Adjudicative tribunals are an integral part of health system governance, yet their real-world impact remains largely unknown. Most assessments focus on internal accountability and use anecdotal methodologies; few, studies if any, empirically evaluate their external impact and use these data to test effectiveness, track performance, inform service improvements and ultimately strengthen health systems. Given that such assessments would yield important benefits and have been conducted successfully in similar settings (e.g. specialist courts), their absence is likely attributable to complexity in the health system, methodological difficulties and the legal environment within which tribunals operate. We suggest practical steps for potential evaluators to conduct empirical impact evaluations along with an evaluation matrix template featuring possible target outcomes and corresponding surrogate endpoints, performance indicators and empirical methodologies. Several system-level strategies for supporting such assessments have also been suggested for academics, health system institutions, health planners and research funders. Action is necessary to ensure that policymakers do not continue operating without evidence but can rather pursue data-driven strategies that are more likely to achieve their health system goals in a cost-effective way.

The challenges facing European health systems have changed little over 30 years but the responses to them have. Policy ideas that emerged in some countries spread to others; however, the way policies were implemented and the impact they have had has been shaped by specific national contexts. Comparative policy analysis has evolved in response to this, moving away from simple classifications of health systems and crude rankings to studies that try and understand more deeply what works, where and why. For policymakers interested in how other countries have dealt with common challenges, it is important that they avoid the naïve transplantation of policy solutions but understand the need to translate policies to fit the institutional context of a particular country. Policies that cross borders will necessarily be shaped by the social and political institutions of a country. These dimensions should not be ignored in comparative research. The next decade will require health systems to deliver improved care for people with complex needs while at the same time delivering greater value. Policymakers will benefit from looking backwards as well as to their neighbours in order to develop appropriate policy solutions.

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.

The conventionally antithetical stereotypes of the United Kingdom and United States health care systems needs to be modified in the case of the elderly. Relative to the rest of the population, the over-65s in the United States are more satisfied with their medical care than their UK counterparts. There is also much common ground: shared worries about the quality of elderly care and similar attitudes towards assisted death. Comparison is further complicated by within country variations: comparative studies should take account of the fact that even seemingly polar models may have pools of similarity.

This paper reviews current research and literature on the issue of informal payments for health care and its context and suggests a new perspective for a better understanding of this phenomenon. This perspective, based on political culture and behavior and on wider social processes, is already used to explain various phenomena from different fields of public policy. The paper explains the impact of a specific type of political culture, called ‘alternative politics’ (AP) in the Israeli literature, on healthcare policy and institutional healthcare settings. AP is based on a ‘do-it-yourself’ approach adopted by citizens to address their dissatisfaction with governmental services. When such a mode of political culture is diffused to all sectors and levels of society, all players, including bureaucrats and politicians, are guided by short-term considerations and apply unilateral strategies that bypass formal rules either through illegal activity or by marginalizing formal rules. Explaining informal payments by analyzing social processes and political culture and behavior has some disadvantages, but it provides us with a better understanding of the phenomenon while covering most of its characteristics and configurations.

This paper aims to fill in the gap in research on the effect of pharmaceutical lobbying on drug reimbursement policy, particularly in Poland, a post-communist country. To this end, we conducted in-depth, semi-structured, anonymous, elite interviews in Poland, supplemented by a review of legislation, policy documents, official reports and press articles, as well as observations. Overall, 109 representatives of stakeholders involved in reimbursement policy were interviewed. We identified two key lobbying methods: informal persuasion and third-party endorsements. These methods are coupled with two supplementary ones: lobbying through parliament and ministries, as well as diplomatic pressure. Pharmaceutical lobbying methods in Poland clearly resemble those used in other European countries. What is notable about the Polish case is extensive reliance on informal lobbying and diplomatic pressure.

Health financing reforms have recently received much attention in developing countries. However, out-of-pocket payments remain substantial. When such payments involve expenditures above some given proportion of household resources, they are often deemed ‘catastrophic’. The research literature on defining catastrophe leaves open a number of important questions and as a result there still exists a lack of consensus on the issue. This paper argues that there is a need to examine the question of what might constitute fair indices of catastrophic payment, which explicitly recognize diminishing marginal utility of income as reflected in some principle of vertical equity. It proposes the use of rank-dependent weights to allow variations in threshold payment levels across individuals on the income ladder. These are then applied to a Nigerian data set. It emerged that the catastrophic headcount (positive gap) obtained using a fixed threshold – weighted or not by the concentration index – is lower (higher) than that predicted by the rank-dependent threshold. More fundamentally there is a need for more research effort to take the ideas in this paper further and examine in various different contexts what a fair construct of catastrophe might look like.

This paper assesses which policy-relevant characteristics of a healthcare system contribute to health-system efficiency. Health-system efficiency is measured using the stochastic frontier approach. Characteristics of the health system are included as determinants of efficiency. Data from 21 OECD countries from 1970 to 2008 are analysed. Results indicate that broader health-system structures, such as Beveridgian or Bismarckian financing arrangements or gatekeeping, are not significant determinants of efficiency. Significant contributors to efficiency are policy instruments that directly target patient behaviours, such as insurance coverage and cost sharing, and those that directly target physician behaviours, such as physician payment methods. From the perspective of the policymaker, changes in cost-sharing arrangements or physician remuneration are politically easier to implement than changes to the foundational financing structure of the system.

