In 2022, the European Health Policy Group (EHPG) commemorated its 21st anniversary, hosted by the London School of Economics and Political Science (LSE). While this coincidental timing may suggest a symbolic coming of age for the group, it was not planned as such. The intended celebration had been originally scheduled for the previous year but was ultimately cancelled due to the pandemic, or rather, transformed into an online event, much like numerous other gatherings affected by the global health crisis.
The EHPG is a collegial network that aims to stimulate international collaboration and cross-country learning for improving health policy. The network brings together a multidisciplinary group of researchers (e.g. in political science, economics, health service research, medicine) and policy advisers from Europe, in the largest sense, including North America, claiming that Europe is a spirit rather than a concept defined by the geographical boundaries. In the Spring of 2022, participants engaged in vibrant discussions regarding the pandemic and its lessons, as well as the lasting impact on national health systems. The pandemic served as a catalyst, not only exposing inherent weaknesses within these systems, as is often the case during any crisis (Ewert et al., Reference Ewert, Wallenburg, Winblad and Bal2023), but also exacerbating long-standing challenges such as those posed by an ageing population, the ever-growing workforce shortages and slow progress in digitisation policies and frameworks necessary to increase the evidence for utilising digital health technologies in the ‘right’ manner.
In this special issue of Health Economic, Policy and Law (HEPL), which marks the final issue under the tenure of Adam Oliver as the Editor-in-Chief, one of the esteemed founding fathers of both HEPL and the EHPG, we present the papers that were deliberated during the London anniversary meeting. Through these papers, the EHPG explores current and emerging themes in the field of health policy, economics, and law that require the attention of the health policy community.
The papers highlight the difficulties in shifting towards integrated care to cater to a larger share of populations requiring long-term care, the necessity for regulation of data-driven technology in healthcare, the role of science and scientists within health systems, and the evolving roles of key stakeholders such as health insurers and nurses in modern health systems. These themes address crucial questions that serve as a starting point for tackling pressing and complex policy problems. The papers adhere to the traditional aim of the EHPG, which emphasises country comparisons to foster cross-national policy learning.
Comparative research, as expounded by Marmor et al. (Reference Marmor, Freeman, Okma, Marmor, Freeman and Okma2009), presents both promise and challenges. Policy makers often commission cross-national studies to facilitate learning from successful or ‘best practices’ implemented in other countries. However, due to substantial and subtle institutional differences between systems, policies often manifest in different ways. Country comparison, according to Marmor et al. (Reference Marmor, Freeman, Okma, Marmor, Freeman and Okma2009), offers policy wisdom and valuable insights into national debates but usually do not provide clear-cut solutions to policy challenges at hand. Nevertheless, it can offer understanding of broader transitions in healthcare, including how care is regulated, financed, and delivered during times marked by demographic transition, workforce shortage, and technological advancements. These transitions increasingly transcend national borders, with technological companies and healthcare professionals operating across multiple countries. This renders policy learning a collective endeavour, as insights gained from different contexts can inform policy development and adaptation.
The papers assembled in this special issue provide insights into how different countries experience and address contemporary challenges, as well as how similar policy strategies manifest differently within distinct institutional settings. The first two papers commence by examining the classic divide between Beveridge and Bismarck healthcare systems to explore how institutional legacies influence their capacity to adapt to changing circumstances.
In a study on integrated care, Apostolos Tsiachristas, Karsten Vrangbæk, Pamela Gongora, and Søren Rud Kristensen compare the transition to integrated care in England and Denmark – both Beveridge systems characterised by tax-funded National Health Systems with free access at point of delivery. They show how different policy pathways have led to similar-looking solutions to the pressing need for integrated care stemming from the growing number of individuals with chronic conditions, further exacerbated by workforce shortages. Integrated care increasingly encompasses social care, also mentioned in Erik Schut and colleagues' contribution on health system transitions. Both Denmark and England introduced choice and competition as part of their reform journey but have since shifted towards government-led cross-sectoral governance structures in pursue of better integrated care. In both countries, national and local governments intervene in specific ways. In England, the focus is on new decentral entities, while in Demark, the national government plays an increasing role in developing care standards, including those related to the use of data and data technology, which are considered integral prerequisites for integrated care – something also emphasised in the contribution of Srivastava et al., on the use of real-world data (RWD) and evidence in health care.
