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 ser vices. 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 t he context of neoliberalism, has been the use of 'managed competition' to i ncrease efficiency. Some countries that flirted with health system competit ion have returned to cooperation. Market relationships tend to be oppositio nal and to stimulate self-seeking behaviour. Health system relationships sh ould encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theo ries from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or fe asibility of implementing them. Private health care has increased in many d eveloping countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unli censed and unregulated, and informal privatization has had a damaging effec t on health worker ethics. The lead policy should be reconstruction of the public health system, invol ving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of pr oactive privatization and marketization. Underlying the two approaches is w hether health care should be viewed as a human right best served by sociali zed provision or a private good requiring governments only to correct marke t failures and ensure basic care for the poor. It is a matter of politics, not economics. Copyright (C) 2000 John Wiley gr Sons, Ltd.