The financial crisis and health care systems in Europe : universal care under threat ? Trends in health sector reforms in Germany , the United Kingdom , and Spain

The paper analyzes trends in contemporary health sector reforms in three European countries with Bismarckian and Beveridgean models of national health systems within the context of strong financial pressure resulting from the economic crisis (2008-date), and proceeds to discuss the implications for universal care. The authors examine recent health system reforms in Spain, Germany, and the United Kingdom. Health systems are described using a matrix to compare state intervention in financing, regulation, organization, and services delivery. The reforms’ impacts on universal care are examined in three dimensions: breadth of population coverage, depth of the services package, and height of coverage by public financing. Models of health protection, institutionality, stakeholder constellations, and differing positions in the European economy are factors that condition the repercussions of restrictive policies that have undermined universality to different degrees in the three dimensions specified above and have extended policies for regulated competition as well as commercialization in health care systems. Universal Access to Health Care Services; Health Care Reform; Health Policy REVISÃO REVIEW


Abstract
The paper analyzes trends in contemporary health sector reforms in three European countries with Bismarckian and Beveridgean models of national health systems within the context of strong financial pressure resulting from the economic crisis (2008-date), and proceeds to discuss the implications for universal care.The authors examine recent health system reforms in Spain, Germany, and the United Kingdom.Health systems are described using a matrix to compare state intervention in financing, regulation, organization, and services delivery.The reforms' impacts on universal care are examined in three dimensions: breadth of population coverage, depth of the services package, and height of coverage by public financing.Models of health protection, institutionality, stakeholder constellations, and differing positions in the European economy are factors that condition the repercussions of restrictive policies that have undermined universality to different degrees in the three dimensions specified above and have extended policies for regulated competition as well as commercialization in health care systems.
Universal Access to Health Care Services; Health Care Reform; Health Policy REVISÃO REVIEW

Resumo
O artigo analisa tendências de reformas de saúde contemporâneas, em contexto de forte pressão financeira, resultante da crise econômica iniciada em 2008, em países europeus com sistemas nacionais de saúde (modelos bismarckiano e beveridgiano) e discute suas consequências para a universalidade.São analisadas reformas recentes na Espanha, Alemanha e Inglaterra.Para descrição dos sistemas de saúde, utiliza-se matriz comparativa da intervenção estatal no financiamento, regulação, organização e prestação de serviços.O exame das repercussões das reformas sobre a universalidade é realizado com base em três dimensões: amplitude da cobertura populacional; abrangência da cesta de serviços; nível de cobertura por financiamento público.Modelos de proteção em saúde, institucionalidade, constelação de atores e posição na economia europeia diferenciados condicionaram as repercussões das políticas restritivas.Elas afetaram a universalidade nas três dimensões, com distinta intensidade nos países, e aprofundaram políticas prévias de competição regulada e comercialização.Acesso Universal a Serviços de Saúde; Reforma dos Serviços de Saúde; Política de Saúde http://dx.doi.org/10.1590/0102-311X00021314 Cad. Saúde Pública, Rio de Janeiro, 30 (11):2263-2281, nov, 2014 Immersed in their worst economic crisis since World War II (comparable to that of the 1930s) 1,2 , European Union member countries are suffering major financial pressures on their universal health systems.Following the international banking crisis of 2008 triggered in the United States (and resulting from deregulation of the financial market in recent decades), the financial crisis sparked a widespread recession in 2009.Since then, Europe has suffered a crisis with heavy indebtedness and public deficits resulting from government takeover of private bank debts, rising and spreading interest rates in the different European states, and fiscal austerity measures 2,3 .European governments used public funds to bail out their financial systems, transferring private bank debts to the public debt, even while the economic recession (with rising unemployment) caused a drop in government revenues 2,4 .This process led to deficits in public budgets and the so-called "public debt crisis".
With the aim of stabilizing the European financial system, a fiscal pact and financial stabilization fund were negotiated to support the countries in crisis.Under the fiscal austerity pact, European Union member countries committed to a sustained reduction in their deficits and greater budget discipline to "consolidate" their public budgets 1,2 .Drawing loans from the stabilization fund, the countries submitted to an austerity and adjustment program that included measures to restructure the labor market and their financial, fiscal, social security, and health systems, along with unprecedented budget cuts in various social programs 3,5 .During this process, international agencies have intervened directly in national health policies 6 .
The current article aims to analyze trends in the contemporary health system reforms in a context of heavy financial pressures stemming from the economic crisis (2008-date) in European countries with universal health systems (Bismarckian and Beveridgean models) and to discuss their immediate and potential consequences for universal coverage.We analyze the recent reforms and principal characteristics of the health systems in Spain, Germany, and England.
The crisis affects the European countries to different degrees and in different ways, depending on each country's capitalist development model and corresponding welfare state regime, with distinct interactions between growth policies, labor market institutions, and social sectors 2 , the correlation of political forces, and countries' differential insertion in the single European market.However, by taking excessive public indebtedness resulting from the banking crisis as the cause of the crisis, the single recipe of the European agencies is a fiscal austerity program that affects social policies and impacts health reforms 5 .
European health systems are already showing repercussions from the economic crisis and fiscal austerity policies.In 2010, in various European countries, real per capita health expenditures decreased, reversing a persistently upward trend (4.6% per year in the previous decade) 7,8 .The economic crisis also impacts access to health services and the population's health status, with an increase in suicides, homicides, mental disorders, and drug abuse in the most heavily affected countries 9,10,11 .

