This article considers two key issues in health economics regarding the question of equity. First, why have health economists not resolved better the issue of what are equity and access? Second, the paper draws attention to the relative lack of analyses of equity concerns outside of health care. The question of whose values should prevail in equity is also addressed. On the first issue, there is an obsession with quantification in economics with the result that in analysing equity, in practice often ‘use’ has been substituted for ‘access’. The problem of defining access has thereby been by-passed. This has taken the pressure off trying to research access per se. Second, what is meant by equity and access are in part culturally determined. The continued efforts of health economists to treat equity as some universal construct are misplaced. The lack of effort on the part of health economists to look at equity more broadly than health care equity is concerning. Certainly, to be pursued in practice, equity in both health and health care need a shift in resources, which will be opposed by those who exercise power over decision making in health care and in society more generally. Currently health economists’ analyses say all too little about power and property rights in health care and in society. It is argued that the relevant citizens or communities which a health service serves are best placed to judge the access barriers they face and their relative heights. A useful definition of equity established by a citizens’ jury in Perth, Australia is used to exemplify this point. It is concluded that the often all too simplistic equity goals adopted in health economics (and sometimes public health discourse) need to be challenged. For health economists, there is a need for more of us to get involved in the issues around inequalities, class and power and the impact of these on health.

While ensuring adequate access to care is a central concern in countries with universal health care coverage, unmet health care needs remain prevalent. However, subjective unmet health care needs (SUN) can arise from features of a health care system (system reasons) or from health care users' choices or constraints (personal reasons). Furthermore, investigating the evolution of SUN within a health care system has rarely been carried out. We investigate whether health needs, predisposing factors and enabling factors differentially affect SUN for system reasons and SUN for personal reasons, and whether these influences are stable over time, using representative data from the Canadian Community Health Surveys from 2001 to 2014. While SUN slightly decreased overall during our period of observation, the share of SUN for system reasons increased. Some key determinants appear to consistently increase SUN reporting over all our observation periods, in particular being a woman, younger, in poorer health or not having a regular doctor. The distinction between personal and system reasons is important to better understand individual experiences. Notably, women report more SUN for system reasons and less for personal reasons, and reporting system reasons increases with age. Given this stability over time, our results may inform health policymakers on which subpopulations to target to ensure access to health care is universal.

Previous studies have described various associations between tax policy and health. Here we propose a unifying conceptual framework of ‘Five R’s’ to stimulate awareness about the importance of tax to health improvement. First, tax can improve representation and democratic accountability, and help make governments more responsive to the needs of its citizens. Second, tax can create a revenue stream for a universal pool of public finance for health care and other public services. Third, progressive taxation when combined with appropriate public spending can help redistribute wealth and income and mitigate social and health inequalities. Fourth, the re-pricing of harmful products (e.g. tobacco, alcohol and unhealthy food) can help reduce their consumption. Fifth, taxation provides a route by which certain harmful industries can be regulated. The paper also discusses the barriers that hinder the full potential for taxation to be used to improve health, including: weak tax administrations, large ‘shadow economies’, international trade liberalisation, tax avoidance, transfer pricing by transnational corporations and banking secrecy. We suggest that a greater awareness of the manifold associations between tax and health will encourage health practitioners to actively promote fairer and better taxation, thereby helping to improve health and reduce health inequalities.

Social capital appears to be an important determinant of health production and health utilization and demand. However, there is limited evidence on the mechanisms underlying this relationship. In this article we draw on the evidence and insights reported in this special issue along with findings from the economic and other social science literature to develop a discussion on the explanations of the likely (behavioural) mechanisms that underpin the connection between social capital and health. An important and under-explored influence mediating the relationship between social capital and health (behaviour) lies in the ‘social formation of health preferences and constraints’ individuals face in determining their life-styles and in using health care. In particular, we point to the interdependence in how individuals in the first place perceive and also respond to common health risks and the role of cultural transmission and social identity as conveyors of this process. We argue that an emerging body of evidence suggesting that interdependent preferences influence health calls for further re-formulation of traditional demand for and production of health models. Additionally, methodological problems are highlighted and possible ways forward suggested.

The period from 1996 to 2008 was one of rapid economic and social change in Ireland, with one of the most significant changes being the transition from a situation of net emigration to one of substantial net immigration. Although research on the impact of immigration on Irish society, as well as the labour market characteristics and experiences of immigrants in Ireland has increased in recent years, comparatively little is known about the health status of immigrants to Ireland. An extensive international literature has documented a ‘healthy immigrant’ effect for large immigrant-receiving countries such as the United States, Canada and Australia, whereby the health status of immigrants is better than comparable native-born individuals. There is also evidence to suggest that immigrants’ health status deteriorates with time spent in the host country. However, the Irish immigration experience differs considerably from that of countries that have been the focus of research on the ‘healthy immigrant’ effect. Using microdata from a nationally representative survey of the population in 2007, this paper finds only limited evidence in favour of a ‘healthy immigrant’ effect for Ireland, although the distinctive features of the Irish immigrant population, and the nature of the data available, may partly explain the results.

After a long period of neglect, the issue of human resources for health (HRH) has recently emerged as a core component on the international health agenda, with policy makers increasingly eager to learn from experience elsewhere. This article investigates systematically the opportunities and challenges associated with the use of cross-national comparisons of HRH policies and practices. It reviews the evidence in favour of using international comparative studies on HRH, discusses emerging opportunities for developing a cross-national research agenda to guide HRH policies in Europe, and highlights obstacles which may hinder the implementation of comparative studies on HRH. While demonstrating many opportunities offered by the comparative approach to improve understanding of human resources processes in the health sector, this article also emphasizes the dangers of simplistic pleas for the transfer of human resource policies without taking into account the context-specific factors and the generative capacity of the social actors in the design and implementation of policy changes.

Since 2001, implementation of a New Zealand’s Primary Health Care Strategy (the Strategy) has led to an increase in the proportion of primary health care services which are publicly funded, the development of 82 primary health organisations (PHOs) to oversee primary health care services and universal public capitation funding of PHOs. This approach has replaced the previous system of fee-for service targeted public subsidies paid to individual general practitioners (GPs). Patient copayments, although at a reduced level but still set by individual practitioners, have remained a core feature of the system.

This paper focuses on the implementation and impact of key policy changes over the first five years of the Strategy. Although patient copayments have fallen and consultation rates have increased, the new funding and payment system has raised a number of unresolved issues – whether to retain the new universal funding system or revert to the former targeted approach; how to achieve the potential gains from capitation when GPs continue to receive their income from a variety of sources and in a variety of different ways; and how to manage the potential for ‘cream skimming’.

Recent improvements in access may, in time, improve health status and reduce inequalities in health, but there is no guarantee that a universal system will necessarily improve average health or reduce inequalities. Much depends on the services being delivered and the populations that are benefiting most – something New Zealand needs better evidence on before determining future policy directions in primary health care.

The Finnish health care system is widely respected for its pilot role in creating primary-care-led health systems. In the early 1990s, however, a severe economic downturn in Finland reduced public funding and weakened the Finnish system’s deeply decentralized model of health care administration. Recent Bank of Finland projections forecasting several decades of slow economic growth, combined with the impact of an aging population, appear to make major reform of the existing public system inevitable. Over the last several years, political attention has focused mostly on administrative consolidation inside the public sector, particularly integration of health and social services. Current proposals call for a reformed health sector governance structure based on a new meso-level configuration of public administration. In addition, Finland’s national government has proposed replacing the current multi-channel public funding structure (which includes health insurance subsidies for occupational health services) with a single-channel public funding structure. This commentary examines several key issues involved in reforming the delivery structure of the Finnish health care system. It also explores possible alternative strategies to reform current funding arrangements. The article concludes with a brief discussion of implications from this Finnish experience for the wider health reform debate.

Most developed democracies have faced the challenge of priority setting in health care by setting up specialized agencies to take decisions on which medical services to include in public health baskets. Under the influence of Daniels and Sabin’s seminal work on the topic, agencies increasingly aim to fulfil criteria of procedural justice, such as accountability and transparency. We assume, however, that the institutional design of agencies also and necessarily reflects substantial value judgments on the respective weight of distributive principles such as efficiency, need and equality. The public acceptance of prioritization decisions, and eventually of the health care system at large, will ultimately depend not only on considerations of procedural fairness, but also on the congruence between a society’s values and its institutions. We study social values, institutions and decisions in three countries (France, Germany and the United Kingdom) in order to assess such congruence and formulate expectations on its effects.

Over recent years, nudge policies have become increasingly popular (if somewhat confused) internationally. This article attempts to clarify what a nudge entails, and critically summarises some of the nudge policies that have been proposed to motivate weight loss in the United Kingdom and the United States. Despite the fact that most of the evidence on nudge-related policy has so far been produced in the United States, and that the leading nudge champions are American, the United Kingdom, at least with respect to considering policy interventions of this kind at the national level, appears to be relatively advanced. That said, nudge interventions remain of marginal practical import everywhere, and are never going to solve completely the obesity problem. Nonetheless, even a marginal effect may extend and improve many lives, a result that would satisfy most behavioural economists.

Belgium is often seen as an outlier in the international experience with the coronavirus disease 2019. We summarize the unfolding of the pandemic in Belgium from February to December 2020, discuss the countermeasures that were implemented and provide some explanations why the numbers indicate a stronger pandemic in Belgium than in its neighbouring countries. To some extent, the seemingly poor performance of Belgium is a measurement artefact. Yet, there were indeed particular factors in Belgium that unnecessarily increased the toll of the pandemic. In the first wave insufficient priority was given to protect care homes. The second wave was larger than necessary due to a failure to timely implement restrictive measures. The latter can, at least partly, be explained by a unique political situation: a temporary, minority government in the middle of a major crisis.

During 2008, some forms of patient co-payments – in particular, patients paying privately for additional medicines as part of an episode of care in the National Health Service – became controversial in political and policy terms in the UK. In response, the UK Government published a report, the Richards’ Review, examining the issues. Richards offered a particular policy solution, but also touched on fundamental principles of social value. Using the methods of normative policy analysis, we seek to understand these principles of social value, accepting the Richards’ framework according to which the relevant arguments can be grouped under the broad headings of equity and autonomy. None of the arguments on either side are decisive, and, in part, the policy decision turns on uncertain empirical conjectures.

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.

Currently, reimbursement decisions based on health technology assessments (HTA) in the Netherlands mostly concern outpatient pharmaceuticals. The Dutch government aspires to broaden the systematic application of full HTA towards other types of health care in order to optimise the content of the basic benefit package. This paper identifies important challenges for broadening the scope of full HTA to other types of health care. Based on a description of the Dutch reimbursement decision-making process, five important characteristics of outpatient pharmaceuticals were identified, which are all relevant to the successful application of HTA: (i) closed reimbursement system, (ii) absence of alternative policy measures, (iii) existence of marketing authorisation, (iv) identifiable and accountable counterparty, and (v) product characteristics. For a selection of other types of health care, which may be subject to HTA more frequently in the future, deviations from these characteristics of outpatient pharmaceuticals are discussed. The implications of such deviations for performing HTA and the decision-making process are highlighted. It is concluded that broadening the application of HTA will require policy makers to meet both important policy-related and methodological challenges. These challenges differ per health care domain, which may inform policy makers which expansions of the current use of HTA are most feasible.

The proportion of the population treated for major medical conditions, including diabetes, cancer and mental illness, increased rapidly during the 1990s. We document the magnitude of these increases and use a model of prevalence to identify three potential causes: increased clinical incidence of disease, longer survival times among persons with chronic illnesses and increased detection. We present a series of analyses to evaluate the contribution of each factor. We find that increases in obesity explain a large proportion of the increase in treatment rates for conditions closely linked to obesity (e.g. diabetes). We provide some evidence that increases in treated prevalence unexplained by changes in the underlying clinical incidence of disease are driven by increased detection and treatment of patients with ‘subclinical’ illness.

Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used ‘sticks’ and ‘sermons’ to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.

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.

Money is the default way in which intangible losses, such as pain and suffering, are currently valued and compensated in law courts. Economists have suggested that subjective well-being regressions can be used to guide compensation payouts for psychological distress following traumatic life events. We bring together studies from law, economic, psychology and medical journals to show that alleviating psychological distress through psychological therapy could be at least 32 times more cost effective than financial compensation. This result is not only important for law courts but has important implications for public health. Mental health is deteriorating across the world – improvements to mental health care might be a more efficient way to increase the health and happiness of our nations than pure income growth.

The European Union's (EU) 2011 Directive on cross-border patient mobility codifies the right of any EU citizen to travel abroad for treatment and be reimbursed on the same terms as they would be at home. Governments hoped it would end the string of court cases that had reshaped EU health law but this article argues that it is likely to produce yet more judicial challenges. Patient mobility is an attractive idea with unclear definitions and divergent implementation. In many cases, providers, insurers and governments will not communicate and leave the patient with a bill – almost daring the patient to sue, and the courts to make more policy. Governments should try to prevent this by investing in coordination and alternative redress for patients who might otherwise sue.