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.

The English government has encouraged private providers – known as Independent Sector Treatment Centres (ISTCs) – to treat publicly funded (NHS) patients. All providers are to be remunerated under a prospective payment system that offers a price per case treated, adjusted by the Market Forces Factor (MFF) to reflect geographical variation in specific input costs. This payment system presupposes that any remaining cost differentials between providers result from inefficiencies. However, the validity of this assumption is unclear. This article describes the constraints that could cause public and private provider costs to differ for reasons outside their control. These constraints may be regulatory in nature, such as taxes and performance management regimens, or relate to the production process, such as input costs, the provision of emergency care, and case mix issues. Most of these exogenous cost differentials can be rectified by adjustments either to the regulatory system or to the payment method. However, differences in capital costs appear less tractable and further investigation into possible solutions is warranted.

Quasi-markets have become fashionable within health care. This is also the case in Norway where primary physician services are organized as a quasi-market. Physicians compete for patients, and patients can choose another physician if they are not satisfied with the physician they have. This is meant to provide incentives for physicians to provide services that are both efficient and of high quality. One condition that is necessary in order for such a market to function is that there is excess supply to ensure that patients have a real opportunity for choice. In this study we investigated the influence of excess supply on patient access and the mobility of patients between primary physicians in Norway. The analyses were performed on data from two comprehensive national surveys. Access to physicians is better for physicians who have spare capacity than for physicians who have a lack of capacity. Patients take advantage of their possibilities for choice. They move from physicians who have too little capacity to physicians who have spare capacity. Patient choice means that patients are not ‘stuck’ with physicians who have too little capacity to provide adequate services for their patients. The results show that quasi-markets can ensure good access to primary physician services, but this presupposes that there is enough spare capacity to provide patients with a real choice of physician.

Cream skimming can be defined as the selective treatment of patients that demand few resources while providing high economic refunds. We test whether cream skimming occurs after the introduction of DRG-based activity-based financing (ABF) in Norway in 1997 and if the problem further increased after the 2002 organizational reform when hospitals were turned into trusts. The DRG-system offers the same economic reimbursement for patients classified within day-surgical DRGs irrespective of whether the patient receives same-day treatment or in-patient care over several days. This provides potential for cream skimming and allows us to investigate cream skimming within the actual diagnoses. Patient data from the period 1999-2005 is analyzed. Waiting times are used as indicators of patient selection and analyzed as a function of severity within each diagnosis, controlling for age and gender of the patient, as well as institutional and time-dependent variables. The analysis gives some evidence of cream skimming in the first period of ABF, in particular within the lighter orthopaedic diagnoses. However, cream skimming does not increase after the 2002 organizational reform but is stable, and for some DRGs even reduced. The study indicates that cream skimming may occur if reimbursement systems are not particularly sophisticated. Softening of budget constraints after the hospital reform of 2002 may explain why cream skimming does not increase after the reform. However, further investigation into this mechanism is needed.

To contain expenditures in an increasingly demand driven health care system, in 2005 a no-claim rebate was introduced in the Dutch health insurance system. Since demand-side cost sharing is a very controversial issue, the no-claim rebate was launched as a consumer friendly bonus system to reward prudent utilization of health services. Internationally, the introduction of a mandatory no-claim rebate in a social health insurance scheme is unprecedented. Consumers were entitled to an annual rebate of ₠ 255 if no claims were made. During the year, all health care expenses except for GP visits and maternity care were deducted from the rebate until the rebate became zero. In this article, we discuss the rationale of the no-claim rebate and the available evidence of its effect. Using a questionnaire in a convenience sample, we examined people’s knowledge, attitudes, and sensitivity to the incentive scheme. We find that only 4% of respondents stated that they would reduce consumption because of the no-claim rebate. Respondents also indicated that they were willing to accept a high loss of rebate in order to use a medical treatment. However, during the last month of the year many respondents seemed willing to postpone consumption until the next year in order to keep the rebate of the current year intact. A small majority of respondents considered the no-claim rebate to be unfair. Finally, we briefly discuss why in 2008 the no-claim rebate was replaced by a mandatory deductible.

This article explores the development of two policies for the governance of medical performance in the UK: the Department of Health's (DH) clinical governance policy and the medical profession's revalidation policy. After discussing the institutional context in which each of these policies emerged, we examine how and why they were constructed. While the clinical governance policy was in large part a swift reaction to high-profile cases of medical misconduct in the late 1990s, revalidation was the profession's response to the politicisation of its self-regulatory apparatus. The profession took notably longer than the DH to piece together its policy as a result of internal disagreements about the role clinical standards should play in the evaluation of a doctor's fitness to practice. Following the Fifth Report of the Shipman Inquiry in late 2004, the government stepped in and eventually introduced legislation that modifies the profession's policy. With clinical governance, the state – via arms-length regulatory organisations – has entered the clinic in new ways, strengthening hierarchy-based forms of governance in the governance of medical performance. However, the success of hierarchical forms of governance is likely to be restricted by the lack of a clear system of sanctioning and the state's reliance on a lengthy chain of command in the National Health Service for the implementation of clinical standards.

