EFFICIENCY AND EQUITY IMPLICATIONS OF THE HEALTH-CARE REFORMS

The purpose of the paper is to reflect on the recent health care refor ms in both developed and developing countries, in the light of the evi dence that has accumulated over the last few years about the efficienc y and equity of different fiscal and organisational arrangements. The scene is set by a brief review of the definitions of efficiency and eq uity and of the confusions that often arise; and of the problems of ma king assessments in practice with real data. The evidence about effect iveness, efficiency and equity at the macro level are reviewed: among OECD countries, there is little evidence that variations in the levels and composition of health service expenditure actually affect levels of health; equity in financing and delivery appears to mirror equity i n other sectors in the same countries; about the only solid-although r ather limp-conclusion which is transferable is that costs can be conta ined best via global budgeting. The range of reforms in the North is s ketched: despite calls to give people 'freedom' to opt out, public fin ances continues to be preferred among OECD countries; and the evidence that health care markets can actually function is 'weak'. Whilst geog raphical redistribution of finance has proved to be possible, inequali ties in health remain in most countries. But the overwhelming impressi on is that the quality of the data base for many of these studies is a ppalling, and the analytice techniques used are simplistic. The move t o introduce user charges in the South is discussed. It seems unlikely that they will raise a significant fraction of overall revenue; exempt ions intended for the poor do not always work; and other trends are li kely to exacerbate the patchy coverage of health care systems in the S outh. The final section reflects on the pressures for increased accoun tability. The emphasis on consumerism in the North has led to an incre asing number of poorly designed 'patient satisfaction' surveys; in the South, there has been an increasing rhetoric on community participati on, but little sign of actual devolution of control. The flavour of th e decade is 'outcome measurement' which has been promoted feverish but with little rigour. We must also be concerned that this emphasis will , once again, be hijacked by the most articulate.