Broomberg J
Health Policy Unit, London School of Hygiene.
Health Policy Plan. 1994 Sep;9(3):237-51. doi: 10.1093/heapol/9.3.237.
There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries.
发达国家当前的改革及政策辩论，以及许多国家普遍存在的公共部门效率低下的看法，激发了人们对发展中国家管理式市场改革前景的兴趣日益浓厚。本综述主要通过借鉴发达国家提出的论点和证据，特别是以医院服务的提供为重点，审视在发展中国家背景下进行此类改革的前景。本文首先讨论这些改革的当前政策背景及其主要特征。文章认为，虽然当前和提议的改革在细节上各不相同，但大多数改革的共同之处在于在医疗保健提供方面引入竞争，同时保留公共融资垄断，这种结构源于解决当前公共部门效率低下问题的双重目标，同时保留公共卫生系统已知的公平和效率优势。然后，本文探讨了支持和反对这些改革的理论论据和实证证据，并研究了它们与发展中国家的相关性。有人认为管理式市场既能提高效率又能促进公平。这些论点从其支持者提出的三个不同主张进行分析：管理式市场将促进供应商之间的竞争加剧，从而提高供应商效率；合同关系比直接管理更有效率；管理式市场的好处将超过其成本。分析表明，在所有这三个问题上，理论论据和实证证据仍然模棱两可，这种模糊性部分归因于对市场内卫生部门行为主体的行为理解不足，以及这些改革的经验有限。在发展中国家的背景下，本文认为除了少数较富裕的发展中国家外，成功实施这些改革所需的大多数条件都不存在，而且这些改革的成本，特别是在公平方面，可能会带来重大问题。因此，广泛的管理式市场改革不太可能成功，尽管有限度地引入这些改革的某些特定要素可能会更成功。发达国家的经验有助于确定此类有限改革可能成功的条件。迫切需要评估发展中国家不同形式合同的现有经验，并根据发展中国家的情况解释发达国家改革中出现的新证据。
