This study examined the role of prospective payment systems in the adoption of new medical technologies across different countries. A literature review was conducted to provide background for the study and guide development of a survey instrument. The survey was disseminated to hospital payment systems experts in 15 jurisdictions. Fifty-one surveys were disseminated, with 34 returned. The surveys returned covered 14 of the 15 jurisdictions invited to participate. The majority (71%) of countries update the patient classification system and/or payment tariffs on an annual basis to try to account for new technologies. Use of short-term separate or supplementary payments for new technologies occurs in 79% of countries to ensure adequate funding and facilitate adoption. A minority (43%) of countries use evidence of therapeutic benefit and/or costs to determine or update payment tariffs, although it is somewhat more common in establishing short-term payments. The main barrier to using evidence is uncertain or unavailable clinical evidence. Almost three-fourths of respondents believed diagnosis-related group systems incentivize or deter technology adoption, depending on the particular circumstances. Improvements are needed, such as enhanced strategies for evidence generation and linking evidence of value to payments, national and international collaboration and training to improve existing practice, and flexible timelines for short-term payments. Importantly, additional research is needed to understand how different payment policies impact technology uptake as well as quality of care and costs.

The English government has given a commitment to improving access to health care services for particular groups perceived as being under-served, or served inappropriately, by existing services. In this article four examples of policies aimed at improving access are considered: enhancing the supply of services to under-served areas, changing the organization of services, setting targets to improve access, and empowering people to make choices. Policies aimed at improving access will work only if they address the source of inequities, which means identifying the key barriers to access and these barriers are unlikely to be uniform across sectors, services, and groups of people. Evidence on the success of these four types of intervention in terms of influencing access and equity of access is discussed, borrowing some concepts from the sociological literature that enable us to understand the importance of how barriers to access may arise for different services and different population groups. It is clear that some policies may not work as well as we would hope, or may even exacerbate inequities of access, because they fail to recognize the source of the particular barriers faced by some groups.

There is a requirement for economic evaluation of health technologies seeking public funding across Europe. Changes to the organisation and delivery of health services, including changes to health policy, are not covered by such appraisals. These changes also have consequences for National Health Service (NHS) funds, yet undergo no mandatory cost-effectiveness assessment. The focus on health technologies may have occurred because larger-scale service changes pose more complex challenges to evaluators. This paper discusses the principal challenges faced when performing economic evaluations of changes to the organisation and delivery of health services and provides recommendations for overcoming them. The five principal challenges identified are as follows: undertaking ex-ante evaluation; evaluating impacts in terms of quality-adjusted life years; assessing costs and opportunity costs; accounting for spillover effects; and generalisability. Of these challenges, methods for estimating the impact on costs and quality-adjusted life years are those most in need of development. Methods are available for ex-ante evaluation, assessing opportunity costs and examining generalisability. However, these are rarely applied in practice. The general principles of assessing the cost-effectiveness of interventions should be applied to all NHS spending, not just that involving health technologies. Advancements in this area have the potential to improve the allocation of scarce NHS resources.

There is an international call for countries to ensure universal health coverage. This call has been embraced in South Africa (SA) in the form of a National Health Insurance (NHI). This is expected to be financed through general tax revenue with the possibility of additional earmarked taxes including a surcharge on personal income and/or a payroll tax for employers. Currently, health services are financed in SA through allocations from general tax revenue, direct out-of-pocket payments, and contributions to medical scheme. This paper uses the most recent data set to assess the progressivity of each health financing mechanism and overall financing system in SA. Applying standard and innovative methodologies for assessing progressivity, the study finds that general taxes and medical scheme contributions remain progressive, and direct out-of-pocket payments and indirect taxes are regressive. However, private health insurance contributions, across only the insured, are regressive. The policy implications of these findings are discussed in the context of the NHI.

Many advocates of policy to implement the findings of research on the multiple determinants of health accord scant attention to the determinants of health policy in democratic countries. The principle determinants of the allocation of scarce resources to improving health include: the priorities of voters; the diffusion of responsibility for improving health; the absence of evidence about matters of consequence to policy makers; the arraying of some evidence in ways that frustrate policy making; resistance to addressing determinants other than clinical services and traditional public health practices among many professionals in these fields, as well as by industries that supply the health sector; and the special political influence of persons who suffer serious chronic disease and of members of their families.

This article seeks to explain local variations in the use of antibiotics in the community and to assess the welfare loss due to heterogeneous attitudes towards the risk of bacterial resistance. Quarterly data on antibiotic sales from 240 small areas in Switzerland over the course of one year are used. An econometric ad-hoc model with spatial lags is proposed in which the demand for antibiotics varies according to the socioeconomic characteristics of the population, the incidence of infections, antibiotic price and local health care supply. Using residual variations we then evaluate the welfare loss due to varying antibiotic prescription styles. Significant differences are observed in the per capita antibiotic consumption across local areas. Individual income, the demographic structure of the population, physician density and the price of drugs are all relevant determinants. We estimate that unexplained variations may account for 12% of the total antibiotic spending in the community, thus leading to a ₠ 6.8 ml loss per year. Understanding the determinants of variations in outpatient antibiotic consumption may help to design more effective policies to counter the threat of bacterial resistance. Our estimate of the welfare loss due to heterogeneous attitudes towards antibiotic treatment is comparable to the expected cost of implementing measures to improve the dissemination of information on bacterial resistance among patients and doctors.

In 2010 the Belgian government introduced a low cost administrative procedure for compensating medical injuries to overcome the major shortcomings of the existing tort system. This paper examines, for the first time, to what extent this reform had an impact on physician specialists’ defensive practices and what are the relevant determinants affecting physicians’ clinical decision making. Based on a survey of 508 physicians, we find evidence of a relatively modest increase in defensive practices among physicians in various specialties. In general, 14% of the respondents, who were aware of the reform, reported to have increased their overall defensive behaviour, while respectively 18 and 13% altered their assurance and avoidance behaviour. Commonly used physician characteristics, such as claims experience and gender, have a similar impact on defensive medicine as documented in existing literature. Furthermore, the determinant physician’s access to an incident reporting system is found to have a significant impact on most of the defensive medicine measures. Health care institutions may therefore play an important role in controlling and reducing physicians’ defensive practices.

Denmark, Finland and Sweden have experienced two major recessions during the last 25 years. The adjustments to the earlier crisis in the late 1980s (Denmark) and early 1990s (Finland and Sweden) resembled the policies in many other European countries during the present crisis. The analysis of relationship of deep economic crises and growth period between them to the health system policies and institutions in the three countries from the 1980s to 2013 is based on a categorisation of reactions to external shocks as path conforming or path breaking. The results of the empirical long-term trends show that the reactions to deep recessions have been mainly temporary adjustments and acceleration of changes already prepared before economic crisis. The economic crisis in the three countries has not been ‘good enough’ to enable paradigmatic changes in the Nordic public, decentralised and equity-oriented health systems. Changes such as the slow privatisation in care funding and production and the adoption of new management practices indicate an ongoing paradigmatic change related to longer-term societal, ideological and political developments rather than directly to economic crises or growth.

Policymakers in publicly funded health-care systems are frequently required to make intricate decisions on which health-care services to include or exclude from the basic health-care package. Although it seems likely that the concept of individual responsibility is an essential feature of such decisions, it is rarely explicitly articulated or evaluated in health policy. This paper presents a tentative conceptual framework for exploring when health-care services contain characteristics that facilitate individual responsibility through private financing. Six attributes for exploring the suitability of private financing for specific health-care commodities are identified: (i) it should enable individuals to value the need and quality both before and after utilization; (ii) it should be targeted toward individuals with a reasonable level of individual autonomy; (iii) it should be associated with low levels of positive externalities; (iv) it should be associated with a demand sufficient to generate a private market; (v) it should be associated with payments affordable for most individuals; and finally, (vi) it should be associated with ‘lifestyle enhancements’ rather than ‘medical necessities’. The tentative framework enables exploration of individual responsibility connected to health care as a heterogeneous group of commodities, and allows policymakers to make decisions on rationing by design rather than default.

Sweden's coronavirus disease 2019 (COVID-19) response, initially based largely on voluntary measures, has evoked strong reactions nationally and internationally. In this study, we describe Sweden's national policy response with regard to the general public, the community and the health care system, with a focus on how the response changed from March 2020 to June 2021. A number of factors contributed to Sweden's choice of policy response, including its existing legal framework, independent expert agencies and its decentralized, multi-level health care governance system. Challenges to the health- and elder care system during the pandemic, such as the need to increase intensive care- and testing capacity, and to ensure the safety of the elderly were addressed largely at the regional and local levels, with national authorities assuming a primarily coordinative role. Although the overall response based on voluntary compliance has persisted, the national government started to take a more prominent role in public messaging, and in enacting legally binding restrictions during subsequent waves of the pandemic. This study illustrates that not only policy responses, but also the fundamental structure of the health- and elder care system and its governance should be considered when evaluating the impact of the COVID-19 pandemic.

