This study contributes to the sparse literature on differences between public and private primary care practices (PCCs). The purpose was to explore if differences in performance and characteristics between public and PCCs persist over time in a welfare market with patient choice and provider competition, where public and private providers operate under similar conditions. The analysis is based on data from a national patient survey and administrative registries in a large Swedish region, covering PCC observations in 2010 and 2019, i.e., the year after and 10 years after introducing choice and competition in the region. The findings suggest that differences across owner types tend to decrease over time in welfare markets. Differences in patients' experiences, PCC size, patient mix and the division of labour have decreased or disappeared between 2010 and 2019. There were small but significant differences in process measures of quality in 2019; public PCCs complied better with prescription guidelines. While the results demonstrate a convergence between public and private PCCs in regards to their characteristics and performance, differences in patients' experiences in regards to socioeconomic conditions persisted. Such unwarranted variation calls for continued attention from policy makers and further research about causes.

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary–secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

Public long-term care insurance (LTCI), which provides home and institutional care benefits, was introduced in July 2008 in South Korea. This study aims to evaluate the effects of the introduction of LTCI on older people's medical service use, including outpatient visits, inpatient services and longer stays (181 days or longer) in hospitals by implementing a quasi-experiment design with a generalised difference-in-difference method. The results showed that the introduction of LTCI did not change the use of outpatient medical services, although the medical costs of older people who used medical services at least once decreased by 9.4%. For the inpatient services, hospitalisation rates declined by 2.7% as a result of the LTCI. Length of stay and inpatient expenses decreased by 15.6 and 9.5%, respectively. For older people of LTC grade 2, eligible for long-term care facilities (LTCF), prolonged hospitalisation rates decreased by 1.6% due to the LTCI. In conclusion, the introduction of LTCI in South Korea has contributed to decreasing the use of inpatient services and longer stays in hospitals, which suggests that the utilisation of LTCF has become a substitute for some social admissions in hospitals.

This study evaluates the impact of the Global Alliance for Vaccines and Immunization (GAVI) on children's health outcomes in developing countries. Using a difference-in-differences identification strategy, we find that GAVI has reduced neonatal, infant and under-five mortality rates. The impact of GAVI on children's health outcomes is larger in countries with lower per capita income. Our findings underscore the relevance of health interventions in improving children's health outcomes in developing economies.

The COVID-19 pandemic has been an ultimate challenge for health systems as a whole rather than just single sectors (e.g. hospital care). Particularly, interface management between health system sectors and cooperation among stakeholders turned out to be crucial for an adequate crisis response. Dealing with such interfaces, it is argued in the literature, demands from health care systems to become resilient. One way to analyse this is to focus on the ways in which bottlenecks in health systems are dealt with during the pandemic. This paper investigates six bottlenecks, including overburdened public health agencies, neglected nursing homes and insufficient testing capacities that have been encountered in the health systems of Germany, Sweden and the Netherlands during the pandemic. Based on empirical findings we identify and critically discuss preliminary lessons in terms of health system resilience, an increasingly popular theoretical concept that frames crises as an opportunity for health system renewal. We argue that in practice health system resilience is hindered by path dependencies of national health systems and, owed to the crisis, interim policies that lack ambition for broader reforms.

Health system governance has been receiving increasing attention in health system research since the 1980s. The contemporary challenges that the German health system is faced with are often closely linked to governance issues. Although Germany has the highest health expenditure as a share of Gross Domestic Product (GDP) in the European Union (EU), the spending on healthcare is out of proportion to the health outcomes of the population. The reason for this lies mainly in the complexity of the German health system which is hard to steer due to several administrative levels in the country and numerous policy actors to whom the decision-making power on healthcare provision is delegated. In this paper, we present the results of focus group discussions on governance and build upon the insights gained through the Neustart project of the Robert Bosch Foundation. Based on an internationally recognised health governance framework from the World Health Organization (WHO), experts who work in, on or for the German health system addressed health governance challenges. They provided evidence-based recommendations for the new legislative period (2021-2025) on transparency, accountability, participation, integrity and capacity of the German health system.

Despite considerable academic and policy interest in the taxation of sugar-sweetened beverages (SSBs), its extra-health implications remain largely unexplored. We investigated the impact of an SSB tax on school absenteeism due to improved dental health, in a framework that accounted for the distribution of the benefit. We designed a quantitative, decision-analytic model that synthesised existing evidence in the areas of dental epidemiology, public health and economics, and simulated causal mechanisms that lead to changes in school attendance in Australian children and adolescents aged 6–17, in a tax vs no tax scenarios. Introducing a 20% sales tax on SSBs would result in a 0.73% (95% confidence interval: 0.38; 1.10), or 4684 (2412; 7071) days per year nationwide, reduction in school absences attributable to dental health reasons. While positive impacts would be seen across the board, the distribution of benefit was favourable towards boys, older teens and those from lower socio-economic status. Our study highlights the need for, and the viability of, quantifying distributions of direct and indirect consequences of public health policy. Despite modest effect size, the equity profile of SSB tax, the long-lasting benefits of educational gains, and potential synergies with other interventions, make it an attractive option for policymakers to consider.

