R. Freeman, COMPETITION IN CONTEXT - THE POLITICS OF HEALTH-CARE REFORM IN EUROPE, International journal for quality in health care, 10(5), 1998, pp. 395-401
The purpose of this paper is to provide a basis for exploring the rela
tionship between competition and quality in health care by delineating
the different institutional, economic and political contexts in which
pro-competitive reform was conceived and carried out in different Eur
opean countries. It begins by distinguishing between national health s
ervices and social insurance systems, suggesting that different kinds
of system generate different kinds of problem. Different patterns of r
eform in Italy, Sweden and the UK, and in France and Germany are then
reviewed in turn. The paper shows how, since the end of the long boom,
health systems in Europe have been exposed to a set of economic, poli
tical and ideological pressures. The way these were brought to bear me
ant that governments in those countries with national health services
were much more disposed to radical, pro-competitive reform than others
. For them, competition represented a way of managing resource constra
int in an increasingly complex and demanding political environment; id
eas about quality were marginal to their purpose. The paper then explo
res the application of competition in different contexts, first among
providers and then among purchasers, for which the UK and Germany serv
e as examples in turn. In each case, competition is only made effectiv
e by new forms of managerial direction. Across systems, competition ar
rears less clearly associated with quality than with political control
.