The structure of professional regulation in health care emerged as an important policy issue in the early 1990s. The initial discussion of regulatory reform had already begun a decade earlier at the more general policy level in many countries (Baldwin et al, 1998). Subsequently, in the health sector, once previously in lockstep, publicly administered hospitals in many Western and Central European countries were transformed into varying degrees of semi-autonomous and/or self-managing organisations (Saltman et al, 2011). Responding to this change, governments introduced revised regulatory arrangements through which to supervise provider behaviour and ensure clinically, financially and socially satisfactory outcomes. These new institutional and regulatory arrangements were conjoined at the popular level with increased patient pressure in a number of tax-funded health systems for reductions in waiting lists, as well as increased choice of health care provider and/or provider institution (Saltman and von Otter, 1992; Le Grand and Bartlett, 1993). In the first decade of the 2000s, reflecting this newly diverse service delivery environment, concepts such as ‘stewardship’ and ‘governance’ began to receive attention in policymaking circles (Saltman and Ferroussier-Davis, 2000; Saltman et al, 2011), and in a number of country contexts, existing regulatory measures were further re-thought, re-justified and (depending on the country) reconfigured.

While the overall purpose and function of health sector regulation remained largely constant, the process and mechanisms through which regulation acted was changed, in some cases quite considerably (Osborne and Gaebler, 1992; Kettl, 1993). Regulation became a more extensive, diverse and complex endeavour, expanding its scope and focus in a variety of different national contexts. In addition to redesigned efforts at national level, varying degrees of de-concentration (independent national agencies), delegation (private organisations) and devolution (regional and local governments) were brought into play. In England, different national agencies – with various degrees of independent structure – were introduced in succession (Saltman, 2012). In Sweden, new supervisory efforts in the 1990s by the National Board of Health and Welfare were supplemented in 2006 by the introduction of ‘open comparisons’, by which the Ministry of Social Affairs and Health published performance measures of each regional public delivery agency (with 21 elected county and regional councils).