Every year, over 250,000 public authorities in the European Union (EU) spend about 14% of GDP on the purchase of services, works and supplies. Many are in the health sector, a sector in which public authorities are the main buyers in many countries. When these purchases exceed threshold values, EU public procurement rules apply. Public procurement is increasingly being promoted as a tool for improving efficiency and contributing to better health outcomes, and as a policy lever for achieving other government goals, such as innovation, the development of small and medium-sized enterprises, sustainable green growth and social objectives like public health and greater inclusiveness. In this paper, we describe the challenges that arise within health care systems with public procurement and identify potential solutions to them. We examined the tendering of pharmaceuticals, health technology, and e-health. In each case we identify a series of challenges relating to the complexity of the procurement process, imbalances in power on either side of transactions and the role of procurement in promoting broader public policy objectives. Finally, we recommend several actions that could stimulate better procurement, and suggest a few areas where further EU cooperation can be pursued.

This study examines the literature on learning lessons from the coronavirus disease 2019 (COVID-19) pandemic to make a conceptual and empirical contribution. The conceptual contribution suggests a simplified policy transfer framework for learning lessons from the proliferation of approaches involving an expanding and confusing mix of hypotheses, questions, criteria, domains, constructs, factors and criteria. This is then used to review the literature of lessons from COVID-19. This fuses the three reasons for transfer failure and the context-mechanism- outcome configuration of realist approaches to suggest three simple criteria of informed transfer (outcomes); complete transfer (mechanisms); and appropriate transfer (context). The empirical contribution suggests that it is difficult to learn lessons from the existing literature. The conceptual framework suggests that lessons about successful transfer involve a clear idea of policy success, understanding how the policy instrument or mechanism links with success in the original context, and how ‘fungible’ it is to the new context. Put another way, the ‘COVID lessons industry’ may itself need to learn that lessons about policy transfer should be informed, complete and appropriate.

The UK's relationship with the European Union (EU) is now embodied in two principal legal instruments: the EU–UK Trade and Cooperation Agreement, which formally entered into force on 1 May 2021; and the Withdrawal Agreement, with its Protocol on Ireland/Northern Ireland, which continues to apply. Using a ‘building blocks’ framework for analysis of national health systems derived from the World Health Organisation, this article examines the likely impacts in the UK of this legal settlement on the National Health Service (NHS), health and social care. Specifically, we determine the extent to which the trade, cooperation and regulatory aspects of those legal measures support positive impacts for the NHS and social care. We show that, as there is clear support for positive health and care outcomes in only one of the 17 NHS ‘building blocks’, unless mitigating action is taken, the likely outcomes will be detrimental. However, as the legal settlement gives the UK a great deal of regulatory freedom, especially in Great Britain, we argue that it is crucial to track the effects of proposed new health and social care-related policy choices in the months and years ahead.

The privatisation of provision and the emerging privatisation of funding, manifested in the rapid rise of private health insurance, are the most obvious signs that the universal, Swedish health system is gradually weakened. Meanwhile, the private welfare industry creates a neoliberal Newspeak where the burdening effects of the private insurance system on public healthcare are said to be unburdening, and where every step away from the principles of a universal welfare model is said to be in line with the principles of a universal welfare model. The language spoken by the private welfare industry spills over into authorities, journalists and scholars. In this article, I discuss, problematise and partially reject two research questions – Does VHI unburden the public health care system? and Are VHI holders less supportive of funding public health care? – where the authors fail to place development in the context of increased inequality and declining tax ratio, and where they use the welfare industry's definitions invented to blur the consequences of a parallel health system.

This paper explores policy mechanisms behind New Zealand's remarkable track record of cost containment in public pharmaceutical spending, contrasting with most other advanced economies. We drew on a review of official policy documents and 28 semi-structured expert interviews. We found that decision making in pricing and reimbursement policy was dominated by a small group of managers at the Pharmaceutical Management Agency (PHARMAC), the country's drug reimbursement and Health Technology Assessment Agency, who negotiated pharmaceutical prices on behalf of the public payer. In formal negotiation over patented pharmaceutical prices these managers applied an array of pricing strategies, most notably, ‘bundling’ consisting of discounted package deals for multiple pharmaceuticals, and ‘play-off tenders’, whereby two or more pharmaceutical companies bid for exclusive contracts. The key pricing strategy for generic drugs, in contrast, was ‘blind-tenders’ taking the form of an annual bidding process for supply contracts. An additional contextual condition on bargaining over pharmaceutical prices was an indirect strategy that involved the cultivation of the PHARMAC's ‘negotiation leverage’. We derived two cost containment mechanisms consisting in the relationship between pricing strategy options and various reimbursement actors. Our findings shed light on aspects of the institutional design of drug reimbursement that may promote the effective use of competitive negotiations of pharmaceutical prices, including specific pricing strategies, by specialist public payer institutions. On this basis, we formulate recommendations for countries seeking to develop or reform policy frameworks to better meet the budgetary challenge posed by pharmaceutical expenditure.

