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From time to time, it is necessary for a painter to step back from his easel and get an overviewv of his work. Such an overview is equally important for health workers, and here is one concerned with the large picture, on a world-wide basis, of health departments and medical care.

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This article provides essential tools for reforming the U.S. health system. It describes the component elements of health systems and discusses the U.S. entrepreneurial health system. Several welfare-oriented examples are presented from which U.S. policymakers might draw, Germany being one case. Also explained are comprehensive health systems such as Great Britain's. The article also notes that even some developing countries, such as Sri Lanka, have managed to provide near 100% of their populations with complete health services. One cannot help but ask, why not in the United States? The socialist model is reviewed, and some general trends are sketched out.

Health maintenance organizations (HMOs) are being promoted as a strategy to modify the XJ.S. health care delivery system toward more economical patterns, encouraging preventive and ambulatory rather than costly hospital services. Evidence of HMO performance has accumulated over the years, much of it reviewed in 1969. Since then, additional evidence suggests that the "prepaid group practice" (PGP) model of HMO continues to yield lower hospital use, relatively more ambulatory and preventive service, and lower overall costs (counting both premiums and out-of-pocket expenditures) than conventional open-market fee-for-service patterns. Economies of scale in group practice per se are still not proved, but some evidence supports this theoretical hypothesis. N ew data point to reduced disability from the PGP model of HMO, as well as to more favorable consumer attitudes {based mainly on the economic advantages, in spite of certain impersonalities of clinics) than exist toward conventionally insured private solo practice. The medical care foundation {free choice of private practitioners with fee payments) model of HMO has yielded some evidence of economies in physi cian's care, but none in hospital use. HM Os entail hazards of underservicing and distorted risk-selection, but with appropriate public monitoring they constitute an approach to health planning, stressing local initiative, competi tion, and incentives to self-regulation.