Marketization, Managerialism and Welfare State Professionalism
Edited by Tanja Klenk and Emmanuele Pavolini
Chapter 1: Marketization and managerialization of health care policies in Europe in a comparative perspective
In recent decades, and especially after the onset of the economic crisis, health care systems (HCS) have been put under pressure (Wendt 2009; Wendt et al. 2009). The most visible type of pressure has been economic, with health care spending continuing to grow much faster than GDP. But health care systems have also been challenged from other points of view: in many countries the issue of health inequalities has become increasingly relevant, as well as the necessity to adapt to changes in the pathologies (with a progressive shift from acute to chronic care needs) (Blank and Burau 2010). A series of reforms and regulatory changes was introduced starting mainly in the 1990s in order to cope with these challenges (Seeleib-Kaiser 2008). These reforms went in three distinct directions: rescaling, privatization and managerialization. What is intended here by rescaling, often meaning decentralization, is the issue of the distribution of powers among actors in HCS at different territorial levels (both national and local). Whereas by privatization, in financing and delivery, we intend the issue which deals both with the distribution of power between public and private actors and the distribution of health care expenditure between the state and the citizens. By managerialization, we refer to the distribution of power among professionals (first of all physicians), bureaucrats/managers and citizens/users in HCS.