Publicly funded health system reforms increasingly require the evaluation of competing programmes. However, programmes are made of multi-dimensional attributes of value (where value refers to latent expectations of health system improvement). This paper identifies the design, implementation and validation of a methodology to elicit health system values to guide health care priority setting. The exercise suggests that the proposed methodology is suitable for eliciting and validating health system values, and its findings show that pursuing health gain alone does not fully capture the dimensions of health system value. More specifically, we identify a list of health system values (elicited by both potential and actual users) and classify them in terms of process-related values (e.g., shorter waiting lists, greater choice, etc.) and improvements in health system equity in addition to value derived from health gain.

The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.

Fragmentation in health systems leads to discontinuities in the provision of health services, reduces the effectiveness of interventions, and increases costs. In international comparisons, Germany is notably lagging in the context of healthcare (data) integration. Despite various political efforts spanning decades, intersectoral care and integrated health data remain controversial and are still in an embryonic phase in the country. Even more than 2 years after its launch, electronic health record (elektronische Patientenakte; ePA) users in Germany constitute only 1 per cent of the statutorily insured population, and ongoing political debates suggest that the path to broader coverage is fraught with complexities. By exploring the main stakeholders in the existing (fragmented) health system governance in Germany and their sectoral interests, this paper examines the implementation of ePA through the lens of corporatism, offering insights based on an institutional decision theory. The central point is that endeavours to better integrate health data for clinical care, scientific research and evidence-informed policymaking in Germany will need to address the roles of corporatism and self-governance.

There has been much recent debate on the impact of competition on the English National Health Service (NHS). However, studies have tended to view competition in isolation and are controversial. This study examines the impact of programme theories associated with the health system reforms, which sought to move from a dominant target-led ‘central control’ programme theory, to one based on ‘market forces’, on orthopaedics across six case-study local health economies. It draws on a realistic evaluation approach to open up the policy ‘black box’ across different contexts using a mixed methods approach: analysis of 152 interviews with key informants and analysis of waiting times and admissions. We find that the urban health economies were more successful in reaching the access targets than the rural health economies, although the gap in performance closed over time. Most interviewees were aware of the policies to increase choice and competition, but their role appeared comparatively weak. Local commissioners’ ability to influence demand appeared limited with providers’ incentives dominating service delivery. Looking forward, it is clear that the role of competition in the NHS has to be considered alongside, rather than in isolation from, other policy mechanisms.

Roma in central Europe face many violations of their rights, including those that impede their access to high-quality health care. Legal frameworks have the potential to address these violations, whereas legal advocacy services offer a means for enforcement of rights. We undertook key informant interviews with Roma civil society organisations and selected knowledgeable individuals in Macedonia, Romania and Serbia to identify lessons from the development of these services. Achievements were reported in four areas. Legal empowerment, with employment of Roma paralegals was especially effective, increasing awareness of the ability to challenge violations. Documentation of human rights violations is an important basis for advocacy, but does not guarantee redress, and may work best in combination with legal empowerment or international pressure. Strategic litigation can play a key role in removing bureaucratic obstacles that prevent Roma from exercising their right to access to health care. Progress in changing the narrative on Roma in the mainstream media has been limited but examples of good practice exist. Although much remains to be done, Roma groups report that legal advocacy has strengthened their ability to challenge rights violations, thereby enhancing their ability to access effective and responsive care.

Patients’ increasing use of alternative sources of information besides their physician and more active involvement in medical decision making may be changing relationships between physicians and their patients. We term patients who provide medical information to their physicians from sources other than their physician as information-oriented patients and investigate the relationship between having such patients and physician career satisfaction. We find that having more information-oriented patients is significantly associated with lower physician career satisfaction. Though healthcare information from alternative sources other than their physicians is thought to promote better-informed patient choices, the adverse relationship with physician career satisfaction found in this study may have important implications for patient access and quality of care.

