Very few European countries are capable of implementing effective healthcare reform. Why?  Here we look at five big obstacles to success. And we argue that trust, political consensus, centralisation, the involvement of the professions and a knowledge of how to control the private sector are all essential to success.

1) Decentralisation. In most European countries, healthcare policy is effectively left in the hands of regional authorities. Finland takes this to the extreme, with primary and secondary care delegated to over 400 municipalities, each with 5,000 to 10,000 people. A senior civil servant in the Finnish Health Ministry told Healthcare Europa that there is precious little that the ministry can do, other than making suggestions, since the municipalities are democratically elected and control spending.

A similar structure applies in Germany, where the Länder have power, and, in the Czech republic, where the regions have a free rein. The Spanish system cannot even be called decentralised. To fully understand healthcare policy there, you have to understand that the 21 regions have near complete autonomy - Spain is best envisaged as a patchwork quilt, rather like the Holy Roman Empire!

Decentralised systems also make accurate measurements very difficult.

Even in centralised systems, like the UK, the Ministry of Health has to negotiate with the Treasury and the Prime Minister's office. But, in general, centralised national health systems can implement reforms much faster - John Appleby, chief economist at the King's Fund in London points out that, at least in Britain, the levers are clear and measurement is easy.

• Decentralisation makes it very hard indeed to ensure that any policies are implemented fast.

2) What the public will accept. Healthcare reform is always deeply emotive, and can only take place within the very limited comfort factor of the electorate.

There are some things that are just unacceptable. This varies, rather surprisingly, from country to country. In Germany, there is now relatively little outcry at the idea of a public hospital being purchased by a private operator (although large scale privatisation of a major city's hospital network is unlikely to be repeated after the problems Asklepios faced in Hamburg).

Any such privatisation would be unacceptable in Sweden or Finland, although here the wholesale outsourcing of the running of a public facility to the private sector is fine. In France, neither of these would be considered acceptable. Instead, an underperforming public hospital is quietly closed down and replaced with a private facility, which just so happens to be built nearby!

Private involvement is far easier in low visibility areas, such as laboratories, imaging and old people's homes.

Equally, the public will not put up with certain things. The Czechs do not spend enough to provide proper healthcare for themselves, yet they will not accept any curtailments in the original basic package - they like their spa treatments, and want them to remain on the menu, even when there is patently not enough funding to pay for them.

• Most electorates are not well educated in health policy, react emotionally and will avoid hard choices.

3) Elections. A single election result can change healthcare policy overnight. In the Czech republic, the social democrats took power this month, and are utterly opposed to any sort of private healthcare. The privatisation programme in Slovakia has been slung into reverse - that is democracy for you!

• Elections will overturn reforms unless these is a strong degree of political consensus that health reforms are necessary.

4) Vested professional interests. Doctor's associations are extremely powerful. The British Medical Association regularly scuppers government policy, such as the move towards larger polyclinics.

It is two years since the Greek courts ruled that a previous stipulation, that a doctor had to own over 50% of any diagnostics lab, was actually contrary to EU law. Yet, thanks to pressure from doctors, the Ministry of Health has constantly stalled any attempt to change the law.

• Professional bodies have a lot of political power and can overturn reforms.

5) A lack of understanding of how the private sector works. In the UK, private hospitals were told they would be paid a unit price per operation, and were then allowed to select the patients they treated. Small wonder they rejected the very elderly, frail and unfit, who were left to be catered for by the public sector.

Or take the way British GPs immediately adjusted their workload to ensure they hit all the targets set by the government. According to Dr Adam Oliver, at the London School of Economics, this transformed them from being one of the worst paid group of family doctors in Europe to the best paid family doctors in the world - one can only conclude that the government didn't think they would jump through hoops for money.

Or take Germany. It took the authorities over a decade to close a loophole that allowed laboratories to pay huge bonuses out of social insurance funds to doctors who carried out unnecessary lab tests. Closing the loophole will lead to a 20% or 25% reduction in lab tests!

Anyone with a grain of commonsense could have predicted how private companies and private individuals would react in these circumstances.  So the question becomes: "Why were government bodies incapable of working it out for themselves?"

Private healthcare will always go for the quick buck. Shaping a regulatory framework which motivates private healthcare to hit the right goals shouldn't be beyond the wit of a health ministry. But these sorts of issues make some policymakers very sceptical of the value of the private sector.  Dr Oliver asks why the government should bother involving the private sector at all, pointing out that administrative costs in the UK are circa 5%, compared to circa 15%-20% in the USA.

• Unless you have an intimate understanding of how private healthcare operators will behave in any situation, you will fail to come up with programmes which will harness their energy and appetite for change.

So what does work?

To succeed, obviously we need the converse of these factors - trust, political consensus, centralisation, the involvement of the professions and a knowledge of how to control the private sector. Countries can be scored against these factors.  The UK, for example, now scores highly on all but the last two factors. France scores fairly poorly on most factors, which explains why reform is proving so hard.

Very few countries can claim high scores across the board - perhaps only the Netherlands and Sweden. Worryingly, it is most lacking in Eastern and Central Europe, the very countries where it is most needed.

This means there is little or no hope of effective healthcare reform here, and that the population will be condemned to years of underfunded, poor quality state provision, coupled with an opportunistic private sector, which will tend to focus on the wealthy.