Six: Choice and competition in health systems

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Over the past two decades, choice and competition have become central planks of health policy in many countries. Such notions are in keeping with the consumerist ethos and increasing commodification of health care now prevalent in health system reform thinking and noted in earlier chapters. Of course, it is quite possible to have choice without competition, and competition without allowing choice. However, the two are generally regarded as going hand in hand, since choice without competition may result in people not having a sufficient range of options from which to choose – the problem of choosing any colour as long as it is black. Competition without choice is seen as unworkable unless there is a mechanism whereby people not only exercise voice if they do not perceive themselves to be getting a good service, but can also exit by taking their health problems elsewhere. For these reasons, these two central planks of health reform have been coupled for the purposes of this chapter.

Opponents of choice are invariably also opposed to competition and believe that both pose serious risks for the ethos and values of a public health service such as the NHS in the UK and threaten to destabilise the principle of universal access to care. Of course, as is discussed below, it is possible to confine competition to the public sector so that a genuinely internal market is created as distinct from a provider market that is open to both public and private providers. Indeed, Julian Le Grand, an influential health adviser to the former British Prime Minister, Tony Blair, argues that it is perfectly possible to have competition between publicly owned entities without any participation from the private sector.

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