Cost-effectiveness analysis (CEA) is a powerful analytic tool for assessing the value of health care interventions but it is a method used sparingly in the US. Despite its growing acceptance internationally and its endorsement in the academic literature, most policy analysts have assumed that US decision makers will resist using CEA to inform coverage decisions. This study sought to clarify the extent to which CEA is understood and accepted by US decision makers, including regulators, private and public insurers, and purchasers, and to identify their points of difficulty with its use. We conducted half-day workshops with a sample of six California-based health care organizations that spanned a range of public and private perspectives regarding coverage of health care services. Each workshop included an overview of CEA methods, a priority-setting exercise that asked participants (acting as ‘social decision makers’) to rank condition treatment pairs prior to and following provision of cost-effectiveness information; and a facilitated discussion of obstacles and opportunities for using CEA in their own organizations. Pre and post-questionnaires inquired as to obstacles toward implementing CEA, attitudes toward rationing, and views on the use of CEA in Medicare and in private insurance coverage decision-making. In post-workshop surveys major obstacles identified included: fears of litigation, concerns about the quality and accuracy of studies that were commercially sponsored, and failure of CEAs to address shorter horizon cost implications. Over 90% of participants felt that CEA should be used as an input to Medicare coverage decisions and 75% supported its use in such decisions by private insurance plans. Despite the wide acceptance of CEA, at the conclusion of the workshop, 40% of the sample remained uncomfortable with support of ‘rationing’ per se. We suggest that how cost-effectiveness analysis is framed will have important implications for its acceptability to US decision makers.

This paper argues on ethical and practical grounds for more widespread use of an integrated approach to refugee healthcare, and proposes a basic model of assessment for integrated systems. A defining element of an integrated approach is an equal ability by refugee and host nationals to access the same healthcare resources from the same providers. This differs fundamentally from parallel care, currently the predominant practice in Africa. The authors put forward a general model for evaluation of integrated healthcare with four criteria: (1) improved health outcomes for both hosts and refugees, (2) increased social integration, (3) increased equitable use of healthcare resources, and (4) no undermining of protection. Historical examples of integrated care in Ethiopia and Uganda are examined in light of these criteria to illustrate how this evaluative model would generate evidence currently lacking in debates on the merit of integrated healthcare.

This paper analyses the introduction of a systemic standards based programme for governing medical performance in Denmark. The programme combines clinical, organisational, and patient related standards and measures, and contains both external evaluation and self-assessment based on standards. The substance of the programme is new compared to the previous decentralised or professionally driven state of affairs that was based on a largely voluntary introduction of clinical standards, combined with a case-by-case evaluation of malpractice incidents. The programme strengthens hierarchy-based forms of governance; these co-exist with salient components of network-based governance as well as some elements of market-based governance. Institutional and contextual factors are important in explaining why a systemic standards based programme emerged as a result of the policy negotiation processes. In particular, the programme reflects stronger governance ambitions from the government in response to claims of a relative decline in the quality of the regional health services. However, the actual design is mediated by institutionalised negotiation processes among the state, decentralised authorities, and health professionals.

The public share of Canadian total health expenditure declined between 1975 and 2005 but categories such as physicians stayed constant while drugs, other institutions, and capital spending saw increases. Regressions find the key determinants of the public share to be: the relative price of health care, per capita income, federal transfers, proportion of population over age 65, provincial dummy variables, political parties, the onset of the Canada Health Act and the Canada Health and Social Transfer (CHST), and a time trend invoking technological change. Increasing income inequality is not a factor eroding the public share. Moreover, provinces governed by center-left parties are associated with lower public shares in the physician and other health professional categories. The significance of variables like the Canada Health and Social Transfer, the Canada Health Act and provincial differences suggest the increase in the private share of health spending since 1975 is partly the result of policy choices. As the public share has only declined from approximately 76% to 70% over 30 years, it appears the shift towards private care is one of marginal increments. Canadians remain in conflict over their health care system as they appear willing to tolerate only marginal accretions in the overall private share of health spending but accept larger changes across health expenditure categories and provincial systems.

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.

