Smoking cost the National Health Service (NHS) in England in 1996 an estimated £1.4–£1.7 billion. In 1998, in Smoking Kills, the Government outlined an action plan for reducing smoking prevalence. This paper estimates 2006 costs and the impact of declining prevalence. Estimates are derived from costs, service use, and attributable proportions based on current and ex-smokers’ prevalence and relative risk compared with never-smokers. Comparable 1996 costs were estimated by substituting 1996 prevalence. Smoking-attributable hospital admissions cost the NHS an estimated £1 billion in 2006, outpatient attendances cost £190 million, general practitioner (GP) consultations £530 million, practice nurse consultations £50 million and GP prescriptions £900 million; £2.7 billion in total. This represents 5% of adult hospital admission costs, 4% outpatients, 11% GP and 8% practice nurse consultations and 12% of prescription costs. Smoking accounted for 24% of respiratory disease hospital admission costs and 16% of cancer and cardiovascular disease costs (people aged ⩾35 years). The 2006 cost is estimated to be 13% lower than if smoking had remained at 1996 levels. Smoking represents a substantial cost throughout the NHS. Significant savings are associated with a reduction in prevalence, but much of this stems from an earlier phase of the smoking epidemic. Securing future such savings requires further policies to reduce smoking prevalence.

Equity is espoused in many national health policy statements but is a complex concept and is difficult to define. The way in which equity is defined in policy has implications for how the health-care system should be structured. Conflicts between different definitions of equity are identified in theory and policy. This paper discusses these issues, with specific focus on the equity principles underpinning the Irish health-care system. The complex mix of public and private funding in the Irish system brings the challenges in identifying (and achieving) equity objectives more sharply into view, and serves as a warning system for other countries.

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.

Published works on health insurance tend to focus on program design and its impact, neglecting the implementation process that links the two and affects outcomes. This paper examines the National Health Insurance [Rashtriya Swasthya Bima Yojana (RSBY)] in India with the objective of assessing the role of implementation structures and processes in shaping performance. The central question that the paper addresses is: why does the performance of RSBY vary across states despite similar program design? Using a comparative case study approach analyzing the program’s functioning in three states, it finds the answer in the differences in governance of implementation. The unavoidable gaps in design of health care program allow abundant scope for opportunistic behavior on the part of different stakeholders. The study finds that the performance of the program, as a result, depends on the extent to which the governance mechanism is able to contain and channel opportunistic behavior during implementation. By opening up the black box of implementation, the paper contributes to improving the performance of national health insurance in India and elsewhere.

Thailand is among the first non-OECD countries to have introduced a form of Universal Health Coverage (UHC). This policy represents a natural experiment to evaluate the effects of public health insurance on health behaviours. In this paper, we examine the impact of Thailand’s UHC programme on preventive activities, unhealthy or risky behaviours and health care consumption using data from the Thai Health and Welfare Survey. We use doubly robust estimators that combine propensity scores and linear regressions to estimate differences-in-differences (DD) and differences-in-DD models. Our results offer important insights. First, UHC increases individuals’ likelihood of having an annual check-up, especially among women. Regarding health care consumption, we observe that UHC increases hospital admissions by over 2% and increases outpatient visits by 13%. However, there is no evidence that UHC leads to an increase in unhealthy behaviours or a reduction of preventive efforts. In other words, we find no evidence of ex ante moral hazard. Overall, these findings suggest positive health impacts among the Thai population covered by UHC.

This paper aims to describe the priority-setting procedure for new original pharmaceuticals practiced by the Swedish Pharmaceutical Benefits Board (LFN), to analyse the outcome of the procedure in terms of decisions and the relative importance of ethical principles, and to examine the reactions of stakeholders. All the ‘principally important’ decisions made by the LFN during its first 33 months of operation were analysed. The study is theoretically anchored in the theory of fair and legitimate priority-setting procedures by Daniels and Sabin, and is based on public documents, media articles, and semi-structured interviews. Only nine cases resulted in a rejection of a subsidy by the LFN and 15 in a limited or conditional subsidy. Total rejections rather than limitations gave rise to actions by stakeholders. Primarily, the principle of cost-effectiveness was used when limiting/conditioning or totally rejecting a subsidy. This study suggests that implementing a priority-setting process that fulfils the conditions of accountability for reasonableness can result in a priority-setting process which is generally perceived as fair and legitimate by the major stakeholders and may increase social learning in terms of accepting the necessity of priority setting in health care. The principle of cost-effectiveness increased in importance when the demand for openness and transparency increased.

