In these countries the role of the State in health care has been put to task by the following factors:

a) The rise in demand for health care, partly due to the increase in levels of welfare, information and culture in society, and partly due to factors such as the rapid incorporation of new technologies;

b) The progressive ageing of society;

c) Changes in family and jobs;

d) The emergence or higher incidence of certain diseases;

e) Budget difficulties in most countries to finance social programmes.

These same elements have led to a series of reforms in health sectors, which, according to Prof. Segura's paper, aim to «increase efficiency by introducing competition in a regulated and publicly financed market». Public financing is necessary for equity reasons, while maintaining a certain degree of regulation, compatible with competition, is a consequence, according to Prof. Segura, of the special characteristics of the sector and health benefits.

Introducing competition is not, however, the only mechanism to achieve a more efficient use of resources. Prof. Mossialos refers to evidence which reveals that quite a large percentage of health services are unnecessary or are offered in an inappropriate way, and introducing or reinforcing competition would not change this situation substantially. To eliminate these inefficiencies it is not enough to have greater competition. Medical treatments and procedures must be evaluated in order to identify which services and benefits are effective and which ones are not. This is, however, a formidable task which requires many years and great expense. Its achievement would therefore greatly benefit from international cooperation.

Another field which clearly needs a common approach and greater cooperation between countries is the evaluation of new technology, in order to overcome the present state of uncoordination with multiple studies using different criteria sometimes inconsistent or inappropriate.