The Health Planning Predicament

VG. Rodwin
Berkeley: University of California Press, 1984. Translated in Italian: I Sistemi Sanitari: Studio Comparativo su Francia, Quebec, Inghilterra e Stati Uniti (Venice: Marsilio Editori, 1986).
 Health planning is in trouble. Health care costs are out of control. Access to services is inadequate, and too many people fail to receive the right services at the right time, at the right place, and for the right reason. Little consensus exists about what is "right," and even when experts agree on the need to redistribute health resources away from hospitals to community-based health and social services, such goals are rarely implemented. These problems constitute what Victor G.Rodwin calls the health planning predicament.
       How did this predicament come about? What are alternative strategies to cope with these problems? Are there lessons we can draw from experiences with health planning in other Western industrialized nations? Dr. Rodwin examines the evolution of health planning efforts in France, Quebec, and England and compares these experiences with that of the United States.
       France is an example of a European national health insurance (NHI) system that covers public and private hospitals as will as private practice. Quebec is an example of a new NHI system characterized by major institutional renovation. England is the exemplar of a national health service: hospitals are controlled by the state, and physicians are reimbursed on the basis of salaries and capitation fees. In each of these different environments, Dr. Rodwin emphasizes how health planners have challenged the model of hospital-centered medical care. He concludes that attempts to redistribute health resources have been hobbled by a central shortcoming: health planning has not been linked effectively to health care budgeting and the financial incentives that influence hospitals and physicians.
       In the United States, the health planning predicament has provoked controversial proposals to dismantle the formal health planning system and replace it by a strategy of encouraging competition in the health sector. But whether health planning strategies reply on regulation, competition," Rodwin argues that the critical policy issue is the design of a reimbursement system that would encourage hospitals and physicians to pursue society's interest as well as their own. This will involve not just technical innovations but political initiatives that overcome the resistance of powerful groups such as organized medicine, and reconcile deep differences in political philosophy.
       This comparative study of national health planning will broaden the debate about health policy in the United States today. It is sure to be of interest to physicians, health planners, and all those concerned with health systems and medical care.
Wagner Faculty