In the UK, the NHS has the incentive to improve its operational efficiency that it simply gets told regularly "we're cutting X billions of your budget. Deal".

The NHS is also split up into a range of trusts that have independent management teams. While there's a lot of cooperation and shared resources, this means there is a lot of opportunity to compare cost and outcomes, and so they can't just hide behind "but that's how much it costs", because the government will know it if there are other trusts delivering similar outcomes at a much lower cost.

And they have the incentive to respond to complaints in service that the NHS Trust in questions board of director will find campaign groups talking to MPs and cabinet ministers, tabloids calling them murderers and the like if they don't keep quality under control, and if they don't respond appropriately, the trust will get put under special measures which can include letting another trust take over management.

There are plenty of ways to apply pressure in addition to markets.

But you have some points: You can certainly make things better by e.g. requiring more transparency.