentage of income per head
Prior to 1945
1945 . . . .
1946 .
1947 .
1948 .
1949 .
1950 .
1951 .
1952 .
1953 .
1954 .
1955 .

—
—
—
—
—
0.47
0.49
0.44
0.41
0.42
0.46

0.18»
0.14
0.14
0.13
0.13
0.14
0.13
0.12
0.11
0.12
0.14
0.14

0.40 4

—
—
—
—

0.33
0.35
0.41
0.36
0.31
0.31
0.31

0.33
0.35
0.41
0.40
0.36
0.36
0.36

—
—
0.38
0.42
0.53
0.66
0.74
0.84
0.92
0.94
0.99

—
—
—
—

—
—

0.99
0.82
0.76
0.79
0.83
0.78
0.73

0.23
0.63
0.55
0.48
0.54
0.66
0.67
0.68
0.74

—
—

0.07

Percentage of reference wag
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

. . . .
.
.
.
.
.
.
.
.
. .
. .

—
—

0.08
0.07
0.07
0.07

0.39
0.40
0.36
0.35
0.37
0.38

—
0.06

—
0.06
0.07
0.07

—
—

0.30
0.33
0.40
0.34
0.29
0.30
0.29

0.30
0.33
0.40
0.38
0.34
0.34
0.34

1
Including optical and orthopaedic appliances (eye-glasses).
(German Reich).
* 1943 or 1943-44.

—
0.32
0.56
0.60
0.66
0.79
0.86
0.90

—•

—

_
—

0.26

—
—

0.51
0.58
0.60
0.60
0.63

' Including dental prostheses.

0.39

—
0.41
0.48
3

1938.

* 1937

207
TABLE D
UNDER ELEVEN SOCIAL SECURITY SERVICES, AND PRIVATE EXPENDITURE
THE INCOME PER HEAD AND OF THE REFERENCE WAGE

Mexico

Netherlands

New Zealand

Switzerland

Venezuela

United States1

Year

Percentage of income per head

_
—
—
—
—
—
3.02
3.14
3.37
3.01

—
—

0.46 6
0.68
0.38
0.36
0.36
0.36
0.36
0.38
0.37
0.35
0.33
0.35

0.24"
0.33
0.39
0.38
0.43
0.42
0.35
0.39
0.47
0.40
0.38
0.48

_
—
0.31
0.29
0.30
0.33
0.32
0.33
0.33
0.34
0.33
0.35

__
—
—
—
—
—
—
—
. 1.27
1.29

—
—

_
—
—
—
0.81
0.83
0.79
0.74
0.73
0.72
0.73
0.72

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Percentage of reference wage

_
—
—
—
—
—
—
3.35

—
—
-—

0.22
0.18
0.20

0.22

—
0.26

—

0.25
0.24
0.27
0.26
0.26
0.24
0.28

0.30
0.29
0.30
0.34
0.29
0.29
0.37

0.23
0.23
0.23
0.24
0.24
0.24
0.25
0.26
0.26
0.27

0.45
0.44

—
—
0.52
0.58
0.58

—
—
—

_
—
—
—
—
0.47
0.46
0.47
0.43

—
—

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

208
TABLE E
EXPENDITURE PER PERSON PROTECTED ON HOSPITAL CARE UNDER 13
UNITED STATES AND TOTAL HOSPITAL EXPENDITURE IN NEW ZEALAND AND
REFERENCE
England and Wales
Belgium

Year

Canada
(Saskatchewan)

Denmark

Excl.
costsharing

Incl.
costsharing

France

Germany
(Federal
Republic)

Italy

Mexico

—
—
—

—
—
—
—
—
—

Percentage of income per head
Prior to
1945
1945 . .
1946 . .
1947 . .
1948 . .
1949 . .
1950 . .
1951 . .
1952 . .
1953 . .
1954 . .
1955 . .

