Health planning and implementation: France, Quebec and England

This study undertook a comparative evaluation of health planning in France, Quebec, and England. France is an example of a European continental national health insurance (NHI) system that covers both public and private hospitals as well as private practice on a fee-for-service basis. Quebec is also an example of such an NHI system; it represents a health system in which active state intervention has produced more ambitious reforms than in France. England is the exemplar of a national health service; its distinguishing features are state-controlled facilities and physician reimbursement based on salaries and capitation fees. Two common phases may be distinguished in the evolution of health planning since World War II: 1) an expansionary phase characterized by efforts to improve access to health services and to coordinate health sector growth; 2) a containment phase characterized by efforts to control rising health care costs and to redistribute resources within the health sector. The first phase succeeded admirably. Since then, health care costs have exploded. groups. Health planners have challenged the predominant medical model of hospital-centered care and they have promoted redistribution of health resources away from hospitals to environmental health services and community-based social services. The case studies indicate that, despite efforts to rationalize the health sector, health planning is not effectively linked to financing, neither in France, nor in Quebec, nor even in England where central control over both planning and financing has been achieved. Health planners have been unable to alter significantly the allocation of health resources in conformance to their plans. This study considers three hypotheses which might explain why implementation is so difficult to achieve. The study concludes that all three hypotheses have limitations, but that together they suggest that the prospects for health planning are equivocal. On another level, the case studies illustrate how health planning efforts are caught between two traditions of social change: social reform and system rationalization. The French case study highlights a prototype model of rationalization as a strategy to contain rising health care costs. The Quebec study illustrates how health planning can serve as an instrument for broadening the scope of medical care to include reform of the welfare and social service sectors and how the goals of such social reforms are easily displaced by strategic objectives which are, in turn, compromised by political and economic interests. The English case study provides an example of administrative reorganizationand shows how planners can make explicit the implicit tradeoffs in the allocation of health resources. (Abstr. Health Care Mgmt. Stud., 1981)