and COOP elements in staff behaviour, but it is claimed that patients were generally treated in
a P/C way, paternalistically and harshly: “In the ward, the patient was isolated... and subject
to authoritarian discipline... they rarely saw [the health staff] ...who treated them with
disdain”(Trumper and Phillips, 1996, p 41). In contrast, in the small private sector, the staff
were mainly motivated by M, the wealthy private sector patients were much more well-
informed about their treatment and generally treated with respect. Nonetheless, the universal
coverage led to high standards of health care, as indicated by infant mortality and life
expectancy rates. The reforms have increased the proportion of the health care facilities
operating primarily in an M mode, not only directly in the growing profit-motivated private
sector, but extending into the public sector as well in response to the incentives offered
medical staff to switch to the private sector.
The UK, like Chile, was a pioneer in introducing market reforms in the economy, under
Thatcher’s leadership, and again like Chile this was soon followed by health sector reforms.
In this case, the reforms consisted in introducing a quasi-market in the allocation of health
care within the system. The net effect was to enhance M motivation, while greatly increasing
the proportion of administrative staff: as le Grand pointed out the assumption of ‘knightly’
behaviour (COOP) was replaced by that of ‘knave’ like behaviour, and this actually changed
the motivation of medical staff in the same direction, reducing COOP behaviour. It appears
that the efficiency of resource allocation increased, but this was offset by the greatly increased
administrative costs (see Le Grand, 1997; Glennerster, 1995).
These are two (perhaps extreme) examples of a general trend. They are being followed
elsewhere - e.g. in Colombia, Argentina and Canada. Many of the reforms are supported by
the World Bank and the Inter-American Development Bank. The changes illustrate the close
connection between the macro-environment for group behaviour and changing mode of
behaviour in particular groups. However, at the same time there are examples of more
participatory community-based health services. For example, an integrated health project in
the poor areas of Salvador in Brazil, involved the three levels of government and “the total
and complete participation of the future beneficiaries”. However, the organiser noted
“Cooperation is not part of our culture; it is a relatively new phenomenen. Institutions and
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