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Pragmatism is beginning to trump ideology in Europe’s ‘public-private’ debate over healthcare

Saltman, R. (2014) “Pragmatism is beginning to trump ideology in Europe’s ‘public-private’ debate over healthcare“, LSE EUROPP, 09 October.


The merits of public vs private healthcare have traditionally formed one of the key ideological divisions between European political parties. Richard B. Saltman writes that while this debate has often been exceptionally heated, over the last few decades a number of European countries have started to take a more pragmatic approach in terms of both the use of private healthcare and the operating philosophy adopted in public hospitals. Although the public-private debate is unlikely to ever disappear entirely, these trends and the pressures of prolonged austerity have steadily reduced its relevance to actual service delivery.

The debate in Europe between proponents of public vs privately run health care providers is long-running and often acrimonious. While the tenor of discourse has improved somewhat from the first international meeting in Brussels in 1984, which was broken up after 10 minutes by chair-throwing, the topic remains ideologically infused and in some countries like England it is still difficult to discuss calmly.

The dimensions of this debate have however changed quite dramatically since the early 1980s. In a number of tax-funded health systems, for example, the majority of primary care services have been shifted from public clinics to private GPs (most Central European countries, also Norway and Sweden). In home care services, similarly, private for-profit actors have become major players (all four Nordic countries, also Central Europe).

Moreover, the operating character of public hospitals has also changed. In many tax-funded health systems, public hospitals are now managed as semi-autonomous institutions, with their own boards of trustees and non-politically appointed managers. Whether they are called foundation hospitals (England), state enterprises (Norway), limited stock companies (Estonia and Czech Republic), or consortios (Spain), the practical impact is that public institutions are being managed more by clinical and financial results and less by political directive. Taken together, these two major changes suggest a melting of the boundaries that previously separated public and private providers.


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