There is currently a heightened need for transparency in pharmaceutical sectors. The inclusion of real-world (RW) evidence, in addition to clinical trial evidence, in decision-making processes, was an important step forward toward a more inclusive established value proposition. This advance has introduced new transparency challenges. Increasing transparency is a critical step toward accelerating improvement in type, quality, and access to data, regardless of whether these originate from clinical trials or from RW studies. However, so far, advances in transparency have been relatively restricted to clinical trials, and there remains a lack of similar expectations or standards of transparency concerning the generation and reporting of RW data. This perspective paper aims to highlight the need for transparency concerning RW studies, data, and evidence across health care sectors, to identify areas for improvement, and provide concrete recommendations and practices for the future. Specific issues are discussed from different stakeholder perspectives, culminating in recommended actions, from individual stakeholder perspectives, for improved RW study, data, and evidence transparency. Furthermore, a list of potential guidelines for consideration by stakeholders is proposed. While recommendations from different stakeholder perspectives are made, true transparency in the processes involved in the generation, reporting, and use of RW evidence will require a concerted effort from all stakeholders across health care sectors.

The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.

Scholars and journalists have devoted considerable attention to understanding the circumstances in which Americans receive surprise medical bills. Previous research on this issue has focused on the scope of the problem, including the conditions that are most likely to lead to surprise bills. However, the existing literature has almost exclusively relied on claims data, limiting our understanding of consumer experiences and attitudes toward policy changes to address surprise billing. Using a survey administered to a nationally representative sample of 4998 Americans, we analyze consumer experiences with surprise billing, knowledge of the issue, how concerned Americans are about receiving surprise bills and how past experiences influence policy preferences toward federal action on surprise billing. Our analysis demonstrates that knowledge and concern about surprise billing are the highest among the educated and those who have previously received a surprise bill. These factors also predict support for federal policy action, with high levels of support for federal policy action across the population, including among both liberals and conservatives. However, more detailed federal policy proposals receive significantly less support among Americans, suggesting that stand-alone policy action may not be viable. Our results show bipartisan support among American consumers for federal action on surprise billing in the abstract but no consistent views on specific policy proposals.

Effective policymaking in health care systems begins with a clear typology of the terminology – need, demand, supply and access to care – and their interrelationships. However, the terms are contested and their meaning is rarely stated explicitly. This paper offers working definitions of need, demand and supply. We draw on the international literature and use a Venn diagram to explain the terms. We then define access to care, reviewing alternative and competing definitions from the literature. We conclude by discussing potential applications of our conceptual framework to help to understand the interrelationships and trade-offs between need, demand, supply and access in health care.

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.

The cost of clinical negligence claims continues to rise, despite efforts to reduce this now ageing burden to the National Health Service (NHS) in England. From a welfarist perspective, reforms are needed to reduce avoidable harm to patients and to settle claims fairly for both claimants and society. Uncertainty in the estimation of quanta of damages, better known as financial settlements, is an important yet poorly characterised driver of societal outcomes. This reflects wider limitations to evidence informing clinical negligence policy, which has been discussed in recent literature. There is an acute need for practicable, evidence-based solutions that address clinical negligence issues, and these should complement long-standing efforts to improve patient safety. Using 15 claim cases from one NHS Trust between 2004 and 2016, the quality of evidence informing claims was appraised using methods from evidence-based medicine. Most of the evidence informing clinical negligence claims was found to be the lowest quality possible (expert opinion). The extent to which the quality of evidence represents a normative deviance from scientific standards is discussed. To address concerns about the level of uncertainty involved in deriving quanta, we provide five recommendations for medico-legal stakeholders that are designed to reduce avoidable bias and correct potential market failures.

Canada's experience with the coronavirus disease-2019 (COVID-19) pandemic has been characterized by considerable regional variation, as would be expected in a highly decentralized federation. Yet, the country has been beset by challenges, similar to many of those documented in the severe acute respiratory syndrome outbreak of 2003. Despite a high degree of pandemic preparedness, the relative success with flattening the curve during the first wave of the pandemic was not matched in much of Canada during the second wave. This paper critically reviews Canada's response to the COVID-19 pandemic with a focus on the role of the federal government in this public health emergency, considering areas within its jurisdiction (international borders), areas where an increased federal role may be warranted (long-term care), as well as its technical role in terms of generating evidence and supporting public health surveillance, and its convening role to support collaboration across the country. This accounting of the first 12 months of the pandemic highlights opportunities for a strengthened federal role in the short term, and some important lessons to be applied in preparing for future pandemics.