This article investigates the current use of Public–Private Partnerships (PPP) in the Danish health sector based on an initial discussion of theoretical approaches that analyze PPP. The empirical analysis concludes that PPP has been used very sparsely in the Danish health sector. There are few examples of large-scale partnership projects with joint investment and risk taking, but a number of smaller partnerships such as jointly owned companies at the regional level. When defining PPP more broadly, we can identify a long tradition for various types of collaboration between public and private actors in health care in Denmark. An analysis of the regulatory environment is offered as an explanation for the limited use of PPPs in Denmark. Major political and institutional actors at the central level differ in their enthusiasm for the PPP concept, and the regulatory framework is somewhat uncertain. A number of general issues and concerns related to PPPs are also discussed. It is suggested that a risk-based framework can be useful for mapping the potential and challenges for both private and public partners. Such a framework can be used to feed into game theoretical models of pros and cons for PPP projects. In general terms, it is concluded that more empirical research is needed for the assessment of the various risk factors involved in using PPPs in health care. Most PPPs are still very young, and the evidence on performance and broader governance issues is only just emerging. Ideally, such assessments should include comparisons with a purely public alternative.

The governance of medical performance is changing and new governing instruments are emerging. Existing analyses highlight the complexity of new governance arrangements, but the more or less dualistic perspective limits the possibility for exploring more fully this complexity. The present article therefore uses recent contributions to the literature on governance to explore the co-existence of different forms of governance with the aim of assessing the relative extent and the substantive nature of governance change. Using recent reforms of the governance of medical performance in Germany as a case study, the analysis suggests that the complexity of governance change takes three forms: first, the balance among (hybrid) forms of governance is shifting; second, the nature of individual (hybrid) forms of governance is changing; and, third, both types of change are reflected in tensions not only between but also within (hybrid) forms of governance. As such, the article also contributes to the recent literature on governance by highlighting the centrality of tensions in contemporary governance, which can also occur within both hybrid forms of governance and `pure' forms of governance.

Privatizations of public services are often driven by economic scarcity and changes in political leadership, in particular election victories for conservative or neoliberal political parties. Data from Norwegian counties on numbers of medical specialists in secondary care over a period of 11 years (1991–2001) allow us to analyse effects of economic, socioeconomic, and political factors on supply of both public and private specialists and the private–public mix. We find striking variations between the main explanatory factors related to public and private supply. Supply of public specialists is explained by counties' revenue levels and demographic factors and is not affected by the party composition of councils. The supply of private specialist medical services is negatively related to the proportion of elderly patients. The scarcity hypothesis is confirmed as lower county revenue levels increase both the absolute and relative proportions of private supply. Political composition of councils affects the private proportion of medical specialists as increased representation of conservatives leads to privatization.

An existing literature demonstrates that adverse changes to health can lead to improvements in health behaviors. Although the exact explanations for these empirical findings are debated, some posit that individuals learn about their true health risks through health shocks. Updated health risk information can then induce changes in health behaviors. While we follow a learning framework, we argue that past work has neglected the role of health insurance and medically related financial risk within this decision making context. Using longitudinal data from 11 European countries, we investigate the impact of a new cardiovascular (CV) health shock on smoking decisions among older adults and examine whether personal exposure to medical spending risk influences the smoking response. We then explore two potential mechanisms for this link: larger updates to health risk beliefs and higher medical expenditures to incentivize behavior change. We find that CV shocks impact the propensity to smoke, with relatively more impact among individuals with high financial risk exposure to medical spending. We also see larger increases in out-of-pocket expenditures following a shock for this group – consistent with the latter mechanism for behavior change.

A primary care choice reform launched in Sweden in 2010 led to a rapid growth of private providers. Critics feared that the reform would lead to an increased tendency among new, profit-driven, providers, to select patients with lower health risks. Even if open risk selection is prohibited, providers can select patients in more subtle ways, such as establishing their practices in areas with higher health status. This paper investigates to what extent strategies were employed by local governments to avoid risk selection and whether there were any differences between left- and right-wing governments in this regard. Three main strategies were used: risk adjustment of the financial reimbursements on the basis of health and/or socio-economic status of listed patients; design of patient listing systems; and regulatory requirements regarding the scope and content of the services that had to be offered by all providers. Additionally, left-wing local governments were more prone than right-wing governments to adopt risk adjustment strategies at the onset of the reform but these differences diminished over time. The findings of the paper contribute to our understanding of how social inequalities may be avoided in tax-based health care systems when market-like steering models such as patient choice are introduced.

