Social capital has been proposed as a potentially important contributor to health, yet most of the existing research tends to ignore the challenge of assessing causality in this relationship. We deal with this issue by employing various instrumental variable estimation techniques. We apply the analysis to a set of nine former Soviet countries, using a unique multi-country household survey specifically designed for this region. Our results confirm that there appears to be a causal association running from several dimensions of individual social capital to general and mental health. Individual trust appears to be more strongly related to general health, while social isolation- to mental health. In addition, social support and trust seem to be more important determinants of health than the social capital dimensions that facilitate solidarity and collective action. Our findings are remarkably robust to a range of different specifications, including the use of instrumental variables. Certain interaction effects are also found: for instance, untrusting people who live in communities with higher aggregate level of trust are even less likely to experience good health than untrusting people living in the reference communities.

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.

The National Institute for Health and Clinical Excellence (NICE) provides guidance to the National Health Service (NHS) in England and Wales on funding and use of new technologies. This study examined the impact of evidence, process and context factors on NICE decisions in 2004–2009. A data set of NICE decisions pertaining to pharmaceutical technologies was created, including 32 variables extracted from published information. A three-category outcome variable was used, defined as the decision to ‘recommend’, ‘restrict’ or ‘not recommend’ a technology. With multinomial logistic regression, the relative contribution of explanatory variables on NICE decisions was assessed. A total of 65 technology appraisals (118 technologies) were analysed. Of the technologies, 27% were recommended, 58% were restricted and 14% were not recommended by NICE for NHS funding. The multinomial model showed significant associations (p ⩽ 0.10) between NICE outcome and four variables: (i) demonstration of statistical superiority of the primary endpoint in clinical trials by the appraised technology; (ii) the incremental cost-effectiveness ratio (ICER); (iii) the number of pharmaceuticals appraised within the same appraisal; and (iv) the appraisal year. Results confirm the value of a comprehensive and multivariate approach to understanding NICE decision making. New factors affecting NICE decision making were identified, including the effect of clinical superiority, and the effect of process and socio-economic factors.

The Italian National Health Service began experimenting with a significant regionalisation process during the 1990s. The purpose of this article is to assess the effects that this regionalisation process is having on the rift between the north and the south of the country. Has the gap between the health care systems of the northern and southern regions been increasing or decreasing during the 1999–2009 decade? Three indicators will be utilised to answer this question: (1) the level of satisfaction expressed by the citizens towards the regional hospital system; (2) the mobility of the patients among regions; (3) the health care deficit accumulated by the individual regions. On the basis of these three indicators, there is evidence to conclude that, during the decade under study, the gap between the North and the South, already significant, has increased further.

Informal payments can be found across Europe, Africa, Asia and South America. Despite its hidden nature, they pose an important policy issue. Reported as being widespread, the true scale and scope of informal payment are unknown, and estimations differ among studies. We look at the Russian health care sector where the existence of informal payments has persisted for decades. We present the scale and scope of informal payments, as well as patterns of informal payments and their determinants. We discuss the reasons for discrepancies in estimations and implications for the ongoing reforms.

Convergence in health and health inequalities reflects not only a sense of equity, but also provides a critical assessment tool for monitoring the health progress of differently placed individuals. This study examines convergence hypothesis for health and health inequalities across major Indian states, using both standard and cutting-edge convergence metrics. The findings lend support to the convergence in average health status among the states and the socioeconomic group of India, examined through select health indicators. However, results also suggest a setback in convergence in decline of health inequalities in recent times, particularly in life expectancy at birth, child immunization and underweight. Evidence signals that from the late 1990s, convergence in decline of health inequalities are replaced by emerging divergence. This paper contributes to health policy and planning by identifying areas where, India needs to work to achieve efficiency with equity in health status across geographical divisions and social groups.

In recent years, a number of low- and middle-income country governments have introduced health insurance schemes. Yet not a great deal is known about the impact of such policy shifts. Vietnam’s recent health insurance experience including a health insurance scheme for the poor in 2003 and a compulsory scheme that provides health insurance to all children under six years of age combined with Vietnam’s commitment to universal coverage calls for research that examines the impact of health insurance. Taking advantage of Vietnam’s unique policy environment, data from the 2002, 2004 and 2006 waves of the Vietnam Household Living Standard Survey and single-difference and difference-in-differences approaches are used to assess whether access to health insurance – for the poor, for children and for students – impacts on health services utilization and health outcomes in Vietnam. For the poor and for students, results suggest health insurance increased the use of inpatient services but not of outpatient services or health outcomes. For young children, results suggest health insurance increased the use of outpatient services (including the use of preventive health services such as vaccination and check-up) but not of inpatient services.

We estimate the effect of changes in the per capita expenditures of county departments of public health on county-level general health status. Using panel data on 40 counties in California (2001–2009), dynamic panel estimation techniques are combined with the Lewbel instrumental variable technique to estimate an aggregate demand for health function that measures the causal cumulative impact that per capita public health expenditures have on county-level general health status. We find that a $10 long-term increase in per capita public health expenditures would increase the percentage of the population reporting good, very good or excellent health by 0.065 percentage points. Each year expenditures were increased would result in ∼24,000 individuals moving from the ‘poor or fair health’ category to the ‘good, very good or excellent health’ category across these 40 counties. In terms of the overall impact of county public health departments on general health status, at current funding levels, each annual expenditure cycle results in over 207,000 individuals being in the ‘good, very good or excellent’ categories of health status rather than the ‘poor or fair’ categories.

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.

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.

The demand for publicly subsidised health care services is insatiable, but the costs can be contained in different ways: formal rules can limit access to and the number of subsidised services, demand and supply can be regulated through the price mechanism, the relevant profession can contain the costs through state-sanctioned self-regulation, and other professions can contain the costs (e.g. through referrals). The use of these cost containment measures varies between countries, depending on demand and supply factors, but the relative professional status of the health professions may help explain why different countries use cost containment measures differently for different services. This article compares cost containment measures in Denmark and Norway because these countries vary with regard to the professional status of the medical profession relative to other health care providers, while other relevant variables are approximately similar. The investigation is based on formal agreements and rules, historical documents, existing analyses and an analysis of 360 newspaper articles. It shows that high relative professional status seems to help professions to avoid user fees, steer clear of regulation from other professions and regulate the services produced by others. This implies that relative professional status should be taken into consideration in analyses of health care cost containment.

This article considers how the ‘accidental logics’ of political settlements for the English National Health Service (NHS) and the Medicare and Medicaid programmes in the United States have resulted in different institutional arrangements and different implicit social contracts for rationing, which we define to be the denial of health care that is beneficial but is deemed to be too costly. This article argues that rationing is designed into the English NHS and designed out of US Medicare; and compares rationing for the elderly in the United States and in England for acute care, care at the end of life, and chronic care.

This study assesses the effect of having informal support available at home on inpatient care use in Switzerland. The main contributions are to consider the availability of care regardless of its source, measured by multiple-adult living arrangements, and to examine this effect by type of inpatient care and source of potential support. A two-part model with region and time fixed effects is estimated to determine the impact of informal care availability on the likelihood of hospitalisation and length of stay, conditional on hospitalisation. The analysis is conducted on a sample of individuals aged 18+ from four waves of the Swiss Household Panel survey (2004–2007). Overall, availability of informal care has no impact on the likelihood of hospitalisation but does significantly reduce length of stay by 1.9 days. Available support has no effect on the shortest stays (up to 10 days), but has a significant impact on acute care stays up to 30 days and longer stays. Additionally, the effect does not significantly vary whether the source of informal support is a spouse only, a spouse and other adults, or other adults only. These results indicate that social changes leading to an expansion in the proportion of one-person households may increase future inpatient care use.

All-cause readmission to inpatient care is of wide policy interest in the United States and a number of other countries (Centers for Medicare and Medicaid Services, in the United Kingdom by the National Centre for Health Outcomes Development, and in Australia by the Australian Institute of Health and Welfare). Contemporary policy efforts, including high powered incentives embedded in the current US Hospital Readmission Reduction Program, and the organizationally complex interventions derived in anticipation of this policy, have been touted based on potential cost savings. Strong incentives and resulting interventions may not enjoy the support of a strong theoretical model or the empirical research base that are typical of strong incentive schemes. We examine the historical broad literature on the issue, lay out a ‘full’ conceptual organizational model of patient transitions as they relate to the hospital, and discuss the strengths and weaknesses of previous and proposed policies. We use this to set out a research and policy agenda on this critical issue rather than attempt to conduct a comprehensive structured literature review. We assert that researchers and policy makers should consider more fundamental societal issues related to health, social support and health literacy if progress is going to be made in reducing readmissions.