There is an increasing interest in assessing unmet need for health care services particularly in European countries. Despite this there has been relatively little analysis of unmet need in the European or wider international setting. It remains a challenge to pin down what types of unmet need can and should be addressed by health care policymakers, and how to go about identifying and quantifying those unmet needs. The objective of this paper is to propose a new way of thinking about unmet need for health care which can in turn guide analysis of unmet need in terms of potential data sources and analytic approaches. Unmet need is shown to be a complex multi-faceted concept that cannot be captured by a single indicator or measurement. To advance the literature in this field, this paper considers what happens to unmet need over time. By introducing a dynamic perspective, three alternative trajectories for health care needs are outlined: non-use of health care, delayed use of health care and sub-optimal use of health care. These trajectories are discussed with a view to improving the focus, and policy applicability, of empirical research in this field.

Azerbaijan is a country with one of the highest child mortality rates in the regions of Eastern Europe and the former Soviet Union. Drawing on the nationally representative Demographic and Health Survey, this study examines the utilization of antenatal care in Azerbaijan to identify the socio-economic determinants of the usage, and its frequency, timing and quality. Consequently, binomial logit, two ordered logit and negative binomial regression models are specified to estimate the effect of various socio-economic characteristics on the likelihood of utilization. Place of living is an important determinant of antenatal healthcare utilization in Azerbaijan. It is important in determining the likelihood of utilization, its timing and quality of care received, whereas it is not significant in the model predicting the frequency of antenatal utilization. Women’s education is also significant in three models out of four. Education is important in explaining the frequency and timing of utilization as well as the quality of services received, but it is not significant in predicting the likelihood of utilization. Wealth gradient is another important determinant of antenatal care utilization in Azerbaijan inasmuch as it is significant in explaining the likelihood of prenatal care utilization and its frequency. In addition, two variables, birth order and desirability of the last child or current pregnancy, are significant only in explaining the likelihood of utilization. Therefore, we confirm the findings of previous studies, which reported that the utilization of prenatal health care is a multistage process in which decisions are sequential. Although the same set of factors may affect decision-making at all stages, the effect of these factors is different at different stages. Implications for reforms in the healthcare sector to improve antenatal care utilization in Azerbaijan are provided and discussed.

In spite of the vast number of studies measuring economic efficiency in health care, there has been little take-up of this evidence by policy-makers to date. This study provides an illustration of how a system-level study drawing on best practice in empirical measurement of efficiency may be of practical use to health system decision makers and managers. We make use of the rich data available in Canada to undertake a robust two-stage data envelopment analysis to calculate efficiency at the regional (sub-provincial) level. Decisions about what the health system produces (the outcome to measure efficiency against) and what are the resources it has to produce that outcome were based on interviews and consultation with health system decision makers. Overall, we find large inefficiencies in the Canadian health care system, which could improve outcomes (here, measured as a reduction in treatable causes of death) by between 18 and 35% across our analyses. Also, we find that inefficiencies are the result of three main sets of factors that policy makers could pay attention to: management factors, such as hospital re-admissions; public health factors, such as obesity and smoking rates; and environmental factors such as the population’s average income.

In a relatively short time, regulation has become a significant and distinct feature of how modern states wish to govern and steer their economy and society. Whereas the former ‘dirigiste’ state used to be closely related to public ownership (e.g. hospitals), planning (volume and capacity planning) and centralised administration (e.g. fixed prices and budgets), the new regulatory state relies mainly on the instrument of regulation to achieve its objectives. In this paper, we wish to relate the rise of the ‘regulatory state’ to the path-dependent trajectories and institutional legacies of discrete European health-care systems. For this purpose, we compared the Dutch corporatist social health insurance system, the strongly centralised National Health Service (NHS) of England and federal regionalised NHS system of Italy. Comparing these three different health-care systems suggests that it is indeed possible to identify a general trend towards the rise of the regulatory state in health care in the last two decades. However, although the three countries examined in this paper face similar problems of multilevel governance of networks of third-party payers and providers, each system also gives rise to its own distinct regulatory challenges.