—
—
—
—
—
—
0.63
0.63
0.70
0.64
0.66
0.64

—
—
—
1.05
1.16
1.36
1.44
1.41
1.46
1.53
1.65
1.76

0.28 3
0.21
0.20
0.19
0.18
0.19
0.17
0.17
0.18
0.19
0.19
0.20

—
—
—
—
—

—
•—
—
—
—

2.20
2.26
2.20
2.12
2.01
1.99
2.08

2.23
2.29
2.23
2.15
2.04
2.02
2.10

—
—
—
0.55
0.76
1.12
1.33
1.23
1.43
1.58
1.59
1.58

0.57 4

—
—
—
—
0.81
0.83
0.74
0.76
0.81
0.78
0.74

0.41
0.66
0.74
0.70
0.69
0.70
0.69
0.72
0.76

0.89
0.87
0.89
0.98

—
—

Percentage of reference wage
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

.
.
.
.
.
.
.
.
.
.
.

—
—
—
—
0.52
0.52
0.58
0.55
0.59
0.53

—
0.56

0.11
0.09
0.09

—

0.69
0.74
0.76
0.75
0.77
0.76
0.85

0.09

—
0.09

—
0.10
0.10
0.10

—
—
—

2.01
2.16
2.12
2.00
1.90
1.90
1.96

2.04
2.19
2.15
2.02
1.93
1.93
1.99

—
0.46

—
1.18
1.21
1.09
1.34
1.47
1.54

—

—
—
—
—
—
0.50
0.56
0.58
0.60
0.63

—

—
—

—
—
—
—
—
—

0.41

0.89

—

—
—.
—

0.13

—
0.35

0.43
0.50

* Excluding construction outlay on mental hospitals but including out-patient care. ' Including out-patient care. * 1938.
• 1937; German Reich.
• 1943 or 1943-44.
• 1939.

209
TABLE E
SOCIAL SECURITY SERVICES, PRIVATE EXPENDITURE ON SUCH CARE IN THE
THE UNITED STATES, IN TERMS OF THE INCOME PER HEAD AND OF THE
WAGE
New Zealand
Netherlands

United States
Norway

Social
security

Total

Switzerland

Venezuela

Total •
Private
(incl.
(excl.
(incl.
voluntary construc- construcinsurance)
tion)
tion)

Percentage of income per head

0.54f
0.73
0.48

0.54
0.57
0.59
0.65
0.73
0.77
0.76
0.76
0.89

0.66 5
0.63
0.54
0.48
0.48
0.42
0.33
0.34
0.33
0.30
0.43
0.56

0.61 •
2.35
2.37
2.36
2.72
2.53
2.27
2.73
2.92
2.79
2.76
2.84

0.52
0.59
0.65
0.63
0.66
0.68
0.76
0.85
0.83
0.81

0.30
0.28
0.32
0.36
0.35
0.33
0.33
0.33
0.32
0.31

'—
—
—
—
—
—
0.85
0.78

—
—•

—
—

•

0.75
0.86
0.88
0.82
0.88
0.93
0.99
1.04

1.09
1.19
1.30
1.61
1.52
1.41
1.53
1.56
1.74
1.73

1.25
1.29
1.76
1.93
1.86
1.74
1.83
1.79
1.98
1.94

—
—

Percentage of reference wage
0.23
0.23
0.31

0.42

0.40
0.44
0.52
0.53
0.57
0.55
0.71

1.59

—

0.33

1.64

0.30
0.28
0.26
0.24
0.22
0.33
0.44

1.81
1.92
2.09
2.10
2.00
2.13
2.21

0.49
0.41
0.49

—
0.54
0.52

•—
—
—

0.23
0.22
0.25
0.27
0.26
0.25
0.25
0.25
0.25
0.24

0.44
0.58

—
—

—
—
. .

—

0.46
0.40
0.39

0.53
0.51
0.56
0.55

0.90
0.87
0.98
0.93

1.11
1.07
1.17
1.07

—
—

—
—
—

210
TABLE F
EXPENDITURE PER PERSON PROTECTED ON DENTAL CARE UNDER SEVEN
IN THE UNITED STATES, IN TERMS OF THE
England and Wales
Year

Belgium

Denmark

Excl. costsharing

Incl. costsharing

Percentage of income per head
Prior
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

to
.
.
.
.
.
.
.
.
.
.
.

1945
. .
. .
. . .
. .
. .
. .
. . ,
. . ,
. .
. .
. . .

