The Canada Health Act 1984 (CHA) is considered foundational to Canada’s publicly funded health care system (known as Medicare). The CHA provides for the federal transfer of funding to the provinces/territories, in exchange for provincial/territorial adherence to Medicare’s key principles of universality; comprehensiveness; portability; accessibility; and, public administration. Medicare is a decentralized health care system, managed independently by Canada’s 10 provincial and three territorial governments, allowing for regional adaptations to fit varying degrees of urbanity, remoteness and needs. The Act is silent on its relationship to the Indigenous health care system – what some have described as Canada’s 14th health care system. The CHA has not kept pace with Indigenous self-government activities that have since spread across Canada. It has unfortunately crystallized the federal/provincial/territorial/Indigenous jurisdictional fragmentation that perpetuates health inequities and has failed to clarify these jurisdictions’ obligations towards Indigenous peoples. As a result of these omissions, access to health services remains a concern for many Indigenous Canadians, resulting in poorer outcomes and premature mortality. In this paper, I argue that Medicare renewal must: make an explicit commitment to Indigenous health equity; clarify jurisdictional obligations; establish effective mechanisms for addressing areas of jurisdictional dispute and/or confusion; and explicitly recognize First Nations and Inuit health care services as integral yet distinct systems, that nevertheless must be welcomed to seamlessly work with provincial health care systems to ensure continuity of care.

In many OECD countries, healthcare sectors have become increasingly concentrated as a result of mergers. However, detailed empirical insight into why healthcare providers merge is lacking. Also, we know little about the influence of national healthcare policies on mergers. We fill this gap in the literature by conducting a survey study on mergers among 848 Dutch healthcare executives, of which 35% responded (resulting in a study sample of 239 executives). A total of 65% of the respondents was involved in at least one merger between 2005 and 2012. During this period, Dutch healthcare providers faced a number of policy changes, including increasing competition, more pressure from purchasers, growing financial risks, de-institutionalisation of long-term care and decentralisation of healthcare services to municipalities. Our empirical study shows that healthcare providers predominantly merge to improve the provision of healthcare services and to strengthen their market position. Also efficiency and financial reasons are important drivers of merger activity in healthcare. We find that motives for merger are related to changes in health policies, in particular to the increasing pressure from competitors, insurers and municipalities.

This paper examines whether delivery practice patterns (Cesarean sections or vaginal) are influenced by lawsuits or whether the hypothesized relationship is confounded by small area variation. The analysis uses multilevel analysis to deal with hospital- and Dartmouth Hospital Referral Region-level variation. The model includes patient clinical variables, patient socio-economic status, and hospital characteristics as control variables. The secondary data sources include hospital discharges from the 2002 Texas Health Care Information Council as well as 1988–2001 Texas Department of Insurance Closed Claim File data. After extracting the variation in delivery practice between hospitals and between Dartmouth Hospital Referral Regions in a multilevel model, the effects of lawsuits on defensive medicine are reduced but are still significant.

At present, health systems across Europe face the same challenges: a changing demographic profile, a rise in multi-morbidity and long-term conditions, increasing health care costs, large public debts and other legacies of an economic downturn. In light of these concerns, this article provides an overview of the international evidence on how to improve productive efficiency in secondary care settings. Updating and expanding upon a recent review of the literature by Hurst and Williams (2012), we set out evidence on potential interventions in the policy environment, hospital management, and operational processes. We conclude with five key lessons for policy makers and practitioners on how to improve productive efficiency within hospital settings, and identify several gaps in the existing evidence base.

After a ‘golden age’ of extraordinary growth in the level of development assistance for health (DAH) since 1990, funding seems to have reached a plateau. With the launch of the Sustainable Development Goals, debate has intensified regarding what international financing for health should look like in the post-2015 era. In this review paper, we offer a systematic overview of problems and proposals for change. Major critiques of the current DAH system include: that the total volume of financing is inadequate; financial flows are volatile and uncertain; DAH may not result in additional resources for health; too small a proportion of DAH is transferred to recipient countries; inappropriate priority setting; inadequate coordination; weak mechanisms for accountability; and disagreement on the rationale for DAH. Proposals to address these critiques include: financing-oriented proposals to address insufficient levels and high volatility of DAH; governance-oriented proposals to address concerns regarding additionality, proportions reaching countries, priority setting, coordination and accountability; and proposals that reach beyond the existing DAH system. We conclude with a discussion of prospects for change.