In January 2009, Britain's National Institute for Health and Clinical Excellence (NICE), following a very public debate triggered by its decision, six months earlier, provisionally to rule against the adoption by the National Health Service (NHS) of an expensive drug for advanced renal cancer, introduced a new policy for evaluating pharmaceuticals for patients nearing the end of their lives. NICE's so-called end-of-life (EOL) guidance for its Committees effectively advises them to deviate from the Institute's threshold range and to value the lives of (mostly) dying cancer patients more than the lives of those suffering from other, potentially curable, chronic or acute conditions. This article tells the story of the EOL guidance. Through looking at specific EOL decisions between 2009 and 2011 and the reactions by stakeholders to these decisions and the policy itself, it discusses the triggers for NICE's EOL guidance, the challenges NICE faces in implementing it and the policy's putative implications for the future role of NICE in the NHS, especially in the context of value-based reforms in the pricing and evaluation of pharmaceuticals, currently under consideration.

New cancer therapies offer the hope of improved diagnosis to patients with life-threatening disease. Over the past 5–10 years, a number of specialty drugs have entered clinical practice to provide better systemic therapy for advanced cancers that respond to few therapeutic alternatives. To date, however, such advances have been only modestly effective in extending life and come with a high price tag, raising questions about their value for money, patient access and implications for health care costs. This article explores some of the key issues present in valuing end-of-life care in the United States in the case of advanced cancer drugs, from the difficult trade-offs between their limited health benefits and high costs to the technical, political and social challenges in assessing their value and applying such evidence to inform policy and practice. A number of initial steps are discussed that could be pursued to improve the value of advanced cancer care.

Both professionals and politicians may affect expenditures for highly professional services provided in the public and private sector. We investigated Danish publicly financed child dental care with a special focus on the influence of politicians and dentists on the expenditure level. By studying spatial patterns in expenditure levels across municipalities, we are able to test the influences of these two main actors and the networks through which learning is achieved. Four hypotheses on the existence of different spatial spillover effects are tested. The empirical analysis is based on annual data from 1996 to 2001 for 226 Danish municipalities, thus allowing for the control for heterogeneity between municipalities and for intra-municipal correlations across time. The results point to differences in expenditures between municipalities with privately and publicly produced dental care. Furthermore, dentists appear to be the most important actors for the spatial spillover effects, and these effects are especially strong for municipalities situated in the same county that use private dental clinics. There is no evidence of political spatial spillover effects between municipalities.

There is a persistent relationship between socioeconomic status and health that appears to have its roots in childhood. Not only do children in families with lower income and with mothers with lower levels of education have worse health on average than those with greater socioeconomic advantage, but also the gradient appears to steepen with age. This study contributes to the literature on the relationship between socioeconomic status and child health by testing the hypothesis that the increasing effect of family income on children's health with age relates to the children's use of health care services. It also investigates the role of specific health conditions, injuries or maternal health in explaining the steepening gradient. Drawing on a nationally representative survey from Canada, the National Longitudinal Survey of Children and Youth from the period 1994/95–2008/09, this study provides further evidence of a steepening socioeconomic gradient in child health with age. It finds that accounting for health care use does not explain the steepening gradient and that the protective effect of income appears to be greater for those who had contact with the health system, in particular with regard to physician care and prescription drug use.

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.

Health technology assessment processes aim to provide evidence on the effectiveness and cost-effectiveness of different elements of health care to assist setting priorities. There is a risk that services that are difficult to evaluate, and for which there is limited evidence on cost-effectiveness, may lose out in the competition for resources to those with better evidence. It is argued here that end-of-life care provides particular challenges for evaluation. Outcomes are difficult to measure, can take place over short time scales, and services can be difficult to characterise as they are tailored to the specific needs of individuals. Tools commonly used to measure health care outcomes do not appear to discriminate well in the end-of-life care context. It is argued that the assumption that units of time of different quality of life can simply be added to assess the overall experience at the end of life may not apply, and that alternative perspectives, such as the Peak and End Rule, might offer useful perspectives.

Current investments in preventive lifestyle interventions are relatively low, despite the significant impact of unhealthy behaviour on population health. This raises the question of whether the criteria used in reimbursement decisions about healthcare interventions put preventive interventions at a disadvantage. In this paper, we highlight the decision-making framework used in the Netherlands to delineate the basic benefits package. Important criteria in that framework are ‘necessity’ and ‘cost-effectiveness’. Several normative choices need to be made, and these choices can have an important impact on the evaluation of lifestyle interventions, especially when making these criteria operational and quantifiable. Moreover, the implementation of the decision-making framework may prove to be difficult for lifestyle interventions. Improvements of the decision-making framework in the Netherlands are required to guarantee sound evaluations of lifestyle interventions aimed at improving health.