0.12
0.10
0.09
0.08
0.09
0.09

0.02»
0.07
0.06
0.06
0.06
0.06
0.06
0.07
0.07
0.07
0.08
0.09

0.45
0.40
0.29
0.18
0.17
0.17
0.20

0.45
0.40
0.30
0.23
0.22
0.22
0.25

Percentage of reference wage
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

0.03
0.03
0.03
0.03

0.10
0.08
0.07
0.07
0.08
0.07

0.04

0.04
0.04
0.05

0.41
0.38
0.28
0.17
0.16
0.16
0.19

0.41
0.38
0.29
0.22
0.20
0.21
0.24

'Conservative care only.
'Conservative dental care for children and adolescents only.
1937; German Reich.
• 1943 or 1943-44.

•1938.

211
TABLE F
SOCIAL SECURITY SERVICES, AND PRIVATE EXPENDITURE ON SUCH CARE
INCOME PER HEAD AND OF THE REFERENCE WAGE
Germany l
(Federal Republic)

Netherlands

New Zealand •

United States

Year

Percentage of income per head
0.23 4

—
—
—
—
0.25
0.24
0.22
0.23
0.24
0.26
0.26

0.18 6
0.15
0.10
0.13
0.13
0.14
0.14
0.15
0.15
0.16
0.16
0.16

—
—
0.03
0.05
0.07
0.06
0.08
0.08
0.09
0.09
0.09

—
—
—
0.38
0.40
0.36
0.32
0.31
0.31
0.33
0.31

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Percentage of reference wage

—
—
—
—
—
0.15
0.17
0.17
0.20
0.22

0.05
0.05
0.08

—
0.02

—

0.10
0.10
0.11
0.11
0.12
0.11
0.13

0.05
0.05
0.06
0.06
0.06
0.07
0.07

—
—
—
—
0.22
0.20
0.20
0.18

—
—

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

212
TABLE G
EXPENDITURE PER PERSON PROTECTED ON CARE NOT INCLUDED IN TABLES B
ON SUCH CARE IN THE UNITED STATES, IN TERMS OF
England and Wales
Year

Belgium

Denmark

Excl. costsharing

Incl. costsharing

France

Germany
(Federal
Republic)

Italy

Percentage of income per head
Prior to 1945
1945 . . .
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

—
—
—
—
—
0.50
0.44
0.47
0.45
~ 0.47
0.50

0.15 4
0.14
0.15
0.14
0.14
0.14
0.13
0.12
0.13
0.13
0.13
0.15

0.03 6

—
•—
—
—

—
—
—
—

0.78
0.68
0.59
0.62
0.61
0.60
0.55

0.78
0.68
0.63
0.67
0.67 :
0.62
0.61

—
—
0.14
0.16
0.19
0.23
0.22
0.23
0.24
0.24
0.24

—
—
—
—
0.03
0.02
0.04
0.05
0.05
0.04
0.05

—
—
0.08
0.11
0.11
0.11
0.11
0.10
0.09
0.10
0.10

Percentage of reference wage
1945 . . .
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

—
—
—
—
0.42
0.37
0.39
0.38
0.41
0.42

0.07
0.07
0.07

—
0.07

—
0.06

—
0.07
0.07
0.07

—
—
—

0.69
0.65
0.56
0.58
0.58
0.57
0.52

0.69
0.65
0.60
0.62
0.63
0.59
0.57

—
0.13

—
0.21
0.22
0.19
0.20
0.23
0.23

—

—
—
—
—
—
0.03
0.03
0.04
0.04
0.04

1
Including transport of doctors and patients, dental benefits and some pharmaceutical expenses.
dental care.
* Including administrative expenses and profits of voluntary-insurance schemes.
' 1937 (German Reich).
• 1943 or 1943-44.
' 1939.

—
0.03

—
0.04

—
—
0.06

—
0.06
0.06
* Including
* 1938.

213
TABLE G
TO F UNDER ELEVEN SOCIAL SECURITY SERVICES, AND PRIVATE EXPENDITURE
THE INCOME PER HEAD AND OF THE REFERENCE WAGE

Netherlands

New Zealand

Norway

Switzerland '

Venezuela

United States 3

Year

Percentage of income per head
0.14 o
0.18
0.14
0.12
0.14
0.13
0.17
0.12
0.08
0.09
0.09
0.12

0.21«
0.23
0.29
0.28
0.36
0.31
0.25
0.26
0.26
0.24
0.25
0.29

0.24'

—

0.27
0.25
0.25
0.24
0.25
0.22
0.22
0.25
0.27
0.27

0.01
0.02
0.01
0.01
0.02
0.01
0.02
0.01
0.02
0.01

—
—
—
—
—
—
—
1.03
1.08

—
—

•

—
—
—
0.30
0.32
0.32
0.30
0.32
0.33
0.39
0.42

Prior to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Percentage of reference wage
0.06
0.06
0.07

0.16

—
0.20

0.24
0.18

—

0.09
0.09
0.09
0.06
0.06
0.06
0.10

0.22
0.22
0.20
0.18
0.17
0.20
0.22

0.18

—
0.17
0.16

—
—
—

0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01

0.33
0.35

—
—
0.37
0.51
0.46

—
—
— •

—
—
—
—

•

0.20
0.18
0.21
0.22

—
—

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

214
TABLE H
NATIONAL INCOME PER HEAD OF THE POPULATION, AND WAGE OF UNSKILLED
NATIONAL
Year

Belgium
(francs)

Canada
(dollars)

Chile
(pesos)

Denmark
(crowns)

France
(francs)

Germany
(Fed. Rep.)
(marks)

Italy
(Ure)

—
—
—

1,176«

—
—
—

Income per head
Prior to
19451 . .
1945.
1946.
1947.
1948.
1949.
1950.
1951.
1952.
1953.
1954.
1955.

—
—
—
—
29,812
31,925
36,241
37,102
38,129
39,562
41,531

—
—
—
852
954
981
1,061
1,223
1,263
1,288
1,240
1,316

6,162 s
7,940
9,037
11,329
13,621
16,422
19,067
24,543
32,119
43,906
69,259
109,363

1,690 •
2,959
3,233
3,517
3,773
3,942
4,415
4,776
4,995
5,152
5,193
5,317

79,367 6
128,933 5
157,180
169,679
216,866
242,332
244,284
268,649
287,299

—
—
—
—
1,349
1,505
1,870
2,024
2,117
2,268
2,524

113,393
129,184
134,472
147,330
167,873
176,228
193,876
203,369
220,829

—
—

357,228 '

Reference wage
1945. . .
1946.
1947.
1948.
1949.
1950.
1951.
1952.
1953.
1954.
1955.

—

(Santiago)

(Copenhagen)

(Paris)

5,566
6,689
7,164

94,016

—
—

1,579 2

24,960
24,960

38,438
38,438
43,680
44,778
44,778
44,778
49,920

1,922 "
2,059 *
2,265
2,443
2,556
2,702
2,728

24,960
29,952
37,440
35,194
46,525
61,427
77,376

7,788

—
9,385

—
9,934
10,259
10,733

—
148,928
185,640
243,776
258,752
262,080
278,720

—

.—
—
2,774
2,774
2,945
2,945
2,945

—
287,340 '

—
—
299,520

—
335,764
339,082

R eference w¡ige as percentage of ine ome per heacI
1945. . .
1946.
1947.
1948.
1949.
1950.
1951.
1952.
1953.
1954.
1955.

_
—
—

—
—
185

129
120
121
121
117
113
120

196
194
185
193
198
218
207

—
276
220
152
157
153
110
106

—
—

188
207
204

—
—

198

95
109
112
107
107
104

—
197

—
193
198
202

118

—

—
—
—

—.
•

—

148
137
139
130
117

—
—
315
214

—
—
170

—
165
154

1
For year, see relevant footnote following. ' Montreal. * 1943 or 1943-44.
* 1938.
* Including the Saar.
' 1937, but national income for 1937 assumed to be the same as that for 1938 (figure in Reichsmarks).
' Rome.
' 1939.
• Oslo.
» 1944.
" Caracas.
'" Federal District.

215
TABLE H
LABOURER EMPLOYED IN MANUFACTURE OF MACHINERY, PER YEAR, IN
CURRENCY
Mexico
(pesos)

Netherlands
(florins)

New
Zealand
(£)

Norway
(crowns)

Switzerland
(francs)

United
Kingdom
(£)

Venezuela
(bolivars)

United
States
(dollars)

—
—
—
—
—
—
—
—

—
—

Year

Income per head
<Year commencing 1 April)

