Health Economics, Policy and Law

Globalization is a key challenge facing health policy-makers. A significant aspect of this is trade in health services. However, little is currently known about how trade in health services will affect the health of populations and national economies. A key determinant of the impact of trade in health services will be the general economic and trade context of the country concerned. One specific aspect of this is the ‘openness’ of a country’s health sector to trade; yet there is little, if anything, currently known about the most appropriate methods to assess openness of the health sector.

The Labour Government elected in 1997 faced similar problems in health care to those faced by the Conservative Government in schools in the early 1990s. And the policies developed for health care in the late 1990s echoed those that had been implemented for schools. This paper considers one of those common policies, namely the creation of new central inspectorates required to visit all organizations over a four-year period: the Office for Standards in Education (OFSTED) to inspect the quality of teaching in schools, and the Commission for Health Improvement (CHI) to review the implementation of the systems and processes of clinical governance in every organization in the National Health Service (NHS). At its creation, CHI was described as an OFSTED for the NHS. This paper compares these two inspectorates; describes origins of policies and institutions; considers their rhetoric and practices; describes the processes the two organizations used and considers their impacts. It argues that structural differences meant that CHI could never have been an OFSTED for the NHS; relational distance is a key aspect of inspection/regulation; and that the key to effective regulation in the case of the NHS was the relational proximity between CHI and the NHS, with the added weight of a strong performance management regime.

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.

Many advocates of policy to implement the findings of research on the multiple determinants of health accord scant attention to the determinants of health policy in democratic countries. The principle determinants of the allocation of scarce resources to improving health include: the priorities of voters; the diffusion of responsibility for improving health; the absence of evidence about matters of consequence to policy makers; the arraying of some evidence in ways that frustrate policy making; resistance to addressing determinants other than clinical services and traditional public health practices among many professionals in these fields, as well as by industries that supply the health sector; and the special political influence of persons who suffer serious chronic disease and of members of their families.

What Works in Tackling Health Inequalities? Pathways, Policies and Practice through the Lifecourse S. Asthana and J. Halliday Bristol: Policy, Press, 2006

Health Action Zones: Partnerships for Health Equity M. Barnes, L. Bauld, M. Benzeval, K. Judge, M. Mackenzie, H. Sullivan Abingdon: Routledge, 2005

Health Inequality: An Introduction to Theories, Concepts and Methods M. Bartley Cambridge: Polity, 2004

Status Syndrome: How your Social Standing Directly Affects your Health and Life Expectancy M. Marmot London: Bloomsbury, 2004

These four texts on health inequalities are all very different books written by leading commentators with different academic backgrounds. This review will concentrate on the policy perspective that may be of most interest to many readers of this journal. It is also arguably the Achilles heel of the health inequalities literature. According to policy makers, much current research on health inequalities was of little use to policy making, and public health researchers have been criticized for political naivety, for lacking understanding of how policy is made, and for having unrealistic expectations (Petticrew et al., 2004: 815–816). Similarly, Klein (2003) points to the problems of ‘making policy in a fog’. The first two texts under review focus on policy and are written by policy analysts.