Freeman R
Department of Politics, University of Edinburgh, UK.
Int J Qual Health Care. 1998 Oct;10(5):395-401. doi: 10.1093/intqhc/10.5.395.
The purpose of this paper is to provide a basis for exploring the relationship 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 European countries. It begins by distinguishing between national health services and social insurance systems, suggesting that different kinds of system generate different kinds of problem. Different patterns of reform 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, political and ideological pressures. The way these were brought to bear meant 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 constraint in an increasingly complex and demanding political environment; ideas about quality were marginal to their purpose. The paper then explores the application of competition in different contexts, first among providers and then among purchasers, for which the UK and Germany serve as examples in turn. In each case, competition is only made effective by new forms of managerial direction. Across systems, competition appears less clearly associated with quality than with political control.
本文旨在通过描绘不同欧洲国家构思和实施促进竞争改革的不同制度、经济和政治背景，为探索医疗保健领域竞争与质量之间的关系提供依据。文章开篇区分了国家卫生服务体系和社会保险体系，指出不同类型的体系会产生不同类型的问题。接着依次回顾了意大利、瑞典和英国，以及法国和德国的不同改革模式。本文展示了自长期繁荣结束以来，欧洲的卫生系统如何受到一系列经济、政治和意识形态压力的影响。这些压力施加的方式意味着，实行国家卫生服务体系的国家的政府比其他国家的政府更倾向于激进的、促进竞争的改革。对它们来说，竞争是在日益复杂和苛刻的政治环境中管理资源限制的一种方式；关于质量的理念对其目的来说处于边缘地位。然后本文探讨了竞争在不同背景下的应用，首先是在提供者之间，然后是在购买者之间，英国和德国依次作为这两方面的例子。在每种情况下，竞争只有通过新形式的管理指导才能有效。在各个体系中，竞争与质量的关联似乎不如与政治控制的关联那么明显。