—
—
—
—
—
—
1,466
1,777
1,932
1,789
2,051
2,519

619 s
450
990
1,168
1,315
1,417
1,545
1,661
1.7J5
1,845
2,012
2,212

199 s
205
208
228
229
257
318
317
324
355
383
396

1,684

2,870 10

—

2,757
3,236
3,530
3,720
4,038
4,762
4,988
5,023
5,416
5,695

3,365
3,723
3,851
3,741
3,869
4,106
4,228
4,271
4,516
4,680

—
—
—
—
—
218
228
251
271
291
311
326

1,734
1,819

—
—

1,270
1,368
1,511
1,449
1,582
1,795
1,853
1,911
1,847
1,960

Prior
to 1945
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Reference wage
(Manchester)

(Federal
District)

—
—
—
—
—
—
1,942

—
—
—

1,398
2,122
2,047

(Los
Angeles)

304

—
329

2,945 9
4,568 •

—

2,072
2,271
2,321
2,471
2,471
2,771
2,771

360
377
414
450
496
496
509

4,717 9

—
6,015
7,227

—
—
—

4,512
4,776
5,040
5,088
5,208
5,496
5,664
5,700
5,856
6,096

—
—
—
239
239
260
288
308
325
345

2,471 "
2,496 "

—
—
3,769 12
3,819 u
3,819

—
—
—

—
—
—
—
2,662
2,912
2,891
3,203

—
—

1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955

Reference iwage as percentage of income )er head

—
303
235

—
198

—
—
101

—
—
—

311
214
175

148

—
144

107
141

—

146
147
140
145
134
138
Ï 125

140
119
131
139
140
130
129

127

—
126
145

—
—

•

—

134
128
131
136
135
134
134
133
130
130

—.
—
—
—
110
105
104
106
106
105
106

—
—
—
—
—
—
—
220

—
—
—

.—.
—
—
—
—
168
162
156
168

—
—

1945
1946
1947
1S48
1949
1950
1951
1952
1953
1954
1955

216
TABLE J
PROPORTION OF ECONOMICALLY ACTIVE PERSONS
IN THE POPULATION
Country

Mexico
Venezuela *
Chile 2
Canada
New Zealand
United States
Netherlands
Belgium
Norway 3
Italy 2
France
Switzerland3
United Kingdom
Germany (Federal Republic)
Denmark

Year

Economically active
persons as percentage
of total population

1950
1950
1952
1951
1954
1951
1950
1947
1947
1950
1951
1954
1954
1950
1951
1950
1954
1952
1953

32.4
33.9
34.0
37.9
35.7
38.2
39.9
40.2
40.9
42.6
43.1
44.1
44.8
45.5
46.2
46.3
49.5
49.9
49.5

1
In the areas in which the insurance scheme was in force the proportion of the population which
was economically active was 39 per cent, in 1950.
' Year Book of Labour Statistics, J 955 (figures
not revised).
* Ibid., 1953 (figures not revised).

PUBLICATIONS OF THE INTERNATIONAL LABOUR OFFICE

Social Security
A Workers' Education Manual
(Published in English, French, German and Spanish
and also in Arabic, Hindi, Japanese and Urdu)
A comprehensive survey of the various types of social insurance
and allied social services which describes t h e general development of
the idea of social protection against contingencies such as sickness,
accident, unemployment, etc., analyses the different types of benefit
and t h e conditions on which t h e y are provided and explains t h e
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is intended for workers' education classes, m a y be used for teaching
directly or b y correspondence. Lists of questions given at t h e end
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included will be of help to t h e teacher as well as t o t h e student.

CONTENTS

FIRST LESSON

Social Security : A New Name for an Old Aspiration.

SECOND LESSON

Persons Protected.

THIRD LESSON
FOURTH LESSON
FIFTH LESSON

Benefits : General—Family Allowances.
Benefits : Sickness and Maternity Insurance.
Benefits : Pensions (Invalidity—Old Age—Death of Breadwinner).
SIXTH LESSON
Benefits : Pensions (Qualifying Periods—Pension Formulas).
SEVENTH LESSON Benefits : Employment-Injury Benefits—Unemployment
Benefit.
EIGHTH LESSON
The Financing of Social Security Schemes : Frequency and
Duration of Benefits.
NINTH LESSON
The Financing of Social Security Schemes : Periodical Distribution of Cost—Distribution of Cost among Population
Sectors.
TENTH LESSON
Administration of Social Security Schemes.
Suggestions for Further Reading.
132 pages

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