Methodology
Comparative analysis of countries is a traditional approach in political science that has been widely used for some time to study regimes and institutions.In the social policy field, it allowed identifying welfare state regimes, as in the classical studies by Titmuss 12 and Esping-Andersen 13 .In public policies, it is common to compare structures and institutions for operational purposes and (more recently) to identify performance determinants 14 .
In health, comparative policy analysis has evolved in recent decades, moving away from simple performance classifications and ranking of health systems between countries, viewed with increasing skepticism 15 , towards studies aimed at a more in-depth understanding of the conditions under which given changes occur: what works, where, and why 16 .
Case studies are still the cornerstone of comparative research, and the trend among comparative scholars is intensive analysis of a few cases, since it allows a comprehensive understanding of the theme under study and the multiple interrelations between the observed phenomena 14,17 .In health policies, the best comparative studies analyze a few cases and examine a specific theme based on a common structure or matrix, and/or a main theoretical question 18 .
For the current study, three cases were selected that exemplify European countries with universal health systems: Germany, Spain, and the United Kingdom.These countries differ in their welfare systems and in the organization of their health care systems, and are subject to different financial pressures from the European crisis.During the pre-crisis period, they were similar in their high economic and social development with an expanded social protection system, universal health coverage with public financing, and public financing exceeding 75% of total health expenditures.The three countries share excellent health indicators and an analogous epidemiological situation and face similar demographic pressures and prevalence rates for chronic diseases (Table 1).
The selected cases allow comparing reforms in the face of the crisis and trends in countries with distinct modalities of health protection and health system organization.The study assumes that differences in health sector institutionality and the countries' positions in the European financial crisis condition the impacts on their respective health systems 18 .
As a tool for comparison and analytical description of the health systems, a matrix was developed that contemplates the dimensions of state intervention in health as suggested by Immergut 19 and the corresponding categories: financing (share of different sources of financing, trends in public financing, copayment, modalities of resource allocation); regulation (insurance, services package and incorporation of medical technologies, relations between financers and providers, payment systems); and health services organization and delivery, grouping ownership of services and health employment (supply and organization of primary outpatient and specialized care, hospital care, share and role of public and private providers, management modalities, employment modalities, changes in public-private relations in the delivery of services).
The analysis of how health system reforms impacted universal coverage was based on the model proposed by the World Health Organization (WHO) 20 , including three dimensions of universal coverage: (i) breadth of population coverage by social health protection (variations in the insured population and rules for inclusion); (ii) depth of the package of services (changes in the package, rationing measures, variation in supply); and (iii) height of coverage by public financing (proportion of health spending covered publicly, trends in public expenditures, and changes in copayment).
The sources of information and techniques included: document analysis of reforms and legislative bills (2008-2012), secondary data from the Organization for Economic Cooperation and Development (OECD) Health Data, and statistics from the European Union and individual countries' information systems.A review of the recent literature was performed to monitor the current reform processes, including the gray literature and press articles, since they examine processes under way, without the delay involved in publishing analytical articles in scientific journals.They provide valuable additional sources of in-formation for analyzing contemporary political processes 21 .

