AIM – HOPE International Conference Paris, 20-21 January 2005
6. THE CURRENT DISTRIBUTION OF FORPROFIT AND NOT-FOR-PROFIT PUBLIC AND
PRIVATE HOSPITALS IN EUROPE
Mrs Marie Lecerf, Chargée de mission, Dexia Crédit Local, France
It is important to define a European model for hospital care against the backdrop of the general
situation that prevails across Europe. Hospitals strike at the very heart of the European equation in the
field of healthcare. This equation involves reconciling the concept of universal access to care with
strong budgetary constraints and the need to make the production of care efficient. All the countries of
the European Union have enacted reforms to solve this very equation. The question is: Will the
changes wrought by these reforms yield a hospitalization model that is predominantly public or
private?
The desire to compare European hospital systems is something of a paradox. On the one hand, there
is a tremendous diversity of national hospital systems: domination of the public sector or the private
sector, variability of the position of the public/private boundary from country to country and variability in
the sharing of political responsibilities (different degrees of deconcentration and decentralization,
where these notions have any meaning). Nonetheless, there are a number of common threads
running through the reforms that have been announced or initiated. The principle that is common to all
countries is the need for reform; all the health systems of the European Union have been undergoing
reforms for two decades.
The convergence of hospital reforms
 Convergent national reforms
Governments express similar concerns about the expenditure on health and hospitals (hospitals
constitute the largest item of expenditure and the main source of leakage of health expenditure). Also,
their diagnosis is similar.
The justifications are the same in all countries. They refer to market demands (efficiency, autonomy,
measurement of activity and the need to refocus on core business). Governments therefore use a
common theoretical corpus, common terms of reference and a common vocabulary.

What form of convergence?
Now that the reforms have been implemented for several years, a convergence can be seen in terms
of processes more than in terms of results.
This convergence is also to be seen in the instruments used. At a macroeconomic level, the following
tools have been employed: institutionalization of the referring physician, reduction in the number of
hospital beds (supply creates demand) and a competitive market in which the hospital is the producer
of care. At a microeconomic level, the states use instruments such as: the management of hospitals
along the lines of businesses, with considerable managerial autonomy (measurement of activity with
the Diagnosis Related Groups, generalized pricing by activity to control costs, the development of
quality and accreditation procedures and definition of the hospital product, in most cases differentiated
from psychiatry or long-term care).
Explaining and understanding the convergence of hospital reforms

The European Union as a factor of convergence in relation to other phenomena
AIM – HOPE International Conference Paris, 20-21 January 2005
The European Union is a new structure where public policies can be produced and defined.
Nonetheless, health is a sector that is still relatively outside the scope of this homogenization process.
There are two factors that favour the rapprochement of countries within this structure. Firstly, there is
hard law, which sets out binding rules that affect health policies in Europe. The main rules are the free
movement of persons and of goods and services. Secondly, there is soft law, which includes all the
non-coercive measures that are designed to lead to a rapprochement of practices through
benchmarking or through best practices. The members of the European Union define common targets
and benchmarks to evolve in a similar direction, in line with the Lisbon open coordination method
(2000).
One might wonder whether there is a similar convergence of health systems outside the European
Union. To answer this question, we must refer to the concepts of globalization and "path dependency".

Understanding convergence thanks to the idea of the European hospital "agreement"
We are currently witnessing the Europeanization of the grid of interpretation of hospital policies. This is
characterized by the rapidly increasing importance of a European hospital agreement governing
hospitals that is somewhere between a constraint and a contract, that is, it is a model of uncertain
origin that is not guaranteed by law. However, we are seeing the emergence of a common
interpretation of phenomena. For example, when the DRGs were created in Germany (1999), doctors,
experts and trade unionists were explicitly instructed to draw inspiration from a foreign example.
Similarly, a common grid of analysis is emerging through the promotion of practices within the
European Union, either through imitation or under the pressure of standards.
All in all, this hospital agreement is efficient because it is a catalyst for reforms within the member
States. It facilitates the exchange of information and the imitation of models. Moreover, it acts as a
filter vis-a-vis outside influences: the implementation of an agreement based on the two principles of
market and solidarity reduces the uncertainty and fear associated with outright liberalization.
Reference document:
-
Hospitals in the 15 countries of the European Union
This book makes a transversal comparison of the hospital sectors of the fifteen countries of the
Union. In addition, there is a table showing the key characteristics of the health systems of each
country.
2003 - 138 pages - 9.00 euros EN, FR) - 2-911065-40-9 - Dexia Editions
-
Hospitals in the 25 countries of the European Union
Table in the form of a map showing the hospitals of the 25 countries of the European Union,
comparing the key points of the analysis of the hospital systems of these countries.
This table supplements the previous document.
2005 - (two languages: EN, FR) - Dexia Editions
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