Public competition versus mixed markets: an analytic comparison

The National Health Services of Brazil and Northern Europe: Universality, Equity, and Integrality-Time Has Come for the Latter

In 1990 the national health services in the United Kingdom and Sweden started to split up in internal markets with purchasers and providers. It was also the year when Brazil started to implement a national health service (SUS) inspired by the British national health service that aimed at principles of universality, equity, and integrality. While the reform in Brazil aimed at improving equity and effectiveness, reforms in Europe aimed at improving efficiency in order to contain costs. The European reforms increased supply and utilization but never provided the large increase in efficiency that was hoped for, and inequities have increased. The health sector reform in Brazil, on the other hand, contributed to great improvements in population health but never succeeded in changing the fact that more than half of health care spending was private. Demographic and epidemiological changes, with more elderly people having chronic disorders and very unequal comorbidities, bring the issue of integrality in the forefront in all 3 countries, and neither the public purchaser provider markets nor the 2-tier system in Brazil delivers on that front. It will demand political leadership and strategic planning with population responsibility to deal with such challenges.

Adopting and adapting managed competition: health care reform in Southern Europe

A new paradigm appeared in Europe in the early 1990 s regarding the reform of health care systems. This paradigm has come to be known as the managed competition paradigm, among other terms. First introduced in Great Britain, it entails the separation of the financing/purchasing and providing functions, so that competition among providers is enhanced, while maintaining universal access and public financing, at least in principle. This article explores to what extent such paradigm has been emulated within the Greek, Italian, Portuguese and Spanish health care systems. Reform in the direction of managed competition may be ascertained in all four countries. However, each country has emphasized different aspects of the paradigm, and the degree and rhythm of implementation of reform has varied. The article considers the circumstances under which the new paradigm was born, and its main characteristics; analyzes actual reforms in Southern European countries; and provides a tentative explanation of the diffusion mechanisms. It concludes that the crucial factor explaining the different paths of policy adoption and adaptation is the character of the initial health care system.

Mortalidade hospitalar como indicador de qualidade: uma revisão

Este artigo visa a discutir as principais questões metodológicas relacionadas à mortalidade hospitalar como indicador de qualidade. Variações nos valores deste indicador se devem a inúmeros fatores, associados ao doente e à doença, que devem ser examinados para que possamos utilizá-lo como medida de desempenho. Presença de comorbidades e a gravidade do caso estão associadas à chance de morrer . Aspectos metodológicos, relevantes para a construção deste indicador, incluem a qualidade das fontes de dados, o intervalo de tempo no qual elas são calculadas e os diferentes tipos de agregação. São discutidos diversos modelos, tanto para classificação da gravidade, quanto para o ajuste das taxas de mortalidade entre serviços. São examinados ainda modelos explicativos para a variação de mortalidade. Conclui-se que nas condições em que a morte não é um evento raro, o emprego de taxas de mortalidade hospitalar representa uma ferramenta útil para indicar serviços com eventuais problemas de qualidade.

Health system reforms--toward a framework for international comparisons

Health care reform efforts internationally are focused more on efficiency than on effectiveness or equity. We lack a coherent theoretical framework for understanding those reforms or for engaging in comparative research. This paper presents some theoretical ideas that could contribute to such a framework. A model constructed from expert opinion suggests that hegemonic systems, national systems and medical care systems all contribute, with specific elements identified in each. Three sociological ideas are suggested: a model of trends leading to a fiscal crisis and a crisis of alienation; communities, professions and markets as ideal typical organizational alternatives; global post-Fordist and world systems theories; and hegemonic projects. Together these could explain the timing, speed and direction of health care reform efforts throughout the world.

Os modelos de reforma sanitária dos anos 80: uma análise crítica

Este artigo analisa os principais modelos de reforma sanitária nos países centrais, nos anos 80, dissecando o corpo de idéias que informou as estratégias de mudança e os elementos constitutivos de uma nova agenda pós-welfare também para o setor saúde. Assume como premissas que a crise fiscal do Estado, a partir de meados dos 70, e a hegemonia neoliberal da década contribuíram para a formulação de um diagnóstico setorial comum e de prescrições que se difundiram como alternativas para o controle do crescimento do gasto sanitário e para o funcionamento dos sistemas de serviços de saúde mais eficiente e voltado para o consumidor. A partir da experiência norte-americana reintroduziu-se a idéia de competição no setor saúde, que teve várias releituras e aplicações no contexto europeu. Nesse processo produziram-se alguns modelos considerados paradigmáticos para a necessária reestruturação dos serviços de saúde, vinculados às exigências macroeconômicas de contenção de custos e de controle de crescimento do déficit público. A avaliação comparativa dessas políticas, nos países centrais, constata que as opções nacionais variaram muito e que existe uma grande distância entre o discurso ideológico e as políticas implementadas, evidenciando-se uma atuação estatal mais reguladora e centralizada, além de uma clara tensão entre os controles político e financeiro e a operacionalização dos mecanismos de competição nos sistemas de saúde.

Patient choice and patient empowerment in northern European health systems: a conceptual framework

The issue of patient choice presents a complicated challenge to publicly operated health systems. Increased patient choice can strengthen the citizen's commitment to traditional welfare state objectives, or alternatively, it can severely damage that commitment, depending upon the design of the choice mechanism and the structural context within which patient choice occurs. For patient choice to be linked to true empowerment, choice must reinforce rather than undercut the accountability of health care providers to the population they serve. This article explores the basic issues involved in empowering patients within publicly operated health systems. The author first reviews the conceptual components that could or should be incorporated within the notion of empowered patients, then examines what would be required to actually empower patients within health systems, defined in terms of expanding not only logistical choice but also clinical influence and decision-making participation. The article concludes with a wide-ranging analysis of the impact of potential policies and mechanisms on the long-term objectives in achieving democratically accountable health care systems.

