Contenu du sommaire : L'adaptation des systèmes de santé : maîtrise des dépenses et défis de santé publique

Responding to the Unexpected : Health Service Responses to AIDS The capacity for adaptation of health services in their response to the risk of AIDS is analysed in relation to four countries : the United Kingdom, France, Italy and Germany. The author compares the processes of construction of expertise and institutional mobilisation, the formation of political consensus and the adoption of a global policy integrating the prevention of AIDS amongst drug addicts and those undergoing blood transfusions. National differences reveal the particular weakness of the practical formulation of public health policies in France.

Regulation of Health Insurance in France and Germany While the French and German Systems of social insurance have strong structural similarities (being para-state Systems), there are important differences in the ways of regulating the Systems. Thus, in France, State representatives occupy a predominant position in the policy of regulation of this sector of health care, a sector which is nevertheless very fragmented ; however in Germany a body of well organised non-state actors play an essential role in the regulation of the System. These essential distinctions have a considerable influence upon policies conceming the limitation of health service expenditure, which are largely negotiated in Germany and imposed by the State in France, and on the result of these policies.

Economic Regulation of Health Expenditure in France : Negociated Wastage For more than twenty years the necessity of curbing health expenditure has been insisted upon in France. The diverse and varied measures put into place have produced only modest results and, while the mechanisms of regulation, at first imposed and then contractual, have to a certain extent been effective, financial organisation and the distribution of health care have considerably limited their scope. The process of regulation is equally hampered by the role played by institutional representatives since the creation of the health service in 1945. In fact the importance of negociation has led to a compromise being sought and forms of regulation being adopted which are least likely to disrupt the System.

Safety in Child-Birth in France and Netherlands : Technical or Organisational Coordination ? In the last few years safety in child-birth has been the object of lively debate in France. At the time at which two reports have been requested from the High Committee of Public Health, it is possible to detect a reorientation in French conceptions of the issue of risk : thus there has been a shift from safety viewed as an accumulation of technical and human resources to safety viewed as the capacity to detect risks and to move women to a particular establishment in the light of the risks incurred. Influenced by the organisation of child-birth in the Netherlands, which is based upon this idea of selection, the article seeks to characterise these different conceptions of safety and their consequences, to evaluate the importance of the reforms envisaged in France and to specify the conditions necessary to their realisation.

Health Care Regulation and Reforms in Europe The Systems of health care in European States have been constructed around a common objective : equal access to health care for all levels of the population. But in the light of increases in health expenditure, notions of “curbing” spending and “efficiency” occupy an increasingly important place. The reforms undertaken by European States show certain similarities. On the one hand, they concem the tools necessary for intervention in curbing expenditure, and, on the other hand, they deal with the flow of financial resources which sustain activity in the health sector. Equally these developments have led to the adoption of a new method of negociation between professionals and govemment which takes into account not only economie variables and medical regulation but also the definition of real “health objectives”.

The Transformation of the Role of Regional Authorities in the Quebec Health Service. The Case of Regional Government Control in Montreal-Centre The System of health care in Quebec has undergone important changes since its reform in 1991. The reform was carried out within a legislative framework and with regard to particular political and administrative traditions. With the objective of curbing expenditure on health care, securing equal access to services and maintaining the political means for redistribution of collective resources, the reform is an attempt at compromise between a technocratie desire to maintain control over the System and a discourse of decentralisation.

The Emergence of the Regional Level in the Management of the Health Service in France At the regional level the division of responsibilities in the management of the health service has had a negative impact upon the global view of what is happening in the service and has generated confrontation between diverse interests. Regional schemes have provided the opportunity for the different actors to work together. The splitting-up of the region into health sectors designed to respond to the behaviour of the population has allowed the diversifies in the region to be addressed. The addition of the task of resource allocation to the attributions of the region in its management of health and social matters gives the region a new role, that of the key player in health service network. The division between health care and social provision appears necessary. It should be undertaken by technicians and not by those who lack expert knowledge. The role of the prefect must be restricted to that of arbitrator.

The Reform of the British National Health Service : the Elusive Consumer The reform of the NHS in 1991 was supposed to represent a balance between public expectations and financial constraints. While continuing to be a universal System financed through taxation, the reformed NHS was designed to encourage competition in order to offer a better standard of care. It is evident that administrative costs are high, that even if the role of those general practitioners who are now fund-holders has been re-evaluated, true competition is still not yet a reality, and that the services offered to patients are frequently being reduced. While profitability, quality and transparency are high on the agenda, the NHS remains a System of health care in which needs are defined by professionals and not by the choices or demands of consumers.

Contractual Regulation : the Example of the Non-Hospital Sector Contractual regulation of health care outside the hospital sector was introduced in 1991 folio wing an overly brutal revision of the remuneration scale. This System of regulation created a three-way relationship between the State, the health insurance and professionals in the making of an annual agreement forecasting future health service expenditure. The basic idea behind contractual regulation is co-responsibility. The financial framework sets out the predicted increase in treatments with an adjustment mechanism operating a rigid System of financial compensation. This is accompanied by recommendations and the creation of means for gathering information conceming the sector. All the objectives which were forecast have been reached, but management of the System is complex. Specific negociation with each profession brings with it a risk of inflexibility in parts of the market. The means of putting the national objective into effect at regional level still has to be worked out. Beyong this it appears that contractualisation has its limits due to the over-protective effect of the contract which prevents spontaneous increases in spending which might be a lot less favourable for professionals. In fact what this method of contractualisation lacks is the State's vision of the aim sought to be achieved.

Contractualisation at the Heart of the National Health Service in the United Kingdom The National Health Service (NHS) in the United Kingdom underwent an important reform in 1991. This huge transformation allowed an improvement in transparency of NHS activities and the highlighting of preoccupations conceming profitability and quality. Nevertheless the desired separation between the purchasers of health care services and the providers of these services, and the introduction of a policy of contractualisation between the two sets of actors has not brought about satisfactory results. In fact obstacles to change remain numerous and have become particularly apparent with regard to the uncertain legal status of the contracts, the as yet insufficient competition between the different actors involved and a certain lack of motivation amongst the district health-authorities over whom no-one exercices control.

Medical Information and Regulation of General Practice Medicine : A Comparative Approach Most industrialised countries recently came to realise that an efficient regulation of health care services was no longer possible without an evaluation of the precise content of medical activity, particularly through the gathering of medical data. A comparative analysis has been carried out conceming the measures for controlling medical practices in the non-hospital sector in three countries : Germany, the United Kingdom and the United States of America. The study shows that the question of control over medical practices has arisen very differently in these three countries and that the response to this question depends upon the general organisation of the System of health care and particularly the mechanisms of macro-economic regulation of health expenditure as well as the mechanisms of micro-economic regulation of the medical profession.

The Force of Knowledge : Transformation in the Regulation of the Hospital Sector Recent transformations in the regulation of the hospital sector are analysed in accordance with a political model which attaches supreme importance to the «knowledges» to which the different protagonists lay claim and which they use strategically. In the light of the dynamics of these knowledges this analysis reveals the unpredictability of the new knowledges, a multiplication of the actors concerned, some of whom are not part of the administration, and finally the administration's orientation towards a management perspective which nevertheless remains attached to the public service of hospital medicine.