Public involvement in disinvestment decision making in health care is widely advocated, and in some cases legally mandated. However, attempts to involve the public in other areas of health policy have been accused of tokenism and manipulation. This paper presents research into the views of local health care leaders in the English National Health Service (NHS) with regards to the involvement of citizens and local communities in disinvestment decision making. The research includes a Q study and follow-up interviews with a sample of health care clinicians and managers in senior roles in the English NHS. It finds that whilst initial responses suggest high levels of support for public involvement, further probing of attitudes and experiences shows higher levels of ambivalence and risk aversion and a far more cautious overall stance. This study has implications for the future of disinvestment activities and public involvement in health care systems faced with increased resource constraint. Recommendations are made for future research and practice.

Effective antitrust enforcement is of crucial importance for countries with a market-based health care system in which hospitals are expected to compete. Assessing hospital market power – a central issue to competition policy – is, however, complicated because the presence of third party payers and the general unobservability of prices make it difficult to apply the standard methods of market definition. Alternative, less formal methods historically employed in the hospital industry have proven inaccurate; these methods were even called inapplicable in a recent US court decision. In this paper, we discuss the strengths and weaknesses of several new approaches to defining hospital markets that are suggested in the recent economic literature. In particular, we discuss the applicability of the time-elasticity approach, competitor-share approach, and option-demand approach to the recently partly deregulated Dutch hospital market. We conclude that the appropriate approach depends crucially on how health insurers contract with hospitals and how patients select their hospital.

As a growing number of countries implement, or announce plans to introduce, a sugar-sweetened beverage (SSB) tax, this paper explores the public health rationale for such a tax and provides an overview of the international normative and policy instruments supporting the introduction of fiscal measures on sugary drinks. After examining parallels between the legal arguments raised by the food and beverage industry in opposition to SSB taxes and those raised by the tobacco industry in response to tobacco control measures, this paper draws four key lessons that will assist countries to design effective and robust SSB tax measures and counter food and beverage industry opposition: regulatory distinctions in tax coverage should be based on bona fide, evidence-based reasoning; evidence-based measures need to be tailored to a country’s public health objectives as part of a comprehensive strategy to address unhealthy diet consumption; procedural requirements and due process should be observed in the drafting and implementation of the measure; and regulatory space exists within domestic constitutions, laws and international trade and investment agreements recognising the sovereign right of states to regulate in the interests of public health.

The United States’ experience with the Ebola virus in 2014 provides a window into US public health politics. First, the United States provided a case study in the role of suasion and executive action in the management of public health in a fragmented multi-level system. The variable capacity of different parts of the United States to respond to Ebola on the level of hospitals or state governments, and their different approaches, show the limitations of federal influence, the importance of knowledge and executive energy, and the diversity of both powerful actors and sources of power. Second, the politics of Ebola in the United States is a case study in the politics of partisan blame attribution. The outbreak struck in the run-up to an election that was likely to be good for the Republican party, and the election dominated interest in and opinions of Ebola in both the media and public opinion. Democratic voters and media downplayed Ebola while Republican voters and media focused on the outbreak. The media was a key conduit for this strategic politicization, as shown in the quantity, timing and framing of news about Ebola. Neither fragmentation nor partisanship appears to be going away, so understanding the politics of public health crises will remain important.

The use of incentives to encourage individuals to adopt ‘healthier’ behaviours is an increasingly popular instrument in health policy. Much of the literature has been critical of ‘negative’ incentives, often due to concerns about equality; ‘positive’ incentives, however, have largely been welcomed as an instrument for the improvement of population health and possibly the reduction of health inequalities. The aim of this paper is to provide a more systematic assessment of the use of incentives from the perspective of equality. The paper begins with an overview of existing and proposed incentive schemes. I then suggest that the distinction between ‘positive’ and ‘negative’ incentives – or ‘carrots’ and ‘sticks’ – is of limited use in distinguishing those incentive schemes that raise concerns of equality from those that do not. The paper assesses incentive schemes with respect to two important considerations of equality: equality of access and equality of outcomes. While our assessment of incentive schemes will, ultimately, depend on various empirical facts, the paper aims to advance the debate by identifying some of the empirical questions we need to ask. The paper concludes by considering a number of trade-offs and caveats relevant to the assessment of incentive schemes.