In this commentary I explore several ways in which the psychology of individual decision-making shapes consumers’ choices in medical settings and the potential for choice-based policies to improve the performance of the health care system. This analysis draws some crucial distinctions among the various pathways though which policymakers expect choice to improve outcomes and the various forms of support that might enhance patients’ engagement with choice. I also consider how choice-promoting policies interact with other strategies for patient empowerment and depend crucially on the ways in which individual patients develop the capacity to make sense of their experiences with medical care. Drawing largely on data and studies from medical consumerism in the US, I identify a number of choice ‘pathologies’ that might compromise the influence or beneficial effects of choice-promoting initiatives. Though these limitations are unlikely to turn public officials away from their consumerist policy aspirations, identifying the realistic limitations of such initiatives makes clear the need to complement them with other strategies for enhancing patients’ well being and encouraging a more responsive health care system.

While moving towards unified social health insurance (SHI) is often a politically popular policy reform in countries where rapid expansion in health insurance coverage has given rise to the segmentation of SHI systems as different SHI schemes were rolled out to serve different populations, the potential impacts of reform on service utilisation and health costs have not been systematically studied. Using data from the Chinese Health and Retirement Longitudinal Study (CHARLS), we compared the mean costs incurred for both inpatient and outpatient care under different health insurance schemes, and the impact of different SHI schemes on treatment utilisation and health care costs using a two-part model. Our results show that Urban Employee Medical Insurance, which offers the most generous benefits, incurs the highest total costs prior to reimbursement when compared to other SHI schemes. Our analysis also shows that utilisation of SHI did not show significant reduction in out-of-pocket payments for outpatients. We argue that, unless effective measures are introduced to deal with perverse provider payment incentives, the move towards a unified system with more generous benefits may usher in a new wave of cost escalation for health care systems in China.

As the share of supplementary health insurance (SI) in health care finance is likely to grow, SI may become an increasingly attractive tool for risk-selection in basic health insurance (BI). In this paper, we develop a conceptual framework to assess the probability that insurers will use SI for favourable risk-selection in BI. We apply our framework to five countries in which risk-selection via SI is feasible: Belgium, Germany, Israel, the Netherlands, and Switzerland. For each country, we review the available evidence of SI being used as selection device. We find that the probability that SI is and will be used for risk-selection substantially varies across countries. Finally, we discuss several strategies for policy makers to reduce the chance that SI will be used for risk-selection in BI markets.

The articles in this special issue have demonstrated how unprecedented transitions have come with both challenges and opportunities for health financing. Against the background of these challenges and opportunities, the Working Group on Health Financing at the Chatham House Centre on Global Health Security laid out, in 2014, a set of policy responses encapsulated in 20 recommendations for how to make progress towards a coherent global framework for health financing. These recommendations pertain to domestic financing of national health systems, global public goods for health, external financing for national health systems and the cross-cutting issues of accountability and agreement on a new global framework. Since the Working Group concluded its work, multiple events have reinforced the group’s recommendations. Among these are the agreement on the Addis Ababa Action Agenda, the adoption of the Sustainable Development Goals, the outbreak of Ebola in West Africa and the release of the Panama Papers. These events also represent new stepping stones towards a new global framework.

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.

This article provides a critical analysis of the introduction of hospital choice in Denmark and Norway. The two Nordic cases provide evidence from public integrated health systems that may be compared to the current implementation of choice in other countries such as England. We use the theoretical concepts of institutional structure, historical legacies, and situational factors to analyze the translation of the general choice idea into a specific health policy design in Denmark and Norway. The results of the study show that even if there are many similarities between the two countries, there are also significant differences. In Denmark the initial implementation of choice was adjusted to the dominant policy objectives of macroeconomic control through regional planning, while in Norway the chosen solution reflects a more limited concern for expenditure control and a greater willingness to experiment. Timing and differences in the relative strength of the decentralized actors are important explanatory factors. Theoretically, this article provides some insights into the problem of introducing policies that contradict existing traditions, norms, and values. It addresses issues of policy design and the relationship between ideas, historically developed institutions, and situational factors, including actor constellations and interests.

Aotearoa New Zealand went ‘hard’ and ‘early’ in its response to COVID-19 and has been highly successful in limiting the spread and impact of the virus. The response has ramped up over time, and has included various levels of: border control; advice on hygiene, physical distancing and mask wearing; advice to remain at home if unwell; and testing and tracing. A four-level Alert Level framework has guided key actions at different levels of risk. Strong leadership from the Prime Minister, Minister of Finance, and Director-General of Health and high levels of community co-operation have supported the response. The country is most vulnerable at its borders, where arrangements have been of concern; advice on testing and the wearing of masks has changed over time; while the use and distribution of personal protective equipment has also been of concern. The country overall was not well prepared for a pandemic, but policy-making has been nimble. Key challenges for 2021 include swiftly rolling out a vaccine, catching up on delayed health care, and deciding how and when the border can reopen. The economic, and associated social, challenges will last many years.

Choice is often touted as a means for change within health care systems. Yet ‘choice’, in this context, takes at least three distinct forms: choice between providers within a publicly funded health care system; choice between competing insurers within a universal plan; and, lastly, choice as between privately financed health care and universal public coverage. In Canada, it is this last form of choice that is under active debate; particularly in light of the Supreme Court of Canada’s decision in Chaoulli, which found a regulation banning private health insurance for medically necessary care was unconstitutional. The argument is frequently made that Canada is an outlier from other countries in having regulation that effectively precludes this kind of choice. This issue is likely to become of concern again in upcoming constitutional challenges where applicants are looking to overturn through judicial challenges Canada’s medicare system. This article tests that argument of whether Canada truly is ‘odd’ from a comparative policy perspective by exploring regulation of choice of privately financed health care in several European countries – the Netherlands, Germany, Sweden, England and France. We highlight commonalities as well as differences, showing the extent to which these countries employ regulation to fetter growth of a large privately financed sector. The article’s thesis is that Canada, in employing more intrusive forms of regulation, is not an outlier per se but at one point in a regulatory spectrum.

Since the onset of the global financial crisis (GFC), health spending has slowed markedly or fallen in many OECD countries after years of continuous growth. However, health spending patterns across the 34 countries of the OECD have been affected to varying degrees. This article examines in more detail the observed downturn in health expenditure growth, analysing which countries and which sectors of health spending have been most affected. In addition, using more recent preliminary data for a subset of countries, this article tries to shed light on the prospects for health spending trends. Given that public sources account for around three-quarters of total spending on health on average across the OECD, and, in an overall context of managing public deficits, the article focuses on the specific areas of public spending that have been most affected. This study also tries to link the observed trends with some of the main policy measures and instruments put in place by countries. The investigation finds that while nearly all OECD countries have seen health spending growth decrease since 2009, there is wide variation as to the extent of the slowdown, with some countries outside of Europe continuing to see significant growth in health spending. While all sectors of spending appear to have been affected, initial analysis appears to show the greatest decreases has been experienced in pharmaceutical spending and in areas of public health and prevention.

Like many jurisdictions, mental health policy-making in Ontario, Canada, has a long history of frustrated attempts to move from a hospital and physician-based tradition to a coordinated system with greater emphasis on community-based mental health care. This study examines policy legacies associated with the introduction of psychiatric hospitals in the 1850s and of public health insurance (medicare) in the 1960s in Ontario; and their effect on subsequent mental health reform initiatives using a qualitative case study approach. Following Pierson (1993) we capture the resource/incentive and interpretive effects of prior policies on three groups of actors: government elites, interests, and mass publics. Data are drawn from academic and policy literature, and key informant interviews. The findings suggest that psychiatric hospital policy produced important policy legacies which were reinforced by the establishment of Canadian medicare. These legacies explain the traditional difficulty in achieving mental health reform, but are less helpful in explaining recent promising developments that support community-based care. Current reform of the Ontario health system presents an opportunity to overcome several of these legacies. Analysis of policy legacies in other countries which had an asylum tradition may help to explain the similarities and differences in their subsequent paths of mental health reform.