Adopting and adapting managed competition: health care reform in Southern Europe.

A new paradigm appeared in Europe in the early 1990 s regarding the reform of health care systems. This paradigm has come to be known as the managed competition paradigm, among other terms. First introduced in Great Britain, it entails the separation of the financing/purchasing and providing functions, so that competition among providers is enhanced, while maintaining universal access and public financing, at least in principle. This article explores to what extent such paradigm has been emulated within the Greek, Italian, Portuguese and Spanish health care systems. Reform in the direction of managed competition may be ascertained in all four countries. However, each country has emphasized different aspects of the paradigm, and the degree and rhythm of implementation of reform has varied. The article considers the circumstances under which the new paradigm was born, and its main characteristics; analyzes actual reforms in Southern European countries; and provides a tentative explanation of the diffusion mechanisms. It concludes that the crucial factor explaining the different paths of policy adoption and adaptation is the character of the initial health care system.