Marketisation is the preferred modernisation strategy and an engine driving many changes in health care. It is introduced into very different systems, flanked by concepts of new public management (NPM) and decentralisation. The role of the service user is thereby becoming ever more important. The second line of development is based on the Alma Ata Declaration of the World Health Organization (WHO, 1981), which calls for the establishment of primary care as the solution to health care problems. The introduction of new models of primary care counts as central to the success of reforms. Marketisation and a radical shift away from highly technical in-patient care to primary care cut deeply into the grown structures and norms of Western health systems. New models of integration and a coordination of provider services and expertise – such as that of the allied health professions, alternative therapists and patients – call for both new models of governance and new patterns of professionalism. A network structure of governance and tighter managerial control are assumed to be the most effective ways to improve the quality of care. The challenges, changes and dynamics of these developments are the themes of this chapter.

Hybrid forms of governance

To a high degree, reform concepts in the health sector depend on policy and system reform (WHO, 2000; Hill, 2002), and attempt to strengthen primary care (Donaldson et al, 1996; Light, 2001; Tovey and Adams, 2001). A comparative study of 15 health systems concludes: “The stronger the primary care, the lower the costs. Countries with very weak primary care infrastructures have poorer performance on major aspects of health” (Starfield and Shi, 2002, p 201). Processes of change are connected to the growing weight accorded to the health of the population on political agendas (World Bank, 1993). There is hardly another area where justice and equality enjoy higher relevance than in the area of health care.

The interplay between tighter economic resources and changes in the system of care, as well as globalisation and European unification, call for new forms of regulation. The introduction and expansion of marketisation and managerialism are the favoured answers to new demands. Although the ‘simple-minded marketisation’ (Reich, 2002) is wishful thinking, developments provoke changes in the regulatory frameworks and the arrangement of players.