Does the health system model shape prevention? Evidence from 22 OECD countries (2004-2023)

Against a background of population ageing, rising healthcare costs, and growing public-health challenges, this study analysed trends in the share of total health expenditure allocated to preventive care from 2004 to 2023 in 22 European countries, examining whether specific health systems are associated with different relative budgetary prioritisation of preventive care. Although there are few studies investigating this issue adopting the standard tripartite classification, to our knowledge, this is the first study to explore the topic using the latest classification of healthcare systems proposed by Böhm.

We conducted a time-trend analysis using secondary data from 22 European OECD countries over a twenty-year period (2004-2023); in addition, a hierarchical semi-log polynomial mixed-effects regression analysis has been performed, including annual country-level percentage of total health expenditure allocated to preventive care in association with the three structural dimensions - regulation, financing and provision - according to Böhm's classification as explanatory variables.

Our results indicate that, in terms of compound annual rate, most countries exhibited an increase in the preventive-care expenditure share (between 0.2% and 3.7%), while seven countries showed a decrease (between -6.3% and -0.2%) during the considered period. The regression analysis shows that the trend of the preventive-care expenditure share did not differ in two of the three dimensions under study: financing and provision. In contrast, in countries with societal regulation, the curvilinear trend was more pronounced than in countries with statal regulation (b = 0.0035; 95% CI = 0.0013, 0.0057).

In conclusion, we found limited evidence that health-system type was associated with the relative share of health expenditure allocated to preventive care in the countries analysed; these findings suggest that the relative budgetary prioritisation of preventive care may be shaped less by formal health-system architecture than by contextual factors, including political priorities, public-health strategies, and major external shocks.