In March 2004, Ireland became the first country to introduce a nationwide workplace smoking ban. The primary aim of the ban was to reduce people’s exposure to second-hand smoke. A 95% compliance rate among employers suggests this aim was achieved. By prohibiting smoking in the majority of indoor working places, an effect of the ban was to increase the non-monetary cost of smoking. The aim of this paper is to examine whether the extra non-monetary cost of smoking was concentrated on the employed. A difference-in-differences approach is used to measure changes in smoking behaviour among the employed relative to the non-working population following the introduction of the workplace smoking ban. The research finds that the workplace smoking ban did not induce a greater reduction in smoking prevalence among the employed population compared with the non-working population. In fact, the evidence suggests a significantly larger decrease in smoking prevalence among the non-workers relative to the employed. Changes in the real price of cigarettes and changes in attitudes to risk are discussed as possible causes for the pattern observed.

Integration in health care is a key goal of health reform in United States and England. Yet past efforts in the 1990s to better integrate the delivery system were of limited success. Building on work by Bevan and Janus on delivery integration, this article explores integration through the lens of economic theories of integration. Firms generally integrate to increase efficiency through economies of scale, to improve their market power, and resolve the transaction costs involved with multiple external suppliers. Using the United States and England as laboratories, we apply concepts of economic integration to understand why integration does or does not occur in health care, and whether expectations of integrating different kinds of providers (hospital, primary care) and health and social services are realistic. Current enthusiasm for a more integrated health care system expands the scope of integration to include social services in England, but retains the focus on health care in the United States. We find mixed applicability of economic theories of integration. Economies of scale have not played a significant role in stimulating integration in both countries. Managerial incentives for monopoly or oligopoly may be more compelling in the United States, since hospitals seek higher prices and more leverage over payers. In both countries the concept of transaction costs could explain the success of new payment and budgeting methods, since health care integration ultimately requires resolving transaction costs across different delivery organizations.

Since the 1990s, there has been substantial expansion of facility-based alternatives to nursing home care, such as assisted living facilities. This paper analyzes the relationship between expansion of the assisted living industry, nursing home market structure and nursing home private pay prices using a two-year panel of nursing homes in the State of Ohio. Fixed effect regressions suggest that the expansion of assisted living facilities are associated with increased nursing home concentration, but find no effect on private pay nursing home prices. This would be consistent with assisted livings reducing demand for nursing homes by delaying entry into a nursing home, though assisted livings are not direct competitors of nursing homes.

The assumption according to which ill individuals can be replaced at work that underpins the ‘friction cost method’ (FCM) to value productivity costs has been primarily discussed within the framework of cost-utility analysis. This paper investigates the consequences of this assumption for cost-benefit analysis (CBA). It makes three contributions. First, it provides the first analytical account of the overall consequences of ill worker replacement on social welfare and it analyzes the associated compensation effects within a CBA framework. Second, it highlights a double counting problem that arises when ill worker replacement is assumed in the CBA of life-saving health care programs. To the best of our knowledge, no satisfactory solution to this problem has yet been provided in the literature. Third, this paper suggests and discusses two original ways to address this double counting issue. One consists in adjusting value of a statistical life estimations for the well-being provided by future incomes. Another possibility lies in the estimation of marginal rates of substitution between health and wealth so as to directly monetize the value of life over and above consumption. We show that both solutions raise unresolved questions that should be addressed in future research to enable appropriate use of the FCM in CBA.

Where do poor people in the United States (US) go when they get sick? Often, they go to Federally Qualified Health Centers (FQHCs) and hospital emergency departments. Even after the implementation of the Patient Protection and Affordable Care Act (ACA), these safety-net health care organizations will continue to play a crucial role in the US health care system. FQHCs have long grappled with some of the biggest questions facing the US health care system and their leaders and clinicians face ethical challenges in everyday practice. Ethical and policy challenges in the US health care safety-net are not usually ‘tragic choices’ involving the allocation of transplantable organs, or ventilators during a pandemic. They are everyday choices with a tragic dimension because, even with the adoption of the ACA, the US has not yet decided whether poor people deserve a ‘home’ or a ‘net’ when they are sick, and whether even a net should be in good repair.