National health systems from a comparative perspective
Germany, England, and Spain have different welfare regimes 13,22 , and in health they represent two main modalities of state intervention: Bismarckian social insurance and Beveridgean national health service models (Table 1).
In Germany, social health protection is guaranteed by compulsory Social Health Insurance, depending on participation in the labor market and solidarity contributions by workers and employers in proportion to wages 23 and currently covering 89% of the population.In the United Kingdom, the National Health Service (NHS), created in 1948, with universal access based on citizenship and tax-based financing, guarantees free coverage to the entire population, using a traditionally single and centralized structure.However, the NHS-UK was decentralized in 2004 to the four countries of the United Kingdom, and the current NHS of England, Scotland, Wales, and Northern Ireland display some distinct characteristics 24 .Therefore, the case analyzed in this article is NHS-England.In Spain, after a prolonged dictatorship, the 1978 Constitution provided the universal right to health care, and 1986 witnessed the creation of the Sistema Nacional de Salud, or National Health System (SNS), with tax-based financing and universal access, decentralized to the 17 Autonomous Communities (State level) 25,26,27 .

Financing
Financing is predominantly public, with distinct sources and characteristics in the three countries, summarized in Table 2. Resource allocation displays different dynamics.In Germany, a Health Fund of the Gesetzliche Krankenversicherung (GKV), created in 2009, combines all the contributions collected by the Sickness Funds and redistributes them on a risk-adjusted per capita basis using age, gender, and presence of 80 diseases among the insured population in each Fund 28 .Allocation between sectors results from negotiations between Sickness Funds and organizations representing providers according to sector of care.
In Spain, the responsibility for health care has been fully transferred to the Autonomous Communities (CCAA) since 2002, and health care financing has been integrated into general  non-binding Federal transfers, calculated on the basis of demographic criteria and public services to be covered 29 .
In England, transfers to the decentralized agencies of the NHS responsible for hiring services (health authorities, subsequently "primary care trusts" or PCTs, and since 2013 the "clinical commissioning groups" or CCGs), are based on a "weighted capitation" formula for equitable resource allocation: per capita allocation adjusted by demographic, epidemiological, socioeconomic, and health inequality factors (Table 2) 24 .