The coronavirus disease 2019 (COVID-19) pandemic has shifted the health policy debate in Canada. While the pre-pandemic focus of policy experts and government reports was on the question of whether to add outpatient pharmaceuticals to universal health coverage, the clustering of pandemic deaths in long-term care facilities has spurred calls for federal standards in long-term care (LTC) and its possible inclusion in universal health coverage. This has led to the probability that the federal government will attempt to expand medicare as Canadians have known it for the first time in over a half century. However, these efforts are likely to fail if the federal government relies on the shared-cost federalism that marked the earlier introduction of medicare. Two alternative pathways are suggested, one for LTC and one for pharmaceuticals, that are more likely to succeed given the state of the Canadian federation in the early 21st century.

The UK, and England in particular, has suffered egregiously poor outcomes in managing the Covid-19 pandemic. This short perspective points to the explanation in terms of both current British politics and the public health policy inheritance. Boris Johnson's Premiership was born in an opportunistic assertion of British exceptionalism, and Johnson's initial, fate-tempting reaction to the novel Coronavirus set the UK on the wrong path. Furthermore, the gradual erosion of professionalism in (especially health) policy-making over almost four decades, and the hollowing-out of the health protection infrastructure, both facilitated and accentuated a toxic approach to managing Covid-19.

Since the beginning of the 1990s, health policy in Italy has been characterised by continuous reform as reflected by the frequency of new measures. Importantly, the reforms have changed considerably many aspects of the health-care system, including the governance of medical performance. The new measures fall into two types: regionalisation and transformation of local providers into ‘health-care enterprises’. In relation to the governance of medical performance, more specifically, the reforms have entailed the introduction of budgeting and quality assurance, the creation of new managerial roles, and the transformation of existing roles, as well as the introduction of new mechanisms for evaluating medical performance. In terms of the specific forms of governance, the reforms have reinforced hierarchy-based forms of governing intermeshed with party governance, and have re-defined professional self-regulation by strengthening collective forms of professional self-regulation. The design and implementation of the reforms are subject to a complex process of negotiation, which involves a wide range of actors spread across different levels of governance and takes place in relation to all aspects of the governance of medical performance.

This paper analyses the introduction of a systemic standards based programme for governing medical performance in Denmark. The programme combines clinical, organisational, and patient related standards and measures, and contains both external evaluation and self-assessment based on standards. The substance of the programme is new compared to the previous decentralised or professionally driven state of affairs that was based on a largely voluntary introduction of clinical standards, combined with a case-by-case evaluation of malpractice incidents. The programme strengthens hierarchy-based forms of governance; these co-exist with salient components of network-based governance as well as some elements of market-based governance. Institutional and contextual factors are important in explaining why a systemic standards based programme emerged as a result of the policy negotiation processes. In particular, the programme reflects stronger governance ambitions from the government in response to claims of a relative decline in the quality of the regional health services. However, the actual design is mediated by institutionalised negotiation processes among the state, decentralised authorities, and health professionals.

Ireland's private health insurance market operates on the basis of community rating, alongside open enrolment and lifetime cover. A risk equalisation scheme was introduced in 2003 to bolster community rating. However, in July 2008 the Irish Supreme Court set aside this scheme, on the basis of the interpretation of community rating in Irish legislation. This decision has significant implications for the Irish private health insurance market. This paper reviews the development of the market, focusing in particular on community rating. The breakdown of community rating in a market with multiple insurers with differing risk profiles is discussed. Applying this to the Irish market, it can be seen that the Irish Supreme Court judgment has significant implications for the application of community rating. Specifically, while community rating operates within plans, it no longer operates across the market, leading to high-risk lives paying more, on average, than low-risk lives. It has also led to greater opportunities for insurers to engage in market segmentation. This may have relevance for the design and operation of other community rated markets.

Our research investigates the effects of the 2005 universal health insurance program for children under age 6 in Vietnam on health care utilization, household out-of-pocket (OOP) spending and self-reported health outcomes using data from the Vietnam Household Living Standard Survey in 2002–2004–2006–2008. We use difference-in-differences to compare children eligible for the program to older children who are ineligible for the program. Results indicate that the program increased insurance coverage by 250% for children age 0–5 relative to the pre-policy period. We found large increases in both outpatient visits and hospital admissions. Health insurance availability also increased outpatient visits at both public and private facilities, suggesting that public and private health care services are complements. Although health insurance was associated with a decrease in inpatient OOP spending for children aged 3–5, it did not reduce outpatient OOP spending for children in general. Health insurance was associated with modest improvements in self-reported health outcomes. Our research suggests that expanded access to insurance among Vietnamese children improved access to care and health outcomes, though it did not necessarily reduce OOP spending.

