Managing a pluralist health system: the case of health care reform in France.

During the last decade increasing health care expenditure led to persistent difficulties in the financing and management of the French health care system. A series of cost-containment measures in the 1980s and early 1990s concentrated on raising patient contributions and establishing global budgets for public hospitals. These initiatives met with limited success and did not address the issue of hospital management. In 1991 new reforms were instigated to strengthen the public sector and achieve a better balance with the private sector. Although these reforms altered management practice within public hospitals, they failed to tackle the underlying problems of the long-term financing and management of the French health system, ensuring continuing attempts at reform. The French experience provides evidence of the difficulties of reforming a pluralist health system that contains few incentives to stem rising expenditure.