Introduction: Reform in the Provision of Health Care

Article excerpt

There can be no doubt that health care systems throughout the world are in a state of flux. Rising health costs combined with increasing demands means that the proportion of countries' GDPs (and per capita expenditure) allocated to health care appears to be rising inexorably, prompting anguish over perceived needs to ration health care, and ensure what is taken to be efficiency in the provision of health care. Following this there is some debate over the role of the market. Consequently, it seems that there are forces driving institutional change in health care in particular directions. Economists have not been slow to contribute to this debate.

The growing literature devoted to health economics, which encapsulates the core tenets of the mainstream offers the seemingly palliative solutions derived from variations, albeit with increasing sophistication, of cost--benefit analyses, and furnishing actors with economizing incentives. For many, such solutions involve an increasing recourse to market-oriented reform. Indeed, with the concomitant rise of the complementary Public Choice and New Institutionalist literatures, market-oriented reform to the welfare state as a whole may be seen as being strongly advocated by this corpus of mainstream theory.

Yet a one-size fits all approach to health care provision fails to recognise the emerging, disparate institutional patterns either spatially or historically. The papers in this special issue emphasize this important point forcefully. The ahistorical techniques of mainstream economics cannot accommodate such issues. Moreover, the papers in this issue all argue that health care is socially embedded, as are the agents providing and receiving health care. The presumption of atomistic, socially disembedded individuals can only furnish an inadequate portrayal of health care, and potentially insidious policy advice.

This collection of papers does not purport to provide a comprehensive overview or analysis of health care reform; that requires a much larger project. The aims of this special issue are more modest in that it contributes to a growing heterodox literature on health and health economics (see for example, Davis 2001). There is a critical need for accelerated growth in this literature given the deficiencies and insidious nature of the mainstream approach, as it masquerades as a neutral source of policy advice. In this issue, aspects of the impact of reform in four different health care systems--Canada, the Netherlands, the USA, and the UK--are analyzed from a perspective that explicitly recognises the social embeddedness of, and evolutionary forces intrinsic to, economic activity. A paper tracing recent emerging global trends in health care provision precedes these papers. Thus, the papers in this volume, whilst offering a range of perspectives share a common theoretical basis: they are informed by schools of tho ught, such as the "old" American Institutionalism associated with Thorstein Veblen, that consider institutions as the durable "settled habits of men" and not mere constraints to the individual's pursuit of utility maximization. From this perspective institutional change represents a potentially radical adjustment to the norms and values guiding and moulding individuals' behavior. Each paper in this issue stresses this fundamental insight in different social and historical contexts to reveal a complex tapestry in the evolution of health care systems in industrialised western economies.

The collection commences with Michael Keaney's "Unhealthy Accumulation: The Globalization of Health Care Provision", which seeks to establish the global nature of the pressures for the reform process. Keaney characterises capitalism in terms of its "remorseless" tendency toward growth. This process is predicated on existing production becoming more efficient, and/or extending the boundaries of capitalism either through processes of innovation, or enclosure of commons (privatization). …

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