Introduction

The market enjoys global currency. In healthcare, the market has been central to reforms across many countries, as is evident from the prominence of managed competition. At the same time, experiences with markets in healthcare suggest that the reforms not only have included considerable re-regulation, but also that such re-regulation remains firmly embedded in country-specific contexts. The present chapter aims to open the black box of ‘global markets’ by identifying country-specific pathways of re-regulation in relation to markets in healthcare in a cross-country comparative perspective. The chapter does so by analysing sector-specific institutional contexts from a cross-country comparative perspective based on five countries – Britain, Denmark, Germany, Italy and Norway. Medical governance is closely related to redistributive policies, where the influence of country-specific institutions tends to be pertinent. At the same time, medical governance is subject to considerable policy pressures centring on tensions between public accountability and professional autonomy. Medical governance therefore provides a good basis for studying both the dynamics of governance and the difference institutions make.

We introduce an analytical distinction between three forms of governance: hierarchy, network-based governance and professional self-regulation. Hierarchy is based on formal authority and is concerned with control, standardisation and accountability. Centralised systems of standard setting and auditing are an example of this form of governance. Network-based governance is characterised by interdependent flows of power and focuses on adaptation and flexibility. An example of this form of governance is the negotiation of quality standards among purchaser, provider and professional organisations. In contrast, the market focuses on maximising output, and governing occurs through competition among multiple and more or less autonomous agencies. In principle, this makes for a more devolved policy process. Yet in practice, it is often the government that sets the goals and targets that form the basis for monitoring, inspecting and auditing the performance of sub-central agencies. Finally, professional self-regulation relies on expert authority and aims for professional control over practice. Clinical guidelines set by professional bodies are an example of this form of governance.

The analysis suggests two things. First, developments in all countries included in the study point to the fact that the new medical governance is indeed characterised by strong elements of hierarchy-based forms of governance, but ones that are combined with other modes of governing, often in the form of hybrids.