In the Dutch health care system, health insurers negotiate with hospitals about the pricing of hospital products in a managed competition framework. In this paper, we study these contract prices that became for the first time publicly available in 2016. The data show substantive price variation between hospitals for the same products, and within a hospital for the same product across insurers. About 27% of the contract prices for a hospital product are at least 20% higher or lower than the average contract price in the market. For about half of the products, the highest and the lowest contract prices across hospitals differ by a factor of three or more. Moreover, hospital product prices do not follow a consistent ranking across hospitals, suggesting substantial cross-subsidization between hospital products. Potential explanations for the large and seemingly random price variation are: (i) different cost pricing methods used by hospitals, (ii) uncertainty due to frequent changes in the hospital payment system, (iii) price adjustments related to negotiated lumpsum payments and (iv) differences in hospital and insurer market power. Several policy options are discussed to reduce variation and increase transparency of hospital prices.

Tackling health inequalities (HI) has become a key policy objective in England in recent years. Yet, despite the wide-ranging policy response of the 1997–2010 Labour Government, socio-economic variations in health continued to widen. In this paper, we seek to explore why. We propose that a meta-narrative has emerged in which the health problems facing England's most deprived areas, and the solution to those problems, have increasingly come to be linked to levels of National Health Service (NHS) funding. This has been, in part, a response to key shortcomings in previous rounds of resource allocation. The very significant sums of money allocated with respect to ‘health inequalities’ reflects and reinforces the belief that the NHS can and should play a central role in promoting health equity. This medicalisation of HI focuses attention on the role of individual risk factors that lend themselves to medical management, but effectively sidelines the macroprocesses of social inequality, legitimising the kind of society that neo-liberal government has produced in the United Kingdom – one in which health (like other assets) has become a matter of individual and not collective responsibility.

Historically, brand-name pharmaceuticals have enjoyed long periods of market exclusivity in Japan, given the limited use of generics after patent expiration. To improve the efficiency of the health-care system, however, the government has recently implemented various policies aimed at increasing generic substitution. Although this has created expectations that the Japanese generic drug market may finally take off, to date, generic usage has increased only modestly. After reviewing the incentives of key market participants to choose generics, we argue that previous government policies did not provide proper incentives for pharmacies to boost generic substitution. We offer some recommendations that may help to increase generic usage.

We outline key conclusions of the World Health Organisation's report 'Making Fair Choices on the Path to Universal Health Coverage (UHC)'. The Report argues that three principles should inform choices on the path to UHC: I. Coverage should be based on need, with extra weight given to the needs of the worse off; II. One aim should be to generate the greatest total improvement in health; III. Contributions should be based on ability to pay and not need. We describe how these principles determine which trade-offs are (un)acceptable. We also discuss which institutions contribute to fair and accountable choices.

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.

It is argued here that an economics centred on subjective utility-maximization is unsuitable for the analysis and policy grounding of health care provision. To some extent, the peculiarities of health care have been recognized by mainstream health economists, who sometimes abandon Paretian welfare considerations to focus on needs instead. This article examines important peculiarities of health care that are relatively neglected in the literature. Some of these concern health care needs: while health itself is a universal need, needs for health care provision are largely involuntary, varied, and idiosyncratic. These issues have important consequences for the planning of health care systems and the extent of transaction costs in any market-based system. These factors, combined with the inherent dynamism of modern health care needs and capabilities, create an opening for alternative approaches to health care economics.

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.

Over the last two decades, there has been an increased focus among the health policy and research communities upon improving efficiency, in terms of activity levels and health outcomes, in the health care systems of the EU member states. In this article, some of these developments are described and to some extent assessed, and an attempt is made to highlight how they may serve to undermine more fundamental aspects of these systems: namely, that access to health care be universal and affordable at the point of use.

In January 2006, the Spanish government enacted a tobacco control law that banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. We analyse the effect produced on cigarette sales by these two bans. We approach this problem using an interrupted time series analysis while accounting for the potential effects of autocorrelation and seasonality. The data source used was the official data on legal sales of tobacco in Spain, from January 2000 to December 2015 (excluding the Canary Islands and the autonomous cities of Ceuta and Melilla). As confounder variables, we use the log-transformed average prices for manufactured and hand-rolled cigarettes (or the average minimum excise tax as a proxy), and log-transformed real-household disposable income. The implementation of a total smoke-free ban in Spain was associated with an immediate reduction in cigarette sales between 9% to 11%. In contrast, in the period immediately following the partial ban, no such reduction was detected, beyond the trend already present. Our results indicate that, in Spain, partial bans on smoking in public places failed, and that only a total tobacco ban worked.

