Introduction

The notion that there is a global pattern to the reforms of health systems in disparate countries is widespread. Ham (1997) argues for the ‘convergence’ hypothesis, identifying a number of ‘common themes’: concern to strengthen the management of health services in order to reduce variations in performance and to introduce a stronger customer orientation; interest in making use of budgetary incentives as a way of improving performance; and a move in some countries to introduce market-like mechanisms into health services. While hedged with caveats about remaining variation, Ham's view is captured most clearly in Figure 7.1, which is reproduced from his publication Management and competition in the NHS (Ham 1997).

In developing countries, similar voices can be heard. For example, Chernichovsky (1995) argues: ‘Paradoxically perhaps, developed and developing nations may be closer to similar systemic solutions than the underlying factors setting them apart might suggest.’ Considering Latin American reform, Londoño and Frenk (1997) conclude that reform initiatives promote convergence on a ‘structured pluralism’ health system model in which the parallel sub-systems of ‘segmented’ health systems (InterAmerican Development Bank 1996) are reconfigured in order to achieve a division of system-wide roles.

Marmor (1997) is among those who dispute this view, which he judges has ‘two central misconceptions’: