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 c
ompetition paradigm, among other terms. First introduced in Great Britain,
it entails the separation of the financing/purchasing and providing functio
ns, so that competition among providers is enhanced, while maintaining univ
ersal access and public financing, at least in principle. This article expl
ores to what extent such paradigm has been emulated within the Greek, Itali
an, 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 a
nd rhythm of implementation of reform has varied. The article considers the
circumstances under which the new paradigm was born, and its main characte
ristics; analyzes actual reforms in Southern European countries; and provid
es a tentative explanation of the diffusion mechanisms. It concludes that t
he crucial factor explaining the different paths of policy adoption and ada
ptation is the character of the initial health care system. (C) 2001 Elsevi
er Science Ltd. All rights reserved.