While there is evidence that weight-loss interventions reduce morbidity, indications of their acceptability are limited. Understanding preferences for lifestyle interventions will help policymakers design interventions. We used a discrete choice experiment to investigate preferences for lifestyle interventions to reduce adult obesity. Attributes focused on: the components of the programme; weight change; short-term and longer-term health gains; time spent on the intervention and financial costs incurred. Data were collected through a web-based questionnaire, with 504 UK adults responding. Despite evidence that dietary interventions are the most effective way to lose weight, respondents preferred lifestyle interventions involving physical activity. While the evidence suggests that behaviour change support improves effectiveness of interventions, its value to participants was limited. A general preference to maintain current lifestyles, together with the sensitivity of take up to financial costs, suggests financial incentives could be used to help maximise uptake of healthy lifestyle interventions. An important target group for change, men, required more compensation to take up healthier lifestyles. Those of normal weight, who will increase in weight over time if they do not change their lifestyle, required the highest compensation. Policymakers face challenges in inducing people to change their behaviour and adopt healthy lifestyles.

A competitive national health insurance system was introduced in Israel in 1995. Comsumer mobility has been traditionally a signal of market (managed) competition. However, since 1998, sickness funds’ switching rate has been stable at around 1% of the population. The low switching rate is explained by limited real options and similarity in the sickness funds functioning, and reluctance to change providers. The paper aims to characterize the 1% of the population who switches sickness fund in relation to the stayers, and to examine the implications for public policy. The National Insurance Institute Health Registry was used to conduct two analyses: (i) bivariate comparisons on selected socio-demographic characteristics of the switchers to those of the stayers in the years 1999–2000, and (ii) a multivariate logistic analysis of the propensity to switch for the entire adult (21+) population in the years 2005–2006. The main result is that switching is an inferior good. Both the bivariate and the multivariate analysis show that persons with lower labor-income, receiving income support or unemployment benefits are more likely to switch. Switchers have more children up to age 18. Arabs and Orthodox Jews are more likely to switch sickness funds. The 1% of switchers does not form a random draw from the age–sex-adjusted population. The over-representation of poor persons among switchers is unique to the Israeli scene, which might have resulted from demand-side initiatives, but also from implicit risk-selection strategies exercised by the sickness funds under the Israeli incomplete age-based risk-adjustment system.

This paper employs widely used analytic techniques for measuring equity in health care financing to update Irish results from previous analysis based on data from the late 1980s. Kakwani indices are calculated using household survey data from 1987/88 to 2004/05. Results indicate a marginally progressive financing system overall. However, interpretation of the results for the private sources of health financing is complicated. This problem is not unique to Ireland but it is argued that it may be relatively more important in the context of a complex health financing system, illustrated in this paper by the Irish system. Alternative options for improving the analysis of equity in health care financing are discussed.

In the 1990s, countries experimented with two models of health care reforms based on choice of provider and insurer. The governments of the UK, Italy, Sweden and New Zealand introduced relatively quickly ‘internal market’ models into their single-payer systems, to transform hierarchies into markets by separating ‘purchasers’ from ‘providers’, and enabling ‘purchasers’ to contract selectively with competing public and private providers so that ‘money followed the patient’. This model has largely been abandoned where it has been tried. England, however, has implemented a modified ‘internal market’ model emphasising patient choice, which has so far had disappointing results. In the Netherlands, it took nearly 20 years to implement successfully the model in which enrollees choose among multiple insurers; but these insurers have so far only realised in part their potential to contract selectively with competing providers. The paper discusses the difficulties of implementing these different models and what England and the Netherlands can learn from each other. This includes exploration, as a thought experiment, of how choice of purchaser might be introduced into the English National Health Service based on lessons from the Netherlands.

This article presents a cross-national analytical framework for understanding current attempts to reform medical governance – in particular, those by third parties to control the practice of medicine. The framework pays particular attention to the ways in which institutions shape policy reform. The article also outlines the main comparative findings of case studies of selected reforms and associated processes of negotiations in Denmark, Germany, Italy and the United Kingdom. These four countries were selected because they are characterised by theoretically interesting variations in the institutional contexts of medical governance. The analysis suggests that although all the four countries have pushed for more control over the way in which doctors practise medicine, in response to similar imperatives, each country differs in the path it has taken. More specifically, the instruments and techniques brought to bear in each case vary considerably and are directed by a country's political institutions towards a unique path.

In parallel to market-like reforms in Swedish primary care, the gathering and compilation of comparative information about providers, for example through survey tools, has been improved. Such information is increasingly being used to guide individuals’ choice of provider and payers’ assessments of provider performance, often without critically reflecting about underlying factors affecting the results. The purpose of this study was to analyze variation in patient satisfaction, with respect to organizational and structural factors, including the mix of registered individuals, among primary care providers, based on information from a national patient survey in primary care and register data in three Swedish county councils. Systematic variation in patient satisfaction was found with respect to both organizational and structural factors, including characteristics of registered individuals. Smaller practices and practices where a high proportion of all visits were with a doctor were associated with higher patient satisfaction. Also practices where registered individuals had a low level of social deprivation and a high overall illness on average were associated with higher patient satisfaction. Factors that are of relevance for how well providers perform according to patient surveys are more or less possible to control for providers. This adds to the complexity for the use of such information by individuals and payers to assess provider performance.

The design of Australia’s Medicare programme was based on the Canadian scheme, adapted somewhat to take account of differences in the constitutional division of powers in the two countries and differences in history. The key elements are very similar: access to hospital services without charge being the core similarity, universal coverage for necessary medical services, albeit with a variable co-payment in Australia, the other. But there are significant differences between the two countries in health programmes – whether or not they are labelled as ‘Medicare’. This paper discusses four areas where Canada could potentially learn from Australia in a positive way. First, Australia has had a national Pharmaceutical Benefits Scheme for almost 70 years. Second, there have been hesitant extensions to Australia’s Medicare to address the increasing prevalence of people with chronic conditions – extensions which include some payments for allied health professionals, ‘care coordination’ payments, and exploration of ‘health care homes’. Third, Australia has a much more extensive system of support for older people to live in their homes or to move into supported residential care. Fourth, Australia has gone further in driving efficiency in the hospital sector than has Canada. Finally, the paper examines aspects of the Australian health care system that Canada should avoid, including the very high level of out-of-pocket costs, and the role of private acute inpatient provision.

Health technology assessment (HTA) is not simply a mechanistic technical exercise as it takes place within a specific institutional context. Yet, we know little about how this context influences the operation of HTA and its ability to influence policy and practice. We seek to demonstrate the importance of considering institutional context, using a case study of Hungary, a country that has pioneered HTA in Central and Eastern Europe. We conducted 26 in-depth, semi-structured interviews with public- and private-sector stakeholders. We found that while the HTA Department, the Hungarian HTA organisation, fulfilled its formal role envisaged in the legislation, its potential for supporting evidence-based decision-making was not fully realised given the low levels of transparency and stakeholder engagement. Further, the Department’s practical influence throughout the reimbursement process was perceived as being constrained by the payer and policy-makers, as well as its own limited organisational capacity. There was also scepticism as to whether the current operational form of the HTA process delivered ‘good value for money’. Nevertheless, it still had a positive impact on the development of a broader institutional HTA infrastructure in Hungary. Our findings highlight the importance of considering institutional context in analysing the HTA function within health systems.