After years of unprecedented growth in development assistance for health (DAH), the DAH system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases and by the economic transition and rise of the middle-income countries. Central to any potent response is a fair and effective allocation of DAH across countries. A myriad of criteria has been proposed or is currently used, but there have been no comprehensive assessment of their distributional implications. We simulated the implications of 11 quantitative allocation criteria across countries and country categories. We found that the distributions varied profoundly. The group of low-income countries received most DAH from needs-based criteria linked to domestic capacity, while the group of upper-middle-income countries was most favoured by an income-inequality criterion. Compared to a baseline distribution guided by gross national income per capita, low-income countries received less DAH by almost all criteria. The findings can inform funders when examining and revising the criteria they use, and provide input to the broader debate about what criteria should be used.

Before his incoherent response to the COVID-19 pandemic, the focus of President Trump's health policy agenda was the elimination of the Patient Protection and Affordable Care Act (ACA), which he has called a ‘disaster’. The attacks on the ACA included proposals to repeal the law through the legislative process, to erode it through a series of executive actions, and to ask the courts to declare it unconstitutional. Despite these ongoing challenges, the ACA remains largely intact as the U.S. heads into the 2020 election. The longer term fate of the law, however, is uncertain and the outcome of the 2020 election is likely to have a dramatic effect on the direction of health policy in the U.S.

One of the main governance decisions that policymakers need to make is whether to implement public services via centralized or decentralized forms. As Costa et al. discuss in their article, when public services are implemented via competing systems, service providers contend to provide good services with the ultimate objective of gaining market quota. This is known as managed competition (MC), as the authorities will have to manage the panoply of public and private organizations offering the service. The alternative is to manage the service more centrally, in what it is identified as vertical integration. As the authors describe, several governments around the globe have abandoned their vertical integrated models in favour of decentralized models. This is the case, as the authors recall, for most health services in Europe. While there is an emerging body of evidence suggesting that decentralized MC outperforms vertically integrated models both in terms of efficiency and in terms of service quality, little is known on how these systems react under different circumstances. This means, for example, how these systems can cope with a sudden increase in their service demands.

The EU Treaties oblige the EU institutions to take health objectives and concerns into account in all policy fields. Nevertheless, this obligation is only marginally honoured in many EU policy areas at best. One problem is the lack of enforcement options to pursue further implementation. This paper examines the obligation to ‘mainstream’ health in Article 168 TFEU and demonstrates the difficulties in enforcing the obligation in more detail. It then offers a new, deeper interpretation of the contents of the mainstreaming obligation and discusses how this definition may be used to facilitate better enforcement in the future.

In the Americas, next to the United States, Brazil and Mexico have the highest prevalence of type-2 diabetes. In contrast to most studies, this article compares and analyzes the politics behind the implementation of type-2 diabetes self-care management programs (DSM), which is a new area of scholarly research. This article claims that Brazil outpaced Mexico with respect to the implementation of effective DSM programs, the product of positive policy spillover effects associated with the president and governing political party’s popular anti-poverty programs, and the enduring legacy of centralized ministry of health financial and human resource assistance to primary care programs in a context of decentralization. Brazil also benefited from having a strong partnership with international health agencies. None of these factors was present in Mexico. Findings suggest that more research needs to go into understanding the complex political and inter-governmental contexts facilitating DSM program implementation, which is a neglected area of research.

The inclusion of both monetary and non-monetary indirect benefits in economic evaluations of public health programmes and services can have significant distributive effects between patient groups. As a result, some patients may be advantaged and others disadvantaged for reasons not directly related to health outcomes or (direct) treatment costs. In pluralistic democracies, there is a case for consulting the community on the fairness of policies that have such distributive implications. This paper reports the results of two pilot studies aimed at uncovering the preferences of the Australian public for the inclusion of indirect benefits in the evaluation of services for its national health scheme, Medicare. The initial survey found some support for taking account of non-monetary indirect benefits – for example, the social contribution made by parents of young children and carers of elderly relatives. By contrast, there was little support for giving high taxpayers priority access to general Medicare services, to life-saving organ transplants, or to very costly drugs, despite the indirect social benefits of doing so. However, such support increased significantly in the follow-up study when the outcomes were characterised as certain, identifiable and health related, and the opportunity costs of failing to take account of indirect benefits were made very clear. The follow-up survey provided evidence of public scepticism about the willingness or ability of government to use additional tax receipts for socially beneficial purposes, and/or a preference for programmes and services that focus on health rather than welfare more generally.

This article studies the implementation of the European Union (EU)’s Patients’ Rights Directive in Germany and Norway. The objective of the Directive was to allow EU member states to have a say in the regulatory work, ensure predictability and uniformity in the application of EU rules on cross-border care, and enhance a move towards EU harmonisation in this area. So far, the implementation processes in Norway and Germany have mixed results regarding the likelihood of achieving uniformity and harmonisation. Although the Directive has had convergent effects on certain areas of cross-border care, such as setting up National Contact Points and providing patients with the basic right to treatment abroad, implementation also shows divergent patterns. In both countries, adapting to EU rules has strengthened patients’ rights to choose freely among health-service providers in a wider European health-service market. However, due to legal discretion and country-specific institutions within which the new rules are applied, divergent patterns prevail.

Legislation in most countries regulates trade in poisons and highly addictive products, such as narcotics. The statements that (1) tobacco harms health and (2) causes addiction are established as facts in international and national law. Yet in Russia, and in many other countries, there is a contradiction between the open sale of this addictive poison and basic laws, such as those on product safety. Provisions in both the Russian constitution and the criminal code can be interpreted as making the sale of tobacco illegal, setting out severe penalties for those involved. Yet, remarkably, tobacco is treated quite differently from other products. In this paper, we describe the experience so far in seeking to enforce this legislation in Russia. Attempts to persuade the police to enforce the legislation have been unsuccessful, although they accept that there is a prima facie case for action but, in private, express fear of taking it. The case for action is currently being argued before the Russian Supreme Court but this could take many years to reach a conclusion. In the mean time, new legislation on the regulation of tobacco production has been passed by the State Duma, with the support of the tobacco industry, which implicitly assumes that tobacco is a lawful product, thereby creating legal confusion. We argue that the only way to redress this situation is to recognize that tobacco production and sales must be regulated in the same way as any other harmful and addictive substance.

A current policy issue is whether, and if so under what circumstances, insurance companies should be given access to genetic test results. The insurance industry argues for mandatory disclosure in order to avoid problems of adverse selection; an alternative would be a moratorium or legislation preventing such disclosure; a third option a voluntary disclosure law. This paper investigates the impact of these policies on individuals' incentives to both acquire genetic information and to disclose it to providers of health and/or life insurance. The theoretical framework used to inform this analysis is provided by the ‘games of persuasion’ literature, in which one agent tries to influence another agent's decision by selectively withholding her private information regarding quality. The application of the theoretical framework to this policy context yields the following results. Individuals have the incentive to acquire genetic information and to disclose the test results if disclosure is voluntary. If, however, they are obliged to disclose the results of any genetic tests they have taken, their incentive may be not to acquire such information. I discuss the policy implications of these findings both from the point of view of the insurance industry and from a public health perspective.

In recent years, a variety of ‘accelerated access’ schemes have been introduced by pharmaceutical regulators and funders globally. These schemes aim to overcome perceived regulatory and reimbursement barriers to accessing medicines – particularly for patients with limited time or therapeutic options. However, patient access to approved medicines is mediated by a number of third parties including regulators and payers, and physicians who act both as gatekeepers and guides to prescribed medications. It is therefore essential to know how physicians think about accelerated access as they are responsible for advising patients on and prescribing medicines made available via these pathways. We conducted semi-structured interviews with 18 Australian physicians focusing on their attitudes towards accelerated access. We identified three ‘archetypes’ of physicians: ‘confident accelerators’, ‘cautious accelerators’, and ‘decelerators’. Although all acknowledged the potential risks and benefits of accelerated access, they disagreed on their magnitude and extent and how they should be balanced in both policy formation and clinical practice. Overall, our results illustrate the diversity of clinical opinions in this area and the importance of monitoring both the prescribing and clinical outcomes that result from accelerated access programmes to ensure that these are both clinically and morally acceptable.