a ratio below 60%. The significant regression result might be driven by some very large countries with very low public expenditure on health like Brazil (48.7), China (24.9), India (13.0), Mexico (41.0) and the U.S.A. (44.1). The average percentage of VSC is, however, well in line with the figures for many European OECD members. It is a common fact that public expenditure on health constitutes a gradually increasing proportion of total public expenditure mainly due to technological progress. The figures for VSC are all in the range of comparable larger countries with two very notable exceptions. Andorra with 38.5% and Micronesia with an enormous 46.3% are very astonish - ing outliers, for which we do not have an explanation. One promising approach might be to simply question these figures.92 To sum up, health systems in VSC are comparable to health systems in larger countries. Size effects neither health system performance nor relative health expenditure significantly. This surprising result might be either due to the fact that the overall health system does not, contrary to our expectations, exhibit considerable economies of scale and, therefore, publicness. However, if we assume the existence of scale economies, the provision of health care, as a consequence, must be organized better in many VSC than in larger 
countries. 4.3.9  Theoretical expectations versus reality – political system It is beyond the scope of this work to go into the details of the political systems of VSC. This chapter is designed to give a brief overview of im- portant political variables. Not unexpectedly, the political systems of VSC differ from political systems of larger countries. Nevertheless, dif- ferences between larger countries and VSC are sometimes less significant than differences among VSC, which can easily be seen in Table A.12 in the Appendix. Hence, difficulties arise when the political peculiarities of 116 
Very small countries: organizational choice and international outsourcing 92Indeed, World Bank (1998) indicates totally different figures for Micronesia. The average government current expenditure on health is 10.8% of current government expenditure (1990–1995) and 10.6% (1995), based on World Bank and IMF data. The large difference cannot be due to different definitions (e.g., current vs. total expendi- ture). Unfortunately, the figure for Andorra could not be checked.