Health reforms in the 1990s reduced the role of the welfare state and gave greater primacy to the market

The state, as the guarantor of equity, has become less effective in many countries. Its powers have been scaled down by deliberate policy measures, by reduced public spending or by declining performance. The coverage it gives to the lowest income social groups has fallen at the same time as poverty has grown.

As a result, many people are now marginalized from effective services and depend on self-help (Equinet, 1998; Simms, 2000). Even where the effects have been less extreme, the state is currently confronted by policy choices over how it implements core public health principles such as equity, solidarity, risk pooling and universality in a diverse environment of purchasers, providers and users of health services.