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Welfare Reform on the Web (June 2001): Health Care - Overseas

ADOPTING AND ADAPTING MANAGED COMPETITION: HEALTH CARE REFORM IN SOUTHERN EUROPE

L Cabiedes and A Guillén

Social Science and Medicine, vol.52, 2001, p.1205-1217

Article explores the extent to which the purchaser/provider split in health care provision has been adopted in the Greek, Italian, Portuguese and Spanish health care systems. Reform in the direction of managed competition has taken place in all four countries, but the degree and rhythm of implementation has varied. Article concludes that the crucial factor explaining the different paths of policy adoption and adaptation is the character of the initial health care system.

CITIZENS, THEIR AGENTS AND HEALTH CARE RATIONING: AN EXPLORATORY STUDY USING QUALITATIVE METHODS

J Coast

Health Economics, vol.10, 2001, p.159-174.

Semi-structured interviews were used to investigate whether citizens want agents to make health care rationing decisions on their behalf, and if so, who these agents might be. Findings suggest that citizens vary considerably in the extent to which they want to be directly involved in making rationing decisions. Important influences on this issue appear to be knowledge and experience, objectivity and the potential distress denying care may cause. Agents, in contrast, view citizens as needing agents to make decisions for them and suggest it is primarily the health authority's role to act in that capacity.

COST CONTAINMENT, SOLIDARITY AND CAUTIOUS EXPERIMENTATION: SWEDISH DILEMMAS

P Andersen, B Smedby and D Vågerö

Social Science and Medicine, vol.52, 2001, p.1195-1204.

Paper explores a "Swedish Dilemma": Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay (a policy emphasizing social solidarity) or must it decide to impose increasing constraints on health service spending (a policy emphasizing "cost containment"). It is apparent that Sweden has had considerable success in containing costs, not through market mechanisms but through government budget controls and service reductions. It further appears that equal access to care may be adversely affected by some of the system changes.

DECENTRALIZATION AND BUDGETING: THE UGANDA HEALTH SECTOR EXPERIENCE

G Awio and D Northcott

International Journal of Public Sector Management, vol.14, 2001, p.75-88.

Presents findings of a study of the impact of decentralization on Uganda health sector budgeting. A questionnaire was used to seek the expert opinion of key participants in health sector budgeting about the effects of decentralization on budgetary participation and the use of budgets for planning and control. Findings suggest that, while decentralization is not a panacea, it has the potential to create a context for improved budgetary practices in developing nations.

HEALTH INSURANCE AND HEALTH SERVICES UTILIZATION IN IRELAND

C Harmon and B Nolan

Health Economics, vol.10, 2001, p.135-145

Numbers buying private health insurance in Ireland have continued to grow despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone is entitled to public hospital care. Paper examines the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics such as education, age, gender, marital status, family composition and income all also influence the probability of purchasing private insurance.

IMPLEMENTING MANAGED COMPETITION IN ISRAEL

R Gross and M Harrison

Social Science and Medicine, vol.52, 2001, p.1219-1231.

Israel's National Health Insurance Law 1995 laid the foundations for regulating competition among the country's four private, not-for-profit sick funds. In practice, rather than fostering competition, the main thrust of the NHI reforms was to enhance central government's control over Sick Fund (SF) expenses in order to contain government spending. The NHI reforms did encourage SFs to cut costs and make visible service improvements. However they did not lead the SFs to reorganise, expand the scope of their services or improve quality of clinical care. Nor did the reforms help eliminate the SFs' operating deficits or ensure financial stability for the whole health system. Furthermore they led to undesirable outcomes including aggressive and illegal marketing by SFs and collaboration among SFs to restrict the extent of care provided under compulsory insurance.

THE MANAGED CARE BACKLASH: PERCEPTIONS AND RHETORIC IN HEALTH CARE POLICY AND THE POTENTIAL FOR HEALTH CARE REFORM

D Mechanic

Milbank Quarterly, vol.79, 2001, p.35-54

Public and media debate about the US healthcare system has focused on the inadequacies of managed care, which are arguably more perceived than real. This has deflected attention from more serious problems including the failure to make progress towards universal healthcare coverage and the growing numbers of people who have no insurance or are underinsured.

MANAGED CARE IN LATIN AMERICA: THE NEW COMMON SENSE IN HEALTH POLICY REFORM

C Iriart, E E Merhy and H Waitzkin

Social Science and Medicine, vol.52, 2001, p.1243-1253

Research analyzed the export of managed care from the US and its incorporation into Argentina, Brazil, Chile and Ecuador. Results presented in this article relate to the transnationalisation of health policies, advanced through reforms supported by international lending agencies, especially the World Bank. Focuses on the entrance of multinational corporations of finance capital into the private sector as both insurers and health care providers as well as their participation in the administration of state institutions and medical social security funds.

THE MARGINAL SUCCESS OF REGULATED COMPETITION POLICY IN THE NETHERLANDS

H Lieverdink

Social Science and Medicine, vol.52, 2001, p.1183-1194

In the second half of the 1980s the government in the Netherlands adopted a regulated competition policy as part of a comprehensive programme designed to re-structure the healthcare system. The programme was a product of its social and political context, promoted by a group of political entrepreneurs and created to improve efficiency. Despite the initial political support and a long debate, the government had to acknowledge by 1992 that the restructuring would not take place. However the changes fostered limited competition between sickness funds and more extensive competition in the small market for supplementary policies. This has not led to sickness funds becoming powerful purchasers that can force hospitals and doctors to improve their efficiency. Instead, they compete for subscribers, become part of large insurance conglomerates and market more supplementary options.

REFORMING THE ISRAELI HEALTH SYSTEM: FINDINGS OF A THREE YEAR EVALUATION

R Gross, B Rosen and A Shirom

Health Policy, vol.56, 2001, p.1-20

The enactment of the National Health Insurance Law in 1995 created a regulated market in health care provision. Paper presents initial findings from an evaluation of the first three years of the reform (1995-1997). Data from the evaluation show that the NHI Law achieved a considerable number of its goals: providing insurance cover for the entire population, ensuring freedom of movement among sick funds and standardising the way resources are allocated to sick funds. The incentives that are embodied in the law have encouraged the sick funds to improve the level of services provided to the average insuree, and to develop services at the periphery and for some of the weaker populations. Concerns the NHI would lead to a rise in the national health expenditure were not realised as of 1997.

TRANSFORMING HEALTH SECTORS: NEW LOGICS OF ORGANIZING IN THE NEW ZEALAND HEALTH SYSTEM

G Fougere

Social Science and Medicine, vol.52, 2001, p.1233-1242

Paper analyzes the ongoing, radical restructuring of health care in New Zealand. Outlines the original reforms, based on a purchaser-provider split, and traces the actual process of restructuring, emphasizing the responses it has evoked from differently situated actors in the health sector.