Poorer resident care in US for-profit relative to not-for-profit nursing homes is usually blamed on the profit motive. But US nursing home performance may relate to Medicaid public financing in a manner qualifying the relationship between ownership and quality. We investigated effects of Medicaid resident census, Medicaid payment, and occupancy on performance. Resource dependence theory implies these predictors may affect discretion in resources invested in resident care across for-profit and not-for-profit facilities. Models on physical restraint use and registered nurse (RN) staffing were studied using generalized estimating equations with panel data derived from certification inspections of nursing homes. Restraint use increased and RN staffing levels decreased among for-profit and not-for-profit facilities when the Medicaid census increased and Medicaid payment decreased. Interaction effects supported a theory that performance relates to available discretion in resource allocation. Effects of occupancy appear contingent on the dependence on Medicaid. Poorer performance among US for-profit nursing homes may relate to for-profit homes having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes. Understanding the complexity of factors affecting resources expended on resident care may further our understanding of the production of quality in nursing homes, whether in the US or elsewhere.

After years of unprecedented growth in development assistance for health (DAH), the system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases, and by the economic transition and rise of the middle-income countries. This raises questions about which countries should receive DAH and how much, and, fundamentally, what criteria that promote fair and effective allocation. Yet, no broad comparative assessment exists of the criteria used today. We reviewed the allocation criteria stated by five multilateral and nine bilateral funders of DAH. We found that several funders had only limited information about concrete criteria publicly available. Moreover, many funders not devoted to health lacked specific criteria for DAH or criteria directly related to health, and no funder had criteria directly related to inequality. National income per capita was emphasised by many funders, but the associated eligibility thresholds varied considerably. These findings and the broad overview of criteria can assist funders in critically examining and revising the criteria they use, and inform the wider debate about what the optimal criteria are.

Ten years ago, it would have been hard to imagine the publication of an issue of a scholarly journal dedicated to applying lessons from the transformation of the United States Department of Veterans Affairs Health System to the renewal of other countries' national health systems. Yet, with the recent publication of a dedicated edition of the Canadian journal Healthcare Papers (2005), this actually happened. Veterans Affairs health care also has been similarly lauded this past year in the lay press, being described as ‘the best care anywhere’ in the Washington Monthly, and described as ‘top-notch healthcare’ in US News and World Report's annual health care issue enumerating the ‘Top 100 Hospitals’ in the United States (Longman, 2005; Gearon, 2005).

Few are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimer's disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.

The recognition that access to health care is a constitutional right in Brazil has resulted in a situation in which citizens denied treatments by the public health care system have brought lawsuits against health authorities, claiming that their right to health was violated. This litigation forces the courts to decide between a patient-centred and a population-centred approach to public health – a choice that forces the courts to assess health care rationing decisions. This article analyses the judgments of the Brazilian Federal Supreme Court in right to health cases, arguing that the Court's recent decisions have been contrary to their long-standing stance against rationing. In 2009, the Court organized a public hearing to discuss this topic with civil society and established criteria to determine when rationing would be legal. However, I argue that these criteria for health care rationing do not adequately address the most difficult health care distribution dilemmas. They force the health care system to keep their rationing criteria implicit and make population-centred concerns secondary to individual-centred ones.

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45–64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65+) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.

This article examines the impact of the Health and Social Care Act 2012 on the regulation of competition in the English National Health Service (NHS), by focussing on the change it marked from a system of sector-specific regulation to one which is clearly based in competition law. It has been suggested that the Act and its associated reforms would significantly alter accountability in the NHS, and would change decisions from the remit of public policy to that of the law. To assess the impact the Act has had in practice, the article compares the interpretation of the rules regarding competition in the NHS by the regulators of competition immediately before, and following, the passing of the Act. It argues that, whilst the reforms have the potential significantly to alter the way competition in the NHS is regulated, the impact of the reforms in this area is limited by the development of systems within the NHS to manage and resolve issues internally where possible.

This paper explores the factors that influence citizens' attitudes toward the alternative provision of health care services, leading them to be willing to make extra, informal payments within the public health care system. We question whether these attitudes depend primarily on inherent normative preferences, such as beliefs about the government's responsibility to its citizens, or on certain aspects of the reality that they experience, such as satisfaction with the quality and quantity of services as well as the fairness of public systems. Analyzing the findings from a national survey, the paper shows that practical considerations and real-world conditions strongly relate to attitudes more than normative perceptions do.

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.

Equity in health care financing is recognised as a main goal in health policy. It implies that payments should be linked to capacity to pay and that households should be protected against catastrophic health expenditure (CHE). The risk of CHE is inversely related to the share of out-of-pocket payments (OOP) in total health expenditure. In Portugal, OOP represented 26% of total health expenditure in 2010 [one of the highest among Organisation for Economic Co-operation and Development (OECD) countries]. This study aims to identify the proportion of households with CHE in Portugal and the household factors associated with this outcome. Additionally, progressivity indices are calculated for OOP and private health insurance. Data were taken from the Portuguese Household Budget Survey 2010/2011. The prevalence of CHE is 2.1%, which is high for a developed country with a universal National Health Service. The main factor associated with CHE is the presence of at least one elderly person in households (when the risk quadruples). Payments are particularly regressive for medicines. Regarding the results by regions, the Kakwani index for total OOP is larger (negative) for the Centre and lower, not significant, for the Azores. Payments for voluntary health insurance are progressive.

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.