Realities of Health For All by the year 2000

The European Region of the World Health Organisation (WHO) took the global lead on Health For All when the Regional Committee in 1980 approved a European Health For All Strategy. This was an important breakthrough for WHO as it was the first time Member States in a Region endorsed a common health policy and agreed to be monitored on their progress towards attainment of the strategy. The paper reviews the progress of Member States to date towards the Regional Health For All goal. Progress is discussed within the context of the six fundamental principles which underpin the Health For All concept, vis: equity; health promotion; community involvement; multisectoral participation; primary (local) health care; and, international cooperation. The paper argues that the commitment of Member States to the Health For All Strategy has been patchy with only moderate success towards meeting the 38 Regional Targets. Poor progress is attributed to changing national and international political and economic circumstances and limited resources but perhaps most importantly to a lack of political will to take the strategy seriously.

Reforming Swedish health care in the 1990s: the emerging role of 'public firms'

A growing number of Swedish county councils have started to develop more flexible methods by which to produce and deliver health services. This paper explores the current status of this reform process both empirically and conceptually. Empirically, it draws upon data obtained by a 1990 questionnaire from all 26 county councils to chart the level of movement across the entire system. Conceptually, it distills from this reform activity a key element that provides an organizational basis for the future, namely the transformation of provider institutions into 'public firms'. The paper concludes that while the precise outcome may be hard to predict, the reform process itself is well underway.

Reforming the Swedish health services: the international context

This article reviews the performance of Swedish health services in the international context. It notes that Sweden stands out as a country which has made a major commitment to the welfare state. Nowhere is this more evident than in the health services. Expenditure on health care is high by international standards and over 90% of expenditure derives from public sources. Despite Sweden's achievement in providing comprehensive health care to its population, a number of problems have emerged in recent years. In response to these problems, there has been a debate about options for reform. It is suggested that management reforms may offer the best way forward in improving the performance of health services. Policy makers should take advantage of the decentralised nature of the Swedish system to initiate and evaluate different reforms in different county councils.

Emerging trends in the Swedish health system

The Swedish health care system has embarked upon a broad process of organizational reform. Confronted by increasing pressures from an aging population, intensive new medical technology, and tightly constrained public sector budgets, Swedish county councils have begun to experiment with new models of health service delivery that incorporate specific elements adapted from market-oriented approaches. This article briefly reviews two of the more influential organizational models presently in place or under development in different counties, and assesses the revised role for health planning that these reforms will require at both county and national levels.

Working the markets: purchaser/provider separation in English health care

In 1991 the U.K. health system embarked upon a series of apparently radical changes in its organization, centering upon the notion of "purchaser/provider separation." After summarizing these changes, and their ostensible rationale, this article reports early experiences of the new system and outlines the alternative proposals of the main opposition Labour Party. Early experience suggests that the new system is unlikely to function as ostensibly intended. The Labour alternative, however, fails to address crucial organizational issues.

Towards a Swedish health policy for the 1990s: planned markets and public firms

The Swedish health system has entered a period of major structural transformation. Most county councils have begun to experiment with new service delivery mechanisms, and the governing Social Democratic Party has proposed wide-ranging reforms intended to improve the efficiency, quality, and responsiveness of all public human services. This paper draws upon key elements in the current Swedish debate to develop an alternative policy model for publicly operated health systems in general. We argue that the limitations of existing planning and market based policy models can be overcome by an approach constructed upon 'planned markets'. This alternative model involves restructuring publicly operated systems into an intentionally designed network of 'public firms' that engage in a socially as well as economically efficient process of 'public competition'. The model harnesses patient choice of provider as the driving mechanism to enhance both production efficiency and democratic participation within the Swedish health system.

GP budget holding in the United Kingdom: learning from American HMOs

A key component of the 1989 British National Health Service White Paper, 'Working for Patients', is the so-called budget holding plan for general practitioners. This controversial proposal calls on GPs to manage their patients' budgets for consultant (specialist) services and hospital care. Most aspects of the scheme, now only contemplated in the U.K., have functioned for years in American health maintenance organisations (HMOs). The thesis of this article is that an analysis of the GP budget holding proposal, in light of the many years of experience with HMOs, will provide valuable insight into how the British innovation might (or might not) function. Moreover, we believe the U.S. HMO experience has a high degree of relevance for the design, implementation and management of budget holding practices in the NHS of the 1990s, as well as other similar proposals being considered across the European continent.

[Changes necessary for continuing health reform: II. The "internal" change]

The article desired organizational and managerial changes in Primary Health Care, so as to develop a sound and feasible social marketing strategy. Key elements that should be changed are: 1. Rigid and centralized administrative structures and procedures. 2. Incentives system centralized and dissociated from the managerial structure. 3. Primary Health Care management units immersed in political conflict. 4. Absence of alternative in the margin. Users cannot choose. 5. Lack of an internal marketing strategy. Several ways of internal markets simulation are assessed as potential means for internal change. The need for an administration reform leading to a less inflexible system in the Spanish national and regional health services in reviewed too. Three changes are considered essential: a) Payment systems in Primary Health Care. b) Modifications in the personnel contracts. c) Reform of the budgeting processes. Specific strategies in each of these issues are suggested, making emphasizing the need of their interrelationship and coherence.

Implementing public competition in Swedish county councils: a case study

Earlier presentations of the theoretical framework for public competition (Saltman and von Otter, 1987) and of the comparative advantage of public competition as against a mixed market model (Saltman and von Otter, 1989a) suggest the importance of concrete arrangements to introduce a public competition approach at the operating level. This paper explores the administrative infra-structure required to implement public competition within the Swedish county-council-based health care system.