In a relatively short time, regulation has become a significant and distinct feature of how modern states wish to govern and steer their economy and society. Whereas the former ‘dirigiste’ state used to be closely related to public ownership (e.g. hospitals), planning (volume and capacity planning) and centralised administration (e.g. fixed prices and budgets), the new regulatory state relies mainly on the instrument of regulation to achieve its objectives. In this paper, we wish to relate the rise of the ‘regulatory state’ to the path-dependent trajectories and institutional legacies of discrete European health-care systems. For this purpose, we compared the Dutch corporatist social health insurance system, the strongly centralised National Health Service (NHS) of England and federal regionalised NHS system of Italy. Comparing these three different health-care systems suggests that it is indeed possible to identify a general trend towards the rise of the regulatory state in health care in the last two decades. However, although the three countries examined in this paper face similar problems of multilevel governance of networks of third-party payers and providers, each system also gives rise to its own distinct regulatory challenges.

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This article presents a cross-national analytical framework for understanding current attempts to reform medical governance - in particular, those by third parties to control the practice of medicine. The framework pays particular attention to the ways in which institutions shape policy reform. The article also outlines the main comparative findings of case studies of selected reforms and associated processes of negotiations in Denmark, Germany, Italy and the United Kingdom. These four countries were selected because they are characterised by theoretically interesting variations in the institutional contexts of medical governance. The analysis suggests that although all the four countries have pushed for more control over the way in which doctors practise medicine, in response to similar imperatives, each country differs in the path it has taken. More specifically, the instruments and techniques brought to bear in each case vary considerably and are directed by a country's political institutions towards a unique path.

Italy has a national health service (SSN) dating to 1978. Italy's system of government is characterized by a rather high degree of decentralization of power, and the health system is likewise decentralized. Most of the responsibilities for health care have been ceded to the regions. The state retains only limited coordinating and supervisory powers. The state has a financial responsibility for the national health service, but state contributions are limited and expenditures in excess of this made by the region must be financed from other sources. Health reforms of 1992-93 aimed at making the regions more sensitive to the need to control aggregate expenditure and to monitor measures to promote efficiency, quality, and citizen-patient satisfaction. The diffusion of individual health technologies has been relatively uncontrolled in many regions in Italy, although tight central constraints on capital spending have contained diffusion of new technology. Regulation of placement of services is a planning function and is the responsibility of both the Ministry of Health and the regions. Health technology assessment (HTA) activities have been expanding since the early 1990s, but these activities tend to be untargeted, uncoordinated, and without priorities. Nonetheless, the principal actors in the SSN at national, regional, and local levels are becoming more sensitive to the need to apply criteria of clinical and cost-effectiveness and to be more rigorous in deciding what services to guarantee. There are reasons to be guardedly optimistic about the future of HTA in Italy.