Recent developments have transformed the role and characteristics of middle-income countries (MICs). Many stakeholders now question the appropriate role of MICs in the system of development assistance for health (DAH), and key funders have already recast their approach to these countries. The pressing question is whether MICs should be recipients, funders, both or neither. The answer has deep implications for individual countries and their citizens, and for the DAH system as a whole. We clarify the fundamental issues involved and emphasise a special feature of many MICs: mid-level gross national income per capita (GNIpc) combined with substantial health needs and large inequalities. We discuss the trade-off between concerns for capacity and need, and illustrate a capacity-based approach to setting the level of a GNIpc eligibility threshold. We also discuss how needs-based exceptions and incentive-preserving instruments can complement such a threshold. Against this background, we outline options for the future roles of MICs in various circumstances. We conclude that major players in the DAH system have reason to reconsider the criteria for allocating DAH among countries and the norms for which countries should contribute and how much.

In September 2016, a case went to trial in British Columbia that seeks to test the constitutionality of provincial laws that (1) ban private health insurance for medically necessary hospital and physician services; (2) ban extra-billing (physicians cannot charge patients more than the public tariff); and (3) require physicians to work solely for the public system or ‘opt-out’ and practice privately. All provinces have similar laws that have been passed to meet the requirements of federal legislation, the Canada Health Act (and thus qualify for federal funds). Consequently, a finding of unconstitutionality of one or more of these laws could have a very significant impact on the future of Canada’s single-payer system (‘medicare’). However, should the court find that a particular law is not in compliance with the Canadian Charter of Rights and Freedoms, the baton is then passed back to the government which may respond with other laws or policies that they believe to be constitutionally compliant. The ultimate impact of any successful Charter challenge to laws protecting medicare from privatization will thus significantly depend on how Canadian governments respond. Provincial governments could allow privatization to undercut equity and access, or they could respond creatively with new legal and policy solutions to both improve equity and access and tackle some of the problems that have long bedeviled Canadian medicare. This paper provides an understanding – grounded in comparative health systems evidence – of law and policy options available to Canadian lawmakers for limiting two-tier care in the wake of any successful challenge to existing laws. The paper presents the results of a large inter-disciplinary, comparative study, started in 2015, that systematically reviewed the legal and broader regulatory schemes used to regulate the public/private divide in 15 Organization for Economic Co-Operation and Development countries with a particular eye to what the effect of such regulations would be upon wait times.

Policy makers like the idea of new initiatives and fresh starts, unencumbered by, even actively overthrowing, what has been done in the past. At the same time, history can be pigeonholed as fusty and antiquarian, dealing with long past events of no relevance to the present. Academic historians are sometimes bound up in their own worlds. The debates central to academe may have little direct relevance to the immediate concerns of policy making. The paper argues that history, as the evidence-based discipline par excellence, is as relevant as other approaches to evidence-based policy making. Case studies can show us the nature of that relevance. How to achieve influence for history also needs discussion. The relationship is not straightforward and will vary according to time and place. History is an interpretative discipline, not just a collection of ‘facts’. The paper discusses how historians work and why it is important for policy makers to engage, not just with history, but with historians as well. Historians too need to think about the value of bringing their analysis into policy.

Rising pharmaceutical prices, increasing demand for more effective innovative drugs and growing public outrage have heightened criticism of the pharmaceutical industry. The public debate has focused on drug prices and access. As a consequence, the patent system is being reexamined as an efficient mechanism for encouraging pharmaceutical innovation and drug development. We propose an alternative to the existing patent system, instead rewarding the innovating firm with direct tax credits in exchange for marginal cost pricing. This concept is based on the fundamental assumption that innovation that benefits society at large may be financed publicly. As an industry which produces a social good characterized by high fixed costs, high information and regulatory costs, and relatively low marginal costs of production, pharmaceuticals are well-suited to such a mechanism. Under this proposal, drug prices fall, consumer surplus increases, access is enhanced, and the incentives to innovate are preserved.

In the last decades, several European health systems have abandoned their vertically integrated health care in favour of some form of managed competition (MC), either in a centralised or decentralised format. However, during a pandemic, MC may put health systems under additional strain as they are designed to follow some form of ‘organisational self-interest’, and hence face reduced incentives for both provider coordination (e.g. temporary hospital close down, change in the case-mix), and information sharing. We illustrate our argument using evidence for the Covid-19 pandemic outbreak in Italy during March and April 2020, which calls for the development of ‘coordination mechanisms’ at times of a health emergency.

This research longitudinally examines the association between levels of state Medicaid prescription spending and the state strategies intended to constrain cost increases: the negotiated pricing strategy, as indicated by state rebate programs, and the price transparency strategy, as indicated by state operation of All-Payer Claims Databases. The findings demonstrate evidence that state Medicaid prescription spending is influenced by the negotiated pricing strategy, especially Managed Care Organization (MCO) rebates under the Patient Protection and Affordable Care Act, but not influenced by the price transparency strategy. State decisions for MCO rebates, such as carving prescription benefits into managed care benefits, were effective in containing levels of Medicaid prescription spending over time, while other single- and multi-state rebate programs were not. Based on these findings, state policymakers may consider utilizing the MCO rebate program to address increases in Medicaid prescription spending.