Although access to health care is frequently identified as a goal for health care policy, the precise meaning of access to health care often remains unclear. We present a conceptual framework that defines access to health care as the empowerment of an individual to use health care and as a multidimensional concept based on the interaction (or degree of fit) between health care systems and individuals, households, and communities. Three dimensions of access are identified: availability, affordability, and acceptability, through which access can be evaluated directly instead of focusing on utilisation of care as a proxy for access. We present the case for the comprehensive evaluation of health care systems as well as the dimensions of access, and the factors underlying each dimension. Such systemic analyses can inform policy-makers about the ‘fit’ between needs for health care and receipt of care, and provide the basis for developing policies that promote improvements in the empowerment to use care.

Since the beginning of the 1990s, health policy in Italy has been characterised by continuous reform as reflected by the frequency of new measures. Importantly, the reforms have changed considerably many aspects of the health-care system, including the governance of medical performance. The new measures fall into two types: regionalisation and transformation of local providers into ‘health-care enterprises’. In relation to the governance of medical performance, more specifically, the reforms have entailed the introduction of budgeting and quality assurance, the creation of new managerial roles, and the transformation of existing roles, as well as the introduction of new mechanisms for evaluating medical performance. In terms of the specific forms of governance, the reforms have reinforced hierarchy-based forms of governing intermeshed with party governance, and have re-defined professional self-regulation by strengthening collective forms of professional self-regulation. The design and implementation of the reforms are subject to a complex process of negotiation, which involves a wide range of actors spread across different levels of governance and takes place in relation to all aspects of the governance of medical performance.

In middle-income Arab countries such as Egypt and Lebanon, income-associated equity in health care remains an elusive policy objective in part due to a relatively high reliance on out-of-pocket payments in financing care. This article examines the effect of income on the use of outpatient and inpatient health care services in Egypt and Lebanon using econometric analysis of cross-sectional data from the World Health Organization. In light of noticeable differences in income and public financing arrangements, these two countries serve as interesting case studies. Multivariate regression results suggest that Egyptian respondents were more likely to use health services than their Lebanese counterparts, holding all else constant, and that this effect was particularly evident for outpatient care. A higher income and insurance increased the likelihood of outpatient use more so than inpatient use, with these effects more pronounced in Lebanon. Overall, lower-income groups tended to report having worse health levels and paying more out-of-pocket on health care as a share of income than did higher-income groups. At the same time, these socioeconomic disparities in health appeared to be greater in Lebanon than in Egypt. Economic barriers to the use of health services are discussed within the context of health financing policy reforms aimed at improving equity in access to care in countries such as Egypt and Lebanon.

Like most industrialized countries, Germany’s health care system is facing two major challenges. The first is to find a sustainable financing system for increasing health care expenditures. The second is to ensure – and improve – the quality of care provided. This article describes the status quo in quality assurance in Germany and analyses the changes introduced into the SHI (Statutory Health Insurance) system with the Modernization Act of 2004. First, a theoretical framework for quality assurance that is consistent with the logic of the German social market economy is outlined. The analysis then describes new actors and their duties in the field of quality assurance, highlighting improvements in regulation and the regulatory instruments applied. Although the strategy for quality assurance is still dominated by regulation and corporatist bodies, the latest reform acts of 2004 and 2007 focus on more and better information about the quality of services provided – an important prerequisite for more competitive elements in the German health care system.

Studies of German health policy often highlight institutional constraints to reform. However, based on a case study of the introduction of clinical standards as part of the Disease Management Programmes for chronic illnesses, this article suggests that negotiating reform at an arm's length from the state can also lead to governance change, although the strengthening of hierarchy is not as prominent as that in some of the countries studied in this special issue. As such, the case of Germany offers interesting insights into the politics of governance change that occur in the shadow, but largely without the direct involvement of the state, which is typical of a corporatist health-care state. In this respect, the analysis identifies three leverages for change. First, the change in medical governance explicitly builds on earlier reforms and gives the reform alliance a competitive edge. Second, the organisations of the joint self-administration, as a more or less open ally of the state, play an influential role throughout the reform process. Importantly and third, this is complemented by the state steering at a distance.

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.

Choice and competition are central planks of the English government’s health reforms and modernisation programme. Wales and Scotland have chosen a different path, which calls into question the suggestion that in an age of consumerism there is no other way to secure overdue changes in the provision and management of health care to improve their quality and responsiveness to user preferences. Yet pro-market enthusiasts pursue their agenda in the face of evidence that calls into question the claims they make. It is a curious position for a government that is wedded to evidence-based policy to find itself in. The policy puzzle is why, despite the contested nature of the alleged virtues of choice and competition, policy-makers persist with introducing a set of reforms which appear to threaten the very values and principles they profess to uphold. An alternative reform paradigm exists which acknowledges what makes public services public. This paper sets out the key features of what rediscovering public service entails adopting the notion of co-production as a means of bringing about a new relationship between professionals and the public that remains true to the National Health Service’s social purpose.