Regulation
Market-oriented health reforms in recent decades have posed new challenges for state regulation and have been accompanied by the creation of specific agencies for the task 30 .Regulation of health protection and the health system in the three countries occurs in different ways, in addition to the respective national legislative processes.In Germany, the decisionmaking process is shared among corporate organizations with public functions, the Federal government, and the 16 States.Health sector regulation is traditionally of the meso-corporatist type, according to which the government delegates regulation of a given sector of society to the stakeholders immediately involved in that activity.Federal legislation defines the structural conditions, while the competencies for their materialization are delegated to the stakeholders, namely representative organizations of the Sickness Funds, and providers, especially the Associations of Accredited Phisicians (KVen) and the Joint Federal Commission of Sickness Funds, Physicians, and Hospitals (G-BA) 31 .
In England, the NHS was traditionally regulated by the Department of Health, which both financed the system and regulated resource allocation and delivery.Beginning with the establishment of the internal market in the 1990s, a series of independent agencies with specific regulatory functions were created and successively restructured, featuring the National Institute for Health and Care Excellence (NICE), Monitor, and Care Quality Commission (CQC) (Table 3) 21, 30,32 .
Regulation of Spain's SNS occurs mainly through national and State legislation and government agencies: Ministry of Health, Inter-Territorial Council of the SNS, and the Consejerias or Boards of Health and Health Services of the 17 Autonomous Communities or CCAA (States).The Federal government, through the Ministry of Health, is responsible for setting basic standards and requirements for the functioning and coordination of the SNS and for guaranteeing equity.The 17 Regional Health Systems organized by the CCAA are autonomous and report to their local parliaments 27 .
In the three countries, the guarantees for entitlement and population coverage are regulated by national legislation, and services coverage is comprehensive at all levels of care.The incorporation of new services and technologies tends to be regulated by specific agencies (Table 3).
Relations between financers and providers are regulated by different mechanisms in the three countries.In Germany, relations are regulated corporately by collective bargaining (with some selective contracts) between Sickness Funds and providers, organized representatively in Associations in each of the health care sectors: accredited physicians, accredited dentists, pharmacies, midwives, as well as directly with the pharmaceutical industry.
In England, with the creation of the internal market and separation of roles between financing and delivery in the NHS, primary care organizations took over the planning, commissioning, and service procurement roles and began to establish contracts with providers of specialized care.Such primary care organizations have assumed different formats over time: in the 1990s, some GP-Fundholders; from 2003 to 2012, the PCTs grouped all the GPs (general practitioners) in a given area, and since 2013 the CCGs were created.Relations between CCGs and other providers are currently regulated by the new health authority, NHS-England, which authorizes, hires, and monitors the clinical commissioning groups (CCGs), transfers resources, and commissions primary care services and part of the higher-complexity specialized care, replacing the previous strategic health authorities.CQCs set standards and monitor safety and quality of services.The Monitor licenses providers, sets prices, and regulates competition between NHS providers 24,33 .
In Spain, the health authority in each CCAA is the Consejeria de Salud, responsible for individual and collective health policy by establishing, regulating, and planning the Autonomous/ Regional Health Service, which adopts different management formats in the various CCAA.Its attributions include health services delivery and management and coordination of networks.The relationship between the Consejeria de Salud (financer) and the Autonomous/Regional Health Service (provider) and between the latter and each health area management tier is regulated by a program contract: a goals-oriented management system that defines the budget, an assessment model, and incentives to strengthen strategic lines of action 26 .

Organization and delivery of services
The state's social protection models and territorial arrangements in each country condition the organization of their health care systems.Germany's Social Health Insurance does not deliver services directly, but contracts them out to public or private providers organized in corporate entities, without regionalization or territorial organization of the network.In the national health services in England (unitary) and Spain (decentralized to the States), the predominant format is the system's own providers with a tradition of regionalized and hierarchical territorial organization of services networks, strong primary care, and general practitioners in the gatekeeper role.Table 4 summarizes the main characteristics of the system's organization and outpatient and hospital care in the three countries.
The three country cases differ as to characteristics of the hospital sector.In Germany, the Sickness Funds establish contracts with each hospital and pay for their users' hospitalizations based on a system of prospective, diagnosis-related payment (adapted DRG).Nearly all of the hospitals in Germany are hired by the all Sickness Funds, with the supply distributed between public (49%), charity (35%), and private providers (17%) 28 .
In the English hospital sector, the establishments are predominantly public (95%), although they have gradually assumed greater management autonomy (trusts), and the physicians are salaried employees of the NHS 24 .
In Spain, 84% of the general hospital beds are public and 81% of hospitalizations are financed by the SNS, of which 92% provided by public hospitals 34 .Each health area, with a population of 200 to 250 thousand inhabitants, has at least one general hospital in charge of admissions, specialized outpatient care, and emergency services.Most hospitals are still under direct public administration with a program management contract with the CCAA Regional Health Service 26 .