The differences in the roles of governments and health insurers in health governance are also explored in the paper by Erik Schut, Zeynep Or, and Cornelia Henschke. They compare France, Germany, and the Netherlands, three Bismarckian healthcare systems where there is mandatory social health insurance. Building on Cutler's (Reference Cutler2002) work, which identified three waves of common reforms in social health insurance systems for achieving universal access (1950–1970s), cost containment (1980–1990s), and improving efficiency and choice (mid-1990s) – the authors trace the evolution of national systems in 2000s in the three countries. They discuss how each country has developed its own distinctive model and underline the differences in the roles played by insurers in controlling quality and price for improving system efficiency. In all three countries, the traditional focus of SHI carriers has been on negotiating prices with care providers despite major differences in the role and structuring of competition between insurers (none in France, more in the Netherlands). However, this is changing with pressing challenges posed by demographic changes and workforce shortages, which requires more proactive and new governance arrangements. Consequently, health insurers in all three countries shift their attention to improving integrated care provision and strengthening care in the community.
Carolyn Tuohy, Gwyn Bevan, and Adelsteinn Brown delve into the role of government in health policy, specifically focussing on the role of science in informing public policy during the Covid-19 crisis. They compare England (UK) to Ontario (Canada), two Westminster systems with different institutional arrangements regarding science advice. By examining the adoption of non-pharmaceutical interventions (especially lockdown measures) and the procuring of vaccines, the authors explore the varying degrees of independence and policy impact that science advice had on national policies. They also assess the extent to which scientists were able to provide ‘serviceable truths’ (as described by Jasanoff, Reference Jasanoff2015) to guide policy-making. The paper highlights the trade-offs between established science-policy arrangement in England, which enabled close contact but offered limited room for independent advice and publication separate from the politicians, and purpose-built sector-spanning bodies in Ontario, which lacked institutional embeddedness but had immediate impact. These findings raise questions about how to establish effective institutional arrangements for science advice that can strengthen the resilience of healthcare in the face of ongoing and enduring (‘perma’) crises, particularly in light of climate change and its consequences.
The last two papers in this special issue direct our attention to the critical matters of regulating digital health technologies in healthcare and addressing workforce shortages, two topics often discussed in conjunction, as technology is seen as a potential solution for growing workforce issues. The belief is that technology can assume (at least partly) the roles of healthcare professionals, allowing patients to receive care in their homes instead of hospitals or nursing homes, thereby enhancing efficiency and reduce public expenditure. While technology holds great promise from a policy perspective, there are also increasing concerns and uncertainties regarding its regulation and the protection of privacy.
Divya Srivastava, Cornelia Henschke, Lotta Virtanen, Eno-Martin Lotman, Rocco Friebel, Vittoria Ardito, and Francesco Petracca conducted a Delphi study to shed light on how real-world data (RWD) and real-world evidence (RWE) use in healthcare are governed in five different countries. They explore how a system of post-market regulation should be structured by developing guiding principles to embed RWD and RWE systematically for digital health technologies to inform decision-making. The authors introduce the concept of ‘digital health technology vigilance’ to encompass a comprehensive approach to the entire product lifecycle of technologies in healthcare.
Iris Wallenburg, Rocco Friebel, Laia Maynou Pujolras, Ulrika Winblad, and Roland Bal discuss the issue of workforce shortages in England, Spain, Sweden, and the Netherlands, with a particular focus on the nursing profession. Through comparative analysis, they uncover similar challenges and misinterpretations among policymakers. They suggest shifting the focus from workforce policies to the realm of politics, by supporting a scenario where care workers have effective representation, voice, and influence within healthcare systems. The current lack of autonomy and a dearth of both public and policy recognition, they argue, contribute to the marginalisation of care workers in contemporary healthcare systems.
In the closing paper, Jan Kees Helderman reflects on 21 years of travelling through health policy issues, visiting the countries of researchers (‘co-travellers’) that make up the EHPG. Standing on the roof top of the LSE, he oversees the health policy and research landscape and their mutual needs.
Collectively, the papers featured in this special issue shed light on contemporary and emerging challenges faced by our healthcare systems. They reveal the interconnected nature of those challenges and emphasise the importance of addressing them with the involvement of policy makers and scientists. These insights highlight the maturity of the EHPG and its role in strengthening the link between research and policy that facilitates collective learning, which is crucial for making healthcare systems more sustainable in the years to come.