In this article we perform an economic analysis of different regulatory frameworks that aim at guaranteeing solidarity in competitive health insurance markets. Thereafter, we analyse the legal conformity of these intervention strategies with EC law. We find that risk compensation schemes are the first-best intervention strategy because they guarantee an ‘acceptable level of solidarity’ without hindering free trade and competition and without reducing efficiency. Second-best options are premium and excess-loss compensation schemes, which guarantee solidarity at the expense of some efficiency. Premium rate restrictions and open enrolment should be avoided because they reduce efficiency and are unnecessary, not proportional, and undesirable to the pursuit of the general good. These conclusions are relevant for EU countries that adopt premium rate restrictions and open enrolment in combination with a risk compensation scheme, such as Ireland and the Netherlands. In these countries policy makers should design the health insurance schemes in conformity with EC law, for example by replacing premium rate restrictions and open enrolment with premium and/or excess-loss compensation schemes.

There has been much recent interest in the trade in human organs in India. This paper examines both the extent to which regulatory controls through the Transplantation of Human Organs Act (1994) are effective in curbing commercialization and the nature of the constraints on the effective implementation of this Act. The study, a politico-economic analysis of health sector regulation, is based on a stakeholder analysis drawing on the views of key decision makers, service providers, organ donors and recipients. The findings indicate widespread acknowledgement of an organs trade and highlight four major constraints on the effective implementation of the Act: the commercial interests of middlemen and service providers, the ambiguities and loopholes in the Act; the low monitoring capacity of the regulatory authorities, and the pressures and responsibilities exerted upon the Authorizing Committees. A feature of the Act is that its implementation is subject to a major incentive compatibility constraint – it is seemingly not in the interests of any of the key players, including the regulatory authorities, to restrict the organ trade. To some extent, this institutional problem is created by the specific nature of the regulatory intervention, and, as a consequence, measures involving straightforward redrafting of the regulation might go some way to addressing this incentive problem. Another solution may entail a ‘harm-reduction’ strategy involving a controlled trade where procurement and organ matching is carried out by a government agency (this would require, however, the prior resolution of the broader ethical question concerning the legitimacy of such trade).

Since the start of the economic crisis, the European Union's (EU's) predominant discourse has been austerity and fiscal consolidation. The detrimental effects on Europe's health systems and the health status of its citizens are well described. However, little is known about the emerging EU-level initiatives to support national health systems handle the challenges of efficient care provision and system reorganisation aimed to meet their future needs. This review analyses the manner, conditions and prospects of such EU support. First, health system objectives are increasingly entering the EU health policy agenda. Second, professional and patient mobility provisions may support member states (MS) in copying with crisis related health challenges but can potentially acerbate them at the same time. Third, in recent initiatives health system goals are more closely tied to the EU's economic growth narrative. And fourth, health system issues are taken up in existing EU-level structures for debate and exchange between MS. In addition, the design of some policies may have the potential to intensify socioeconomic and health inequalities rather than ameliorate them.

Medical savings accounts (MSAs) allow enrolees to withdraw money from earmarked funds to pay for health care. The accounts are usually accompanied by out-of-pocket payments and a high-deductible insurance plan. This article reviews the association of MSAs with efficiency, equity, and financial protection. We draw on evidence from four countries where MSAs play a significant role in the financing of health care: China, Singapore, South Africa, and the United States of America. The available evidence suggests that MSA schemes have generally been inefficient and inequitable and have not provided adequate financial protection. The impact of these schemes on long-term health-care costs is unclear. Policymakers and others proposing the expansion of MSAs should make explicit what they seek to achieve given the shortcomings of the accounts.

This paper focuses on eliciting the willingness to pay (WTP) for policy measures aimed at improving the health care offered to patients suffering from Alzheimer’s disease (AD). We utilize a discrete choice experiment (DCE) approach for the elicitation of the preferences of the general population for three alternative policies: home care, day care centres, and medium or long-stay centres. The results show that these policies are significantly valued across the surveyed population. The monthly WTP per hour of home care is estimated as €4 per individual, while the monthly WTP values for full population coverage in day centres and medium–long-stay centres are estimated as €0.43 and €0.42 respectively. We compare the results of classical and Bayesian estimation methods, and conclude that the latter provide a better representation of the heterogeneity in the sample. The results are significant for health care, as they enable policymakers to identify the social demand for such services, as well as the relative economic values placed on the alternative policy measures.

Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structure’s influence on productivity, less research has explored the link between provider mix and access for different patient types – which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.