Financial crisis and health reforms
In recent decades, facing economic, demographic, epidemiological, and political pressures, health systems in European countries have undergone repeated reforms.Particularly in the 1990s, accompanying neoliberal economic policies, widespread reforms were implemented, introducing market mechanisms to increase competition in public health systems, with different results between countries, conditioned by the institutional legacy, traditions of state interven- tion in health, stakeholder constellations, power distribution, and values 31,35,36,37 .
In the context of the crisis, the three countries experience distinct financial pressures (Table 5) with different repercussions on the health systems.Spain, UK, and Germany entered a recession in 2009, but their different positions in the European economy conditioned both the ways they dealt with the crisis 38,39 and its consequences for the national health systems, as presented next, beginning with Spain.
Spain was one of the European countries most heavily affected by the 2008 financial crisis.With a production model characterized by low competitiveness, moderate deindustrialization after the country's entry into the European Union, growing economic dependence on the construction market and mortgages, and a real estate boom that led to progressive private indebtedness, the burst in the real estate bubble had disastrous effects: widespread default by indebted families, growing unemployment, and rising interest rates (European Central Bank.Statistical data warehouse 2013.http://sdw.ecb.europa.eu,accessed 13/Jan/2013) 40,41 .With the ongoing recession, the public deficit has remained above 10% since 2009 (Table 5).
In the face of the crisis, Spain submitted to fiscal austerity dictates by imposing major cuts in public expenditures 41  specific national act called the Royal Decree Law 16/2012 42 included drastic measures: seven billion Euros in cuts in the SNS, a change in entitlement, excluding undocumented immigrants, changes in the common package of services, expanded copayments, and changes in the regulation of pharmaceutical care.Table 6 summarizes the impacts of this reform on universal coverage.Considered a counter-reform move against the guarantee of a universal public system 26,43,44 , RDL 16/2012 42 imposed a legal change in entitlement and thereby broke with the principle of health as a right of citizenship and established Social Security membership as a condition, in opposition to the universal citizen's right and the spirit of the General Health Law of 1986 that created the SNS, in a break with previous consensuses and a return to its Bismarckian origins, according to various researchers that have criticized the reform 26,43,45 .
The Conservative government has created a drastic scenario of cuts in the SNS that have already reduced the mean per capita budget in the SNS from 1,343 to 1,203 Euros between 2010 and 2012 46,47,48 .The spending reduction was achieved mainly through cuts in staff (wage freezes and cuts, lack of employee replacement, increased workload) and in pharmaceutical care, given increases in copayment and new rules for rational use 47   the cuts, staff downsizing, and purchase of services, waiting times have increased for elective surgeries 34 .
The CCAA are suffering growing pressure to enforce cuts, but the CCAA have responded differently, depending on their respective governments: five CCAA have filed appeals against RDL 16/2012 on grounds of unconstitutionality and continue to provide treatment to immigrants, with differential enforcement of the legislation 43 .
In the United Kingdom, due to the great importance of the financial sector, the banking crisis of 2008 had serious consequences for the British economy.The UK suffered a recession with a drop in the GDP in 2009, slow growth in the following years, a strong increase in the public debt (92%), and a public deficit that reached -11.5% of GDP in 2009, despite persistently low interest rates (European Central Bank.Statistical data warehouse 2013.http://sdw.ecb.europa.eu,ac-

