Generating evidence to guide investments in new service delivery platforms remains a major challenge. We applied a linear constrained optimisation model, ex ante, to estimate the potential health impact and trade-offs of integrating community-based providers (CBPs) into Uganda’s essential healthcare package. Specifically, we compared a facility-only delivery strategy with an integrated strategy that included Village Health Teams (VHTs) and medicine retailers. Outcomes included potential expansion of the optimal service package, additional net disability-adjusted life years averted, average cost-effectiveness, and maximum cost-effective investment per provider. Integrating CBPs could avert an additional 4.7 million net disability-adjusted life years and expand Uganda’s optimal health package by 25 interventions compared to the facility-only strategy. VHTs achieved health gains at $42 per net DALY averted and remained cost-effective at an investment of up to $3,423 per provider; medicine retailers remained cost-effective up to $19,792 per provider. Although current policies restrict CBP utilisation, results indicate substantial potential for health system strengthening. Constrained optimisation provides a systematic approach to quantify the value of new delivery platforms. Our findings provide an evidence-based roadmap for integrating CBPs in Uganda, while the adaptable model itself serves as a replicable tool to inform similar analyses in other settings.

Inadequate or ineffective health financing poses a significant challenge to the Government of Lao People’s Democratic Republic’s goal of achieving universal health coverage by 2030. Here we explore possible application in the Lao context of the Center for Global Development’s New Compact approach, including locally-led evidence-informed prioritisation, domestic financing and consolidated supplementary aid. Using WHO’s political economy analysis guide we identify opportunities and barriers and propose a road map towards implementation of the New Compact. This includes firstly, increasing local capacity and systems to generate and use evidence in policy and resource allocation decisions, starting with specific use cases related to the Essential Services Health Package and vaccines portfolio. Secondly, shifting available domestic resources to highest priority services, including at the primary health care level, based on deeper understanding of existing funding and where efficiency, cost-effectiveness and equity can be optimised. Thirdly, improving government and donor coordination aligned to national priorities and gradually increasing funds pooling as feasible.

The COVID-19 pandemic unfolded alongside an unprecedented ‘infodemic’ that reshaped public engagement with science, health, and authority. This study examines how online infodemics translated into collective resistance and influenced population health through political mobilisation. Using structural equation models across six European countries, I conceptualise resistance as a latent construct – captured by residential mobility and protests opposing vaccines, lockdowns, and public health measures linked to populist radical right (PRR) movements – acting as a behavioural bridge between digital information environments and epidemic outcomes. The findings reveal a robust infodemic–resistance–epidemic pathway: greater exposure to infodemic content consistently predicts stronger opposition to non-pharmaceutical interventions (NPIs) and vaccination. This effect is strongest in Germany and Italy, where PRR networks amplified narratives of ‘elite overreach’ and ‘freedom under threat’, transforming online discontent into organised mobilisation. In other countries, resistance appears weaker and more pandemic-specific. By integrating informational, political, and epidemiological processes, the analysis shows how epidemics can evolve into politicised collective behaviour that undermines compliance and sustains transmission. The results highlight populist mobilisation as a key amplifier of epidemic risk and suggest that effective responses must rebuild trust, depoliticise health communication, and address structural sources of grievance.

The growing involvement of private health insurers within universal health systems has intensified debate over their effects on access, equity, and long-term system sustainability. This paper examines the role of private insurers in the United Kingdom (UK) and South Africa through a case study of the Discovery Group, operating across both settings. We explore how private sector engagement shapes health financing, workforce dynamics, service delivery, digital infrastructure, and governance. Our analysis reveals that the impact of private health insurance on universal health systems is fundamentally context-dependent, mediated by institutional frameworks, regulatory environments, and the stage of universal coverage development. We find that private insurers can contribute meaningfully to digital health innovation and behavioural health interventions. However, expansion also introduces significant risks concerning workforce distribution, financing sustainability, and equity of access. These dynamics manifest differently across contexts. In the UK’s mature universal system, private insurance plays a supplementary role offering expedited access to care for members. In South Africa’s transitional dual system, private insurers more fundamentally shape whether quality care is accessible at all. As health systems evolve, the central challenge lies in developing governance frameworks that enable beneficial private sector contributions while safeguarding equitable access and national health system priorities.

Numerous consumer protection regulations (e.g., No Surprises Act, Transparency in Coverage) have been implemented recently in the United States that could impact private health insurance prices and patient cost-sharing for many health care services. We use a large multi-payer database of health insurance claims for employer-sponsored health plans in the U.S. to describe the trajectory of prices and patient cost-sharing for the services of clinicians that are likely most affected by these regulatory changes: emergency physicians, radiologists, pathologists, and neonatologists. We find that in-network prices and patient cost-sharing generally increased for all four specialties between 2012 and 2022. However, all four specialties experienced periods of decline in out-of-network prices and cost-sharing, with different starting points, and substantial reductions in prices and cost-sharing from 2021 to 2022, particularly for self-funded health plans. Although we cannot isolate the causal impact of any law or regulation, our results suggest that out-of-network prices and cost-sharing decreased when the NSA and TIC were implemented in 2022, especially for the previously less regulated self-funded health plans. Our results imply that patients who previously struggled with the financial burdens of surprise out-of-network medical bills may have benefited significantly from the recent regulatory changes.

This paper examines the relationship between provider market consolidation, setting-of-care (SOC) dynamics, and healthcare costs in the United States. The authors argue that consolidation is not solely a driver of rising unit prices, but also a response to structural pressures, including rising practice costs, stagnant physician reimbursement, and increasing administrative complexity. Drawing on recent empirical analyses, the authors demonstrate that prices vary substantially by SOC, with hospital outpatient departments representing the highest-cost settings. They further show that physician affiliation models are associated with distinct patterns of SOC utilisation. These findings suggest that the relationship between consolidation and cost is not uniform and depends on underlying organisational incentