Change in the control of health care systems in Europe Implications for professional autonomy

Major changes are taking place in European health care systems,especially those in the former communist countries. However,in Western European countries reorganization is also on itsway, guided by the rhetoric of deregulation and competition.This might lead to a convergence in the institutional controlof health care systems, although it appears that different pathshave been chosen by Eastern European health care systems andWestern national health services. It is argued that the implicationsof these changes for the professional autonomy of doctors differand this is influenced by the way health care changes tie upclinical autonomy and economical autonomy.     

Managing the transitions: a Western European View of Health Care Development in Eastern Europe

The health care systems of Eastern Europe are undergoing rapidchange. Ministries of Health in the Eastern countries are turningto the West for solutions. This paper offers an overview ofthe health systems of four Eastern European countries, the catalystsof reform in those countries, and possible strategies for managingthe transitions. The objectives of health care reform are outlinedas well as the key issues and obstacles facing Eastern governmentsas they attempt to change both the structure and function ofhealth care systems.     

Explaining trends in the privatization of health services in South Africa

This paper analyses the two major factors that have affectedthe trend towards privatization in the health sector in SouthAfrica. The first is the shift in government policy in favourof greater private sector participation in hearth care. Thesecond is the increase in medical aid scheme membership. The shift in government policy towards privatization shouldbe seen in the context of a shift away from welfarism to monetaristmacro-economic policies, witnessed in several advanced industrializedcountries. The change in SA's health policy should also be seenin the light of the post-1977 reform strategies of the Apartheidstate. However, the most important factor in the policy shiftsis the state's inability or unwillingness to fund hearth servicesadequately. Yet for privatization to succeed there has to be an increasein demand for private health care, i.e., an increase in thenumber of people able and willing to afford private health care.In SA the market amongst whites for private care is more orless saturated. Thus the second major factor promoting the growthof private medicine in SA is the increase in the number of blackscovered by medical aid schemes (i.e. health insurance). Thereasons for this trend are outlined. Finally, the implicationsof this analysis for policy interventions are discussed.     

Privatizing health care: caveat emptor

Many Western European countries are moving toward privatization of their health care systems. The United States' health care system, since it is almost entirely privatized, is therefore worthy of study. Doing so raises several questions. How is privatization being managed in the US? How could its management be improved? What management lessons must be kept in mind if it is to be used effectively? What potential pitfalls should European countries consider as they move toward greater privatization? With operating costs, European countries must avoid the mistakes that have led to dramatic increases in annual health care costs in the US, simultaneous with reductions in access and quality. Doing so requires designing systems that promote hospital behavior consistent with a country's health objectives. With capital costs, an approach must be designed that allows policy-makers to work closely with both managers and physicians in order to make strategically sound choices about access and quality. Such an approach will require physicians to incorporate their clinical judgments into community standards of care, and to adopt a regional (rather than an institutional or personal) perspective in the determination of any incremental capital expenditures. By making regulation proactive and strategic, rather than punitive, health policymakers in Western Europe can achieve the best privatization has to offer without feeling the sting of its unintended consequences. In so doing they can help to move their health systems toward achieving the multiple and illusive goals of access, quality and reasonable cost.     

Occupational and environmental health in eastern Europe: challenges and opportunities

As the nations of Eastern Europe undergo political and economic transitions, they face considerable occupational and environmental health challenges. Although occupational health services are relatively well developed, environmental health services and policies are not. There are major needs in the areas of education and training, supplies and equipment, and policy development. In addition, privatization poses a variety of new challenges and dangers to occupational and environmental health. This commentary discusses the challenges that face Eastern European nations, and describes opportunities for collaboration among scientists, policymakers, labor, management, and community groups in the United States and Eastern Europe.     

Privatization, social structures and delivery of health care in the Slovak Republic.

Each country in Central and Eastern Europe has developed a variety of strategies for implementing interventions and improvements in their health care delivery system. Transformation efforts in the Slovak Republic have focused on decentralization, privatization, democratization and liberalization. While the pressures for change have unevenly fallen throughout Central and Eastern Europe, the Slovak Republic has initiated structural changes, particularly in the area of privatization. The concept of privatization requires further discussion especially when considering the principle of subsidiarity and the need to develop coherent social structures. Areas for structural changes in the Slovak Republic are examined in the area of privatization of transformation efforts. Characteristics of successful voluntary organizations in private economies are discussed with appropriate future concerns identified for further analysis.     

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.     

Restructuring health care financing in Chile

The current Chilean government adopted a neoclassical model of development and subsequently introduced various incentives for the privatization of medical care. This paper analyzes health care financing in Chile during the last decade and evaluates government efforts to minimize state-financed medical care. In so doing, this paper provides a framework for analyzing private vs public medical care delivery systems in developing countries. For this reason, the first section discusses the major attributes and issues of public and private delivery systems followed by a case study examining the origins, effectiveness and impact of the restructured health system in Chile.     

Analysing health care systems performance: the story behind the statistics

This commentary paper argues that the Asia-Pacific region would benefit from a home-grown version of the European Observatory on Health Care Systems to inform health sector policy: an Asia-Pacific Observatory. The countries in this diverse region, ranging from highly developed to very poor countries, are undergoing dramatic and diverse health sector changes, often on the basis of little evidence and with little information on successes and failures in neighbouring countries. The international community also is interested in knowing more about the many distinctive models of Asia-Pacific health care. While statistical comparisons are important, health policymakers and researchers need to understand the story behind the statistics in order to interpret the numbers and to formulate policies and strategies. Health system profiles therefore are useful instruments that describe how a complex health sector works, offer a comparative framework for cross-national comparisons, identify trends in health system design, and with standardised measures and regular updates measure progress against benchmarks. These reports and expanded analyses have influenced both national and Europe-wide debates on health policy. In the Asia-Pacific region, health systems research has built up a critical mass of studies and people with strong links across countries. The next ambitious steps are to identify sponsors able to support an enterprise that transcends national boundaries and to begin a project of comparative studies of national health systems.     

The privatization of health care in three Latin American social security systems

Most Latin American social security institutes are direct providers of medical care services to their beneficiaries. As many of the institutes have developed serious financial problems over the course of the last decade and a half, they have come under increasing attack for (a) exacerbating inequalities in access to and use of health care, (b) further heightening the geographic overconcentration of services, (c) focusing a disproportionate amount of resources on high technology, curative care to the near total exclusion of primary health care, and (d) being administratively top heavy and, more generally, inefficient. In the past few years, many Latin American countries have begun searching for methods to ameliorate these problems. This paper analyzes three recent efforts, all of which involve some degree of privatization: (1) El Salvador's partial privatization of specialty physician outpatient consultations, (2) Peru's minor surgery and its decentralized ambulatory care programme, and (3) Nicaragua's "administrative services only' approach wherein social security beneficiaries choose to join a certified public or private provider organization for one year, and, on behalf of the individual, social security pays the organization a fixed, annual, per capita fee to provide all health care for the enrollee. The paper also identifies political and technical considerations, as well as health care market characteristics that have shaped these efforts and that condition their likelihood of success, including: the size, composition, level of capacity utilization, degree of organization and geographic distribution of private sector resources; relative prices in the private vis-a-vis the public sector; and the size and nature of the private health insurance market. Other Latin American countries would do well to examine these factors and characteristics before embarking on efforts to reform their own social security health care delivery systems.     

Medical dominance and neoliberalisation in maternal care provision: The evidence from Canada and Australia

Since the 1970s, governments in many high-income countries have implemented a series of reforms in their health care systems to improve efficiency and effectiveness. Many of these reforms have been of a market-oriented character, involving the deregulation of key services, the creation of competitive markets, and the privatization of health and social care. Some scholars have argued that these “neoliberal” reforms have unseated the historical structural embeddedness of medicine, and in some cases even resulted in the proletarianisation of physicians. Other scholars have challenged this view, maintaining that medical hegemony continues to shape health care provision in most high-income countries. In this paper we examine how policy reforms may have altered medical dominance over maternity care in two comparatively similar countries – Canada and Australia. Our findings indicate that neoliberal reforms in these two countries have not substantially changed the historically hegemonic role medicine has played in maternity care provision. We discuss the implications of this outcome for the increased medicalisation of human reproduction.     

Payment systems and incentives in primary care: implications of recent reforms in Estonia and Romania

Since the early 1990s, major reform in healthcare has been adopted in former communist countries in Central and Eastern Europe. More than 20 years after, reform in healthcare still draws much interest from policy makers and academics alike. One of the dynamic components of reform has been the reform of payment systems in primary care. This article looks at recent developments in payment systems and financial incentives in Estonia and Romania. We conclude that finding the appropriate mix in paying and incentivizing primary care providers in a transitional context is no easy solution for healthcare policy makers who need to carefully weigh in the advantages and inherent problems of various payment arrangements. In a transitional, rapidly changing healthcare system and society, and a context of financial stringency, the theoretical effects of payment mechanisms may be more difficult to predict and manage than it is expected. Copyright © 2013 John Wiley & Sons, Ltd.     

论欧盟国家卫生制度设计的团结安排及变化趋势

团结思想是欧洲卫生公平和卫生政策的重要基础,但正不断受到个人责任、自由主义、私营化改革等新理念冲击,在部分欧洲国家甚至存在因资源匮乏而加大个人自付弱化团结的危险。但团结仍然是欧洲卫生体制安排最具标志的价值观之一,并继续成为欧洲政府对卫生安排的政治承诺和问责的道德基础。在从大政府走向大社会这一全球医改浪潮中,欧洲多国政府通过加强精细化监管来进一步实现卫生系统团结。     

District health systems in a neoliberal world: a review of five key policy areas

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.     

Public health in the new millennium

In the new millennium the world has become a ?global village?. Urbanization, economical imbalance, changing social structures and globalization resulting in ever-increasing interpenetration and interdependence between local, national and transnational events constitute the new operational field of public health. This article discusses the challenges and constraints faced by developing countries in its efforts to improve equity in health care. It is noted that the challenges include globalization; emergence of diseases and epidemics; privatization of health care; improving the quality of care; developing Healthy Public Policy; effective decentralization; and a focus on the poor, vulnerable and marginalized groups. In terms of the constraints, most notable is the disagreement between providers of individual care and practitioners of population-based medicine, and the noncontribution of public health research to public policy. In view of such, several recommendations are cited in order to overcome these challenges and constraints and in turn, achieve the goal of improving equity in health care. In this regard, the importance of health systems development including health sector reform in shaping the system and practice of public health in the new millennium is emphasized.     

Canadian and the United States' health care systems performance and governance: elements of convergence

International comparisons of the organisation and performance of health care sectors are increasingly informing policy makers about potential policies relating to health care. Politicians, academics and critics in both the United States and Canada have compared and contrasted the health care systems in the two countries. Public debate tends to emphasise the differences between the US and Canadian health care systems. But, dramatic differences between the organisation and performances of health care systems of the two countries would be surprising given that most elements of divergence have only emerged in the last fifty years, and that health systems tend to be driven by the same basic economic problems. This paper provides an overview of the main economic efficiency issues that must be addressed by health care delivery systems, as well as statistical and related evidence on both input usage and output performance of the two health care systems. While Canada clearly spends less on health care, it is difficult to conclude that Canada has a more efficient health care system than the United States. In particular, the US population puts greater demands on its national health care system owing to a combination of behavioural patterns and socio-economic disparities that contribute to much higher rates of violent accidents, as well as specific diseases and other health problems. Also, the stylized representation of the US system as being 'market-driven' and the Canadian system as being 'centrally controlled' is, increasingly, inept. Both systems are evolving toward bureaucratic models that rely more on internal competition than market competition for governance. In this respect, economic forces are nudging both systems towards a convergence of structure and performance.     

Privatization in French health politics: few projects and little outcome

The author presents the main features of the organization of the French health care system, revealing an important mixture of public and private actors and institutions and a large number of political restraints that oppose resistance to privatization. In spite of traditional references to "liberal medicine" and recurrent debates opposing public and private intervention, neither the doctors nor the political decision makers have really supported the few projects that have been proposed for privatization or liberalization of health care. On the contrary, the cost-control policy introduced growing State intervention and new management methods into the health care sector, whose actors were not used to it. The privatization and liberalization debates appear as a rhetoric necessary to accommodate these difficult changes.     

Comparing health policy agendas across eleven high income countries: islands of difference in a sea of similarity

Does the way in which health systems are financed influence whether health policymakers are more or less interested in accessible and equitable health services? Are social democratic governments more interested in primary health care reform than conservative governments? Have particular domains of health policy really become more important over the past decade across a range of countries? In this exploratory article, we investigate the similarities and differences in patterns of attention in health policy in eleven high income countries using data from the Health Policy Monitor database from 2003 to 2010. Our study suggests significant 'islands of difference' in an overall 'sea of similarity' between the health policy agendas of the selected countries. The key findings are: (i) that improving population health outcomes is more likely to be on the agenda under tax-based systems and when centre-left parties are dominant in government; (ii) health systems funded through social insurance are more preoccupied with efficiency and cost-containment than tax-funded systems; (iii) the political complexion of governments is not a major factor shaping health policy agendas; and (iv) since 2003 there has been an increasing interest in initiatives that address public health concerns, access and equity, and population health outcomes.     

Health care reform: informing difficult choices

During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals.