The paper analyses the achievements and problems stemming from Nye Bevan’s model of a tax funded national health care system, on the assumption that only so could equity be achieved. The evidence shows that indeed the National Health Service (NHS) scores highly on equity, so vindicating Bevan’s vision. The price paid is that fiscal crises are the norm for the NHS, with ever more centralisation, intensive regulation and performance management. Successive reorganisations represent attempts to square the circle – to combine the strengths of Bevan’s model and those of a less hierarchic system – but have so far failed to deliver and can be expected to continue.

Our research investigates the effects of the 2005 universal health insurance program for children under age 6 in Vietnam on health care utilization, household out-of-pocket (OOP) spending and self-reported health outcomes using data from the Vietnam Household Living Standard Survey in 2002–2004–2006–2008. We use difference-in-differences to compare children eligible for the program to older children who are ineligible for the program. Results indicate that the program increased insurance coverage by 250% for children age 0–5 relative to the pre-policy period. We found large increases in both outpatient visits and hospital admissions. Health insurance availability also increased outpatient visits at both public and private facilities, suggesting that public and private health care services are complements. Although health insurance was associated with a decrease in inpatient OOP spending for children aged 3–5, it did not reduce outpatient OOP spending for children in general. Health insurance was associated with modest improvements in self-reported health outcomes. Our research suggests that expanded access to insurance among Vietnamese children improved access to care and health outcomes, though it did not necessarily reduce OOP spending.

There is a growing recognition of the importance of evidence to support allocative policy decisions in health care. This study is based on interviews with politicians in four regional health authorities in Sweden. Drawing on theories of strategic use of knowledge, the article analyses how politicians perceive and make use of expert knowledge represented by the National Guidelines, embracing both a scientific and a political rationale. As health care is an organisation with a dual basis for legitimacy – at the same time a political and an action organisation – it affects knowledge use. We investigate how the context of health care priority setting influences the conditions for knowledge use among regional politicians. Our findings illustrate the dilemma of political decision-makers and how they prefer to use expert knowledge. The politicians use this policy instrument in a legitimising fashion, as it will fit into the current political debate on more equal care. As an instrument for resource allocation the politicians noted that ‘facts’ per se could not provide them with a sufficient basis for legitimising their governing of health care. The dualistic organisational context makes knowledge important as a political weapon in negotiations with the medical profession.

Amidst the NHS’s (National Health Service) success lies its major weakness, although one that Klein overlooks in his reflections on the NHS as it approaches 70. The focus on, and investment in, curing ill-health has been at the expense of attending to the public’s overall health and well-being. This preoccupation poses a greater threat to the NHS’s future than privatisation. Despite the weakness having been diagnosed decades ago, redressing the imbalance has proved stubbornly hard to achieve. Rhetoric has not been translated into reality. Yet, we may be on the cusp of a tipping point where in order to ensure a sustainable NHS, and one that is capable of meeting the 21st century challenges facing it, there is a renewed and overdue interest in promoting health and well-being in communities. But for this to succeed, the NHS will need to embrace its bete noire, local government.

Previous evidence suggests that members of the public value life saving services differently when they are for patients with a pre-existing permanent disability and when they are for patients who become disabled at the onset of treatment – for example, as a result of treatment that is not entirely effective. However, the valuation of services in these two cases has also been found to differ with the order in which they are presented in a population survey. This casts doubt upon the validity of the results and leaves unresolved the nature of the public’s true preferences. The study reported here had three main objectives: (i) to determine the considered, underlying preferences of a sample of the Australian public with respect to the treatment of the permanently disabled and chronically ill, (ii) to gain insight into the reasons for respondent’s distributive preferences and (iii) to eliminate or significantly reduce the order effect. Eight semi-structured, small-group discussions were held with 66 members of the public in Victoria, Australia. Order effects were effectively eliminated. The study found substantial support among participants for the equal treatment of the permanently disabled and chronically ill regardless of when the problem commenced.

For almost a century, the Netherlands was marked by a large market for voluntary private health insurance alongside state-regulated social health insurance. Throughout this period, private health insurers tried to safeguard their position within an expanding welfare state. From an institutional logics perspective, we analyze how private health insurers tried to reconcile the tension between a competitive insurance market pressuring for selective underwriting and actuarially fair premiums (the insurance logic), and an upcoming welfare state pressuring for universal access and socially fair premiums (the welfare state logic). Based on primary sources and the extant historiography, we distinguish six periods in which the balance between both logics changed significantly. We identify various strategies employed by private insurers to reconcile the competing logics. Some of these were temporarily successful, but required measures that were incompatible with the idea of free entrepreneurship and consumer choice. We conclude that universal access can only be achieved in a competitive individual private health insurance market if this market is effectively regulated and mandatory cross-subsidies are effectively enforced. The Dutch case demonstrates that achieving universal access in a competitive private health insurance market is institutionally complex and requires broad political and societal support.

This paper explores what motivates improved health care performance. Previously, many have thought that performance would either improve via choice and competition or by relying on trust and altruism. But neither assumption is supported by available evidence. So instead we explore a third approach of reciprocal altruism with sanctions for unacceptably poor performance and rewards for high performance. These rewards and sanctions, however, are not monetary, but in the form of reputational effects through public reporting of benchmarking of performance. Drawing on natural experiments in Italy and the United Kingdom, we illustrate how public benchmarking can improve poor performance at the national level through ‘naming and shaming’ and enhance good performance at the sub-national level through ‘competitive benchmarking’ and peer learning. Ethnographic research in Zambia also showed how reputations count. Policy-makers could use these effects in different ways to improve public services.

The existence of different forms of out-of-pocket payments (OOPs) for pharmaceuticals across the globe provokes the question whether they can achieve more negative or positive consequences. A systematic literature review was conducted to assess the association between drug cost sharing and health care services utilization, health care costs as well as health outcomes. Studies published in The Cochrane Library, PubMed, Embase were searched with such keywords as: drug, pharmaceutical, cost sharing, out of pocket, co-payments paired with the following: impact, health outcomes, health care costs and utilization. The final review included 18 articles. A total of 11 publications reported the association between drug cost sharing and health care utilization patterns, of which nine found a statistically significant direct relationship. In all 10 publications concerned the association between drug copayments and health care costs. Majority were limited to the impact on the drug budget. Seven studies looked into the link between drug cost sharing and health outcomes, of which five reported statistically significant inverse relationship. There is some evidence for the association between drug copayments, health outcomes and health care services consumption. The optimal system of OOPs’ payments for pharmaceuticals needs to prevent drugs’ overconsumption and mitigate the risks of excessive cost sharing’s burden.

Health technology assessment (HTA) is not simply a mechanistic technical exercise as it takes place within a specific institutional context. Yet, we know little about how this context influences the operation of HTA and its ability to influence policy and practice. We seek to demonstrate the importance of considering institutional context, using a case study of Hungary, a country that has pioneered HTA in Central and Eastern Europe. We conducted 26 in-depth, semi-structured interviews with public- and private-sector stakeholders. We found that while the HTA Department, the Hungarian HTA organisation, fulfilled its formal role envisaged in the legislation, its potential for supporting evidence-based decision-making was not fully realised given the low levels of transparency and stakeholder engagement. Further, the Department’s practical influence throughout the reimbursement process was perceived as being constrained by the payer and policy-makers, as well as its own limited organisational capacity. There was also scepticism as to whether the current operational form of the HTA process delivered ‘good value for money’. Nevertheless, it still had a positive impact on the development of a broader institutional HTA infrastructure in Hungary. Our findings highlight the importance of considering institutional context in analysing the HTA function within health systems.

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.

There are several advantages of Bevan’s design, such as progressive funding through taxation and equity of access regardless of income, that we must not lose sight of as we celebrate the NHS’s (National Health Service) 70th birthday. However, there remain historical fault-lines dividing health and social care. The challenge is how to preserve equity if a more radical reform were implemented to fully integrate both the funding and delivery of health and social care. Funding from national taxation with defined entitlements could preserve both equity in funding and geographical equity. This does not solve the issue of the pull to the centre, which has been a feature of the NHS throughout its history, according to Klein. This will require a fundamental shift in the use of data. Data must be wrenched from the hands of the regulators and put back in the hands of those who generate them for the purposes of improvement.

The creation of the National Health Service (NHS) marked a radical break with the past, making health care universally available on the basis of need rather than means. The NHS was conceived during wartime emergency and has had to survive further regular crises to reach its 70th year, but it now faces challenges that are unprecedented in scale and there are doubts about its ability to continue in its present form. Resources have not increased with need, and the NHS can no longer function as a comprehensive service during periods of peak demand. Policymakers look for solutions in service rearrangements, new technologies, quality improvement initiatives and alternative funding arrangements; meanwhile, chronic lack of capacity is taking a predictable toll on patient care and staff morale. The NHS has become a formidably resilient institution, but securing its future may take as great a collective effort as the one that created it.

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.

Transparency is recognised to be a key underpinning of the work of health technology assessment (HTA) agencies, yet it has only recently become a subject of systematic inquiry. We contribute to this research field by considering the Polish Agency for Health Technology Assessment (AHTAPol). We situate the AHTAPol in a broader context by comparing it with the National Institute for Health and Care Excellence (NICE) in England. To this end, we analyse all 332 assessment reports, called verification analyses, that the AHTAPol issued from 2012 to 2015, and a stratified sample of 22 Evidence Review Group reports published by NICE in the same period. Overall, by increasingly presenting its key conclusions in assessment reports, the AHTAPol has reached the transparency standards set out by NICE in transparency of HTA outputs. The AHTAPol is more transparent than NICE in certain aspects of the HTA process, such as providing rationales for redacting assessment reports and providing summaries of expert opinions. Nevertheless, it is less transparent in other areas of the HTA process, such as including information on expert conflicts of interest. Our findings have important implications for understanding HTA in Poland and more broadly. We use them to formulate recommendations for policymakers.

The Irish health care system is unusual within Europe in not providing universal, equitable access to either primary or acute hospital care. The majority of the population pays out-of-pocket fees to access primary health care. Due to long waits for public hospital care, many purchase private health insurance, which facilitates faster access to public and private hospital services. The system has been the subject of much criticism and repeated reform attempts. Proposals in 2011 to develop a universal health care system, funded by Universal Health Insurance, were abandoned in 2015 largely due to cost concerns. Despite this experience, there remains strong political support for developing a universal health care system. By applying an historical institutionalist approach, the paper develops an understanding of why Ireland has been a European outlier. The aim of the paper is to identify and discuss issues that may arise in introducing a universal healthcare system to Ireland informed by an understanding of previous unsuccessful reform proposals. Challenges in system design faced by a late-starter country like Ireland, including overcoming stakeholder resistance, achieving clarity in the definition of universality and avoiding barriers to access, may be shared by countries whose universal systems have been compromised in the period of austerity.

One goal of the Affordable Care Act is to increase insurance coverage by improving competition and lowering premiums. To facilitate this goal, the federal government enacted online marketplaces in the 395 rating areas spanning 34 states that chose not to establish their own state-run marketplaces. Few multivariate regression studies analyzing the effects of competition on premiums suffer from endogeneity, due to simultaneity and omitted variable biases. However, United Healthcare’s decision to enter these marketplaces in 2015 provides the researcher with an opportunity to address this endogeneity problem. Exploiting the variation caused by United Healthcare’s entry decision as an instrument for competition, we study the impact of competition on premiums during the first 2 years of these marketplaces. Combining panel data from five different sources and controlling for 12 variables, we find that one more insurer in a rating area leads to a 6.97% reduction in the second-lowest-priced silver plan premium, which is larger than the estimated effects in existing literature. Furthermore, we run a threshold analysis and find that competition’s effects on premiums become statistically insignificant if there are four or more insurers in a rating area. These findings are robust to alternative measures of premiums, inclusion of a non-linear term in the regression models and a county-level analysis.

As the National Health Service (NHS) turns 70, it bears comparison with another universal system celebrating an anniversary this year: Canada’s 50-year-old medicare model. Each system is iconically popular, and each revolves around a profession-state accommodation. Both the popularity and the central axis of each system have been tested by external shocks in the form of periodic fiscal cycles of investment and austerity, and internal stresses generating organizational cycles of centralization and decentralization. In addition, the English NHS has undergone periodic bursts of major policy change, which have arguably moved the system closer to the Canadian single-payer model.

As a growing number of countries implement, or announce plans to introduce, a sugar-sweetened beverage (SSB) tax, this paper explores the public health rationale for such a tax and provides an overview of the international normative and policy instruments supporting the introduction of fiscal measures on sugary drinks. After examining parallels between the legal arguments raised by the food and beverage industry in opposition to SSB taxes and those raised by the tobacco industry in response to tobacco control measures, this paper draws four key lessons that will assist countries to design effective and robust SSB tax measures and counter food and beverage industry opposition: regulatory distinctions in tax coverage should be based on bona fide, evidence-based reasoning; evidence-based measures need to be tailored to a country’s public health objectives as part of a comprehensive strategy to address unhealthy diet consumption; procedural requirements and due process should be observed in the drafting and implementation of the measure; and regulatory space exists within domestic constitutions, laws and international trade and investment agreements recognising the sovereign right of states to regulate in the interests of public health.

Although there is substantial literature on the impact of smoking laws, the number of studies that investigate the impact of such policies on college campuses is sparse. Using a rich data set from various waves of the American College Health Association National College Health Assessment survey for a mid-sized public university in the southern United States, we investigate a possible causal link between a limited smoking policy and smoking behaviours, health and academic outcomes among college students. We employ propensity score matching methods to control for endogeneity of unobservable characteristics. Our results show a significant reduction in the propensity to smoke cigarettes and cigars following the introduction of the policy. Further, we find that the policy has increased academic outcomes; however, it has no significant effect on student health. These findings have important policy implications for schools that are considering instituting comprehensive smoking bans on college.