This article considers two key issues in health economics regarding the question of equity. First, why have health economists not resolved better the issue of what are equity and access? Second, the paper draws attention to the relative lack of analyses of equity concerns outside of health care. The question of whose values should prevail in equity is also addressed. On the first issue, there is an obsession with quantification in economics with the result that in analysing equity, in practice often ‘use’ has been substituted for ‘access’. The problem of defining access has thereby been by-passed. This has taken the pressure off trying to research access per se. Second, what is meant by equity and access are in part culturally determined. The continued efforts of health economists to treat equity as some universal construct are misplaced. The lack of effort on the part of health economists to look at equity more broadly than health care equity is concerning. Certainly, to be pursued in practice, equity in both health and health care need a shift in resources, which will be opposed by those who exercise power over decision making in health care and in society more generally. Currently health economists’ analyses say all too little about power and property rights in health care and in society. It is argued that the relevant citizens or communities which a health service serves are best placed to judge the access barriers they face and their relative heights. A useful definition of equity established by a citizens’ jury in Perth, Australia is used to exemplify this point. It is concluded that the often all too simplistic equity goals adopted in health economics (and sometimes public health discourse) need to be challenged. For health economists, there is a need for more of us to get involved in the issues around inequalities, class and power and the impact of these on health.

Previous studies have described various associations between tax policy and health. Here we propose a unifying conceptual framework of ‘Five R’s’ to stimulate awareness about the importance of tax to health improvement. First, tax can improve representation and democratic accountability, and help make governments more responsive to the needs of its citizens. Second, tax can create a revenue stream for a universal pool of public finance for health care and other public services. Third, progressive taxation when combined with appropriate public spending can help redistribute wealth and income and mitigate social and health inequalities. Fourth, the re-pricing of harmful products (e.g. tobacco, alcohol and unhealthy food) can help reduce their consumption. Fifth, taxation provides a route by which certain harmful industries can be regulated. The paper also discusses the barriers that hinder the full potential for taxation to be used to improve health, including: weak tax administrations, large ‘shadow economies’, international trade liberalisation, tax avoidance, transfer pricing by transnational corporations and banking secrecy. We suggest that a greater awareness of the manifold associations between tax and health will encourage health practitioners to actively promote fairer and better taxation, thereby helping to improve health and reduce health inequalities.

This article describes and analyzes the U.S. health care legislation of 2010 by asking how far it was designed to move the U.S. system in the direction of practices in all other rich democracies. The enacted U.S. reform could be described, extremely roughly, as Japanese pooling with Swiss and American problems at American prices. Its policies are distinctive, yet nevertheless somewhat similar to examples in other rich democracies, on two important dimensions: how risks are pooled and the amount of funds redistributed to subsidize care for people with lower incomes. Policies about compelling people to contribute to a finance system would be further from international norms, as would the degree to which coverage is set by clear and common substantive standards – that is, standardization of benefits. The reform would do least, however, to move the United States toward international practices for controlling spending. This in turn is a major reason why the results would include less standard benefits and incomplete coverage. In short, the United States would remain an outlier on coverage less because of a failure to make an effort to redistribute – a lack of solidarity – than due to a failure to control costs.

Social capital appears to be an important determinant of health production and health utilization and demand. However, there is limited evidence on the mechanisms underlying this relationship. In this article we draw on the evidence and insights reported in this special issue along with findings from the economic and other social science literature to develop a discussion on the explanations of the likely (behavioural) mechanisms that underpin the connection between social capital and health. An important and under-explored influence mediating the relationship between social capital and health (behaviour) lies in the ‘social formation of health preferences and constraints’ individuals face in determining their life-styles and in using health care. In particular, we point to the interdependence in how individuals in the first place perceive and also respond to common health risks and the role of cultural transmission and social identity as conveyors of this process. We argue that an emerging body of evidence suggesting that interdependent preferences influence health calls for further re-formulation of traditional demand for and production of health models. Additionally, methodological problems are highlighted and possible ways forward suggested.

The period from 1996 to 2008 was one of rapid economic and social change in Ireland, with one of the most significant changes being the transition from a situation of net emigration to one of substantial net immigration. Although research on the impact of immigration on Irish society, as well as the labour market characteristics and experiences of immigrants in Ireland has increased in recent years, comparatively little is known about the health status of immigrants to Ireland. An extensive international literature has documented a ‘healthy immigrant’ effect for large immigrant-receiving countries such as the United States, Canada and Australia, whereby the health status of immigrants is better than comparable native-born individuals. There is also evidence to suggest that immigrants’ health status deteriorates with time spent in the host country. However, the Irish immigration experience differs considerably from that of countries that have been the focus of research on the ‘healthy immigrant’ effect. Using microdata from a nationally representative survey of the population in 2007, this paper finds only limited evidence in favour of a ‘healthy immigrant’ effect for Ireland, although the distinctive features of the Irish immigrant population, and the nature of the data available, may partly explain the results.