Increased waiting times
No.
There  5).The economy's heavy dependency on the financial sector and the private indebtedness during the crisis forced the British government to deal with the dual challenge of dwindling revenues from the financial sector and the simultaneous need to inject public resources into this sector to avoid a collapse in the banking industry 11 .However, the British austerity program did not result from an imposition by the European Union.The United Kingdom did not introduce the Euro, and to defend its financial elites, it refused to participate in the fiscal pact of 2012, which included guidelines for regulating the financial system 39 .In England, with the new UK Conservative-Liberal coalition government, 2010 witnessed an important reform in the NHS, regulated in 2012 in the Health and Social Care Act 2012 33 , which established a budget cut policy in NHS-England (20 billion pounds in five years) and stepped up previous trends towards privatization of services and the introduction of greater competition within the NHS, with the reorganization of relations between financing/purchasing and delivery and expanded roles for the regulatory agencies 32,49,50 .The CCGs were created as local organizations of GP clinics, replacing the PCTs since April 2013 in hiring specialized and hospital services for their enrolled patients (abandoning territorial accountability 51 and taking over management of 70% of NHS expenditures).To encourage competition, the CCGs are mandated to purchase services from "any qualified provider", which includes the public hospitals of the NHS (all of which to be turned into Foundation Trusts) and private providers.The CCGs are also expected to present referred patients with different options for providers 33 , a measure intended to incentivize private supply, which still has a limited presence in the NHS.The CCGs are intended as small administrative structures and hiring Commissioning Support Services (CSS) for the commissioning tasks 52,53 .The aim is to cut administrative expenditures in the NHS by 45%, with an estimated 30 thousand displaced NHS employees 32 (Table 6).
The CCGs will have greater autonomy and will be regulated by NHS-England, an independent organization vis-à-vis the Department of Health, a move that has been interpreted as eliminating the responsibility of the Secretary of State for Health in guaranteeing care 54 .The CCGs should guarantee health care delivery but are not responsible for the population's health in a given geographic area, except for urgent and emergency care.According to Pollock & Price 55 , government's duty to provide comprehensive care has been abolished, since according to the new law, government only has the duty to promote comprehensive care, not to guarantee it.
Germany, with a production model based on high-tech development, a highly skilled workforce, and high productivity, was benefited by the introduction of the Euro 2 , which facilitated exportation within the region.In an advantageous positon due to growing German trade surpluses with the other European countries and extremely low interest rates, Germany resumed positive growth in 2010, reduced unemployment (Table 5), and received investments, and the social insurance schemes showed surpluses in 2012 due to rising employment 38 .
In Germany, the financial crisis was not accompanied by new containment measures or a structural health reform, but the crisis did serve as the catalyst and legitimation for the intensification of social cuts and the commodification of health by the Conservative-Liberal coalition 5 .The country enacted a series of laws on financing, pharmaceutical care, and regulation and improvement of the services supply in rural areas 28 .
The 2009 recession led to forecasts of deficits in the GKV, and initially to compensate for revenue losses resulting from the crisis, the country established an additional transfer of fiscal resources to the GKV Health Fund (created in 2007).In 2010, the contribution rate in the GKV was increased to 15.5% and the parity contribution was revoked: employers' contribution was fixed at 7.3% and workers' contribution was increased to 8.2% of wages.The limit was also abolished on charging an additional tax (a per capita amount bearing no relationship to wages and paid directly by members to the Sickness Fund in case the latter was unable to cover its expenses with the resources from the GKV Fund), thereby reducing solidarity in financing 56 .
Germany also passed an important law in 2010 to restructure the pharmaceutical market, establishing a set of rules for price controls and cuts for medicines and rigorous standards for systematic evaluation of the benefits of new drugs by the GKV Joint Federal Commission, expanding its functions 28,56 .

Immediate and potential repercussions for universal coverage
The reforms in the three countries impact the three dimensions of universal coverage to different degrees (Table 6).The first dimension, "breadth of population coverage by the public system" is affected in Spain by changes in the rules for inclusion, which will result in reductions in the proportion of the population insured in the short and long term, with the exclusion of undocumented immigrants and residents not enrolled in Social Security.However, no changes have been observed so far in the indicators for population coverage, since the number of undocumented immigrants is relatively small, and some Autonomous Communities and services have resisted enforcing the restrictions.
In the three countries, coverage by the public system has remained at the previous levels, and there has been no increase in coverage by private insurance.The proportion of the population with duplicate coverage in Spain and England has not changed, and in Germany the population covered by substitute private insurance has remained at the same level (Table 3) 29 .
The dimension of universal coverage "depth of the services package" is under stress and is suffering various types of restrictions in the three countries.Spain is experiencing changes in the package of services, with the explicit exclusion of Cad.Saúde Pública, Rio de Janeiro, 30 (11):2263-2281, nov, 2014 certain services.In England, the CCGs will be able to define the services they consider necessary 54 .In the three countries, implicit rationing measures with prioritization of services tend to result from budget cuts.There has been stricter control on the inclusion of new services in the package, strengthening the regulatory bodies' role (Table 6).The increase in waiting times for elective surgeries is an immediate effect of the cuts in Spain and those planned in England.Spain is suffering a reduction in the supply of health services due to cuts in staff and investments.
New management formats in public establishments, public-private partnerships for investments, privatization, and outsourcing of hospital administration are trends in all three countries that can influence the availability of services, given their commercial orientation.In England, all public hospitals are to be turned into Foundation Trusts with greater autonomy and the possibility of raising private funds, and the CCGs will be required to hire any provider, thus pointing to greater private sector participation in health care delivery.Even so, in Spain, the Conservative government in Madrid gave up on its plan to privatize public hospitals due to the widespread social mobilization of the marea blanca movement in defense of public hospitals and the five-week health workers' strike 57 .
The third dimension of universal coverage, "height of coverage by public financing" has been affected by budget cuts and increases in copayments, although no immediate impact has been seen in the proportion of health expenditures covered publicly, which were slightly higher in 2011 than in 2007 and maintained their share of GDP (Tables 2 and 6).The legislation set restrictions.Beginning in 2009, the trend was towards decreasing public expenditures in Spain and the UK and a slowdown in Germany, mirroring the overall trend in European countries towards reducing public health expenditures since the financial crisis 7,8 .
Increases in copayments shift the responsibility for financing from the state to families.Following the trend in other European countries 6 , copayments were expanded explicitly in Spain and implicitly in England, since public hospitals transformed into autonomous organizations have started offering NHS patients the "option" of direct private payment for certain services 58 .In Germany, on the contrary, given the GKV surplus, copayment was abolished from outpatient care due to pressure by physician specialists who were constituents of the Liberal Party, part of the Conservative government coalition 38 .

Final remarks
The recent international financial crisis heightened the economic pressures on national health systems and was used as an opportunity by conservative governments to extend restrictive measures, expand market space and competition, and reduce state intervention 5,39 .
Recent policies in the face of the financial crisis follow the previous strategies of "marketoriented reforms" and extend regulated competition, with separation of roles between financers/purchasers and providers of services in the national health systems, besides mechanisms to expand competition between insurance organizations in social insurance.There has been an expansion of management measures inspired by the "New Public Management", with new management models in public services and the relationship between providers and purchases regulated by contracts.
Responses to the crisis in the three cases had common objectives of containing public health expenditures and austerity policies to control the public deficit, however with different measures.Spain, the country of the three most heavily affected by the crisis, has suffered more drastic cuts with an emphasis on increases in copayment, exclusion from coverage, and cuts in staff expenditures.The English reform is the deepest, with extensive reorganization of the NHS and of the relations between financers and providers with a reduction in management roles and administrative personnel and opening of the "internal market" to private providers, with an increase in competition and commercialization in the NHS.Financing remains public, but with a trend towards privatization in various components of the NHS: encouragement for private use of hospital services, delivery of GP services by private companies, changes in the management and ownership models in NHS hospitals, and outsourcing of funds management with the creation of the CCGs.Decisions on allocation of the majority of NHS resources will be made by CSS outsourced, and no longer by NHS agencies as in the case of the PCTs.Germany, better positioned in the crisis, with low unemployment, showed a surplus in its Social Health Insurance and reinforced its policies to stabilize the contribution rates.The country froze the employers' contribution, shifting the responsibility for future increases to employees, allowing additional taxes stipulated by the Sickness Funds in case the latter fail to cover their expenditures with resources from the GKV Fund, forcing competition between Sickness Funds and a reduction in expenditures.
The degree of impact of restrictive measures differs between the three countries, due to their diverse health protection models, institutional frameworks, and health sector stakeholder constellations, besides their very different positions in the European financial crisis and economy.The "breadth" of the insured population has only been explicitly affected in Spain.The "depth" of the package of services covered by their health systems has been affected indirectly in the three countries, with greater control over the incorporation of new procedures and restrictions on delivery.Per capita public expenditures have decreased in Spain and England, affecting the "height" of universal coverage.
Nevertheless, these changes have only had a marginal effect on universal coverage thus far: public schemes cover the vast majority of the population, the package of services insured by the system remains deep, and in the three countries more than 74% of health expenditures remain public.In the face of the crisis, the European countries in general have not made important changes in the package of legally insured benefits, and reductions in population coverage have mostly been marginal 6 .However, there has been a stagnation or reduction in public health expenditures which, if it persists, could have harmful consequences for universal coverage in the medium term.
This is an open process.The financial crisis has placed serious pressures on the European welfare states and national health systems, but analyses of the repercussions of previous experiences with conservative reforms in the 1980s and 90s suggest non-linear processes with both backward and forward trends.Pro-market rhetoric has been more intense than its implementation in practice, and the principle of solidarity and the health systems' public nature have not been seriously shaken 35,37,59,60,61 .
Meanwhile, crises can also engender positive consequences and new solutions.Economic crisis situations highlight the importance of social policies to mitigate their adverse effects, and citizens can rally to defend such policies 62 .The intensity of repercussions on universal coverage in the medium and long term will be conditioned by the action of social stakeholders and the nature of the crisis (whether situational or structural) as a crisis of democratic capitalism characterizing Western Europe in the latter half of the 20 th century 1 .
This study of selected national cases revealed a diversity of situations in the respective health systems in the face of the financial crisis, while contributing to the contemporary debate on universal coverage 63 .Nevertheless, this was a situational analysis limited to examining the recent literature and general data, which does not allow identifying the consequences for specific social groups or geographic and social inequalities.Unveiling the long-term trends requires further follow-up and new studies.

Resumen
El artículo analiza las tendencias de reformas de salud contemporáneas -dentro del contexto de la crisis económica (2008)-en países europeos con sistemas universales de salud (modelos bismarckiano y beveridgiano) y discute las implicaciones para la universalidad.Se analizan las reformas de salud en España, Alemania y Reino Unido.Para la descripción de los sistemas de salud se utiliza una matriz comparativa de la intervención del Estado en la financiación, regulación, organización y prestación de servicios.Se examinan los efectos de las reformas sobre la universalidad en base a tres dimensiones: amplitud de la cobertura a la po-blación; composición de la cesta de servicios; y nivel de cobertura con fondos públicos.La diversidad de modelos de protección en salud, instituciones implicadas, constelaciones de actores y la posición de esos países en la economía europea han condicionado el impacto de las políticas restrictivas en cada uno de ellos.Estas últimas afectaron a la universalidad en sus tres dimensiones, con diferente intensidad, y profundizaron políticas anteriores de competencia regulada y comercialización.Acceso Universal a Servicios de Salud; Reforma de la Atención de Salud; Política de Salud GDP: Gross Domestic Product.* Data from the European Commission.(Eurostat: statistics.http://epp.eurostat.ec.europa.eu/portal/page/portal/statistics/search_database, accessed 22/Jan/2014); ** Data from the European Central Bank (Statistical data warehouse 2013.http://sdw.ecb.europa.eu,accessed 13/Jan/2013); *** Refers to December each year.Implicit in payment systems.Implicit in staff and investment cuts.Due to budget cuts, CCGs will be forced to ration services; already practiced by PCTs, which have excluded services with low costeffectiveness, and have regulated access.Control of entry of new services in package Reinforced action by Joint Federal Commission of the GKV in the definition of whether services will be incorporated into the package Increased discretionary power by Ministry of Health in cutting services; expanded control over the entry of new services through creation of the Spanish Network for Health Technology Assessment of the SNS.Expands the functions of the National Institute for Health and Care Excellence (NICE): includes social care -assesses whether the procedures are cost-effective and safe and develops guidelines for priorities.

Table 1
General characteristics of selected case countries: Germany, Spain, and United Kingdom.

Table 2
Financing of national health systems in Germany, Spain, and England.

Table 3
Regulatory characteristics of the national health systems in Germany, Spain, and England *.Numerical data refer to the United Kingdom and to the specifications of NHS-England.

Table 4
Organization and provision of services in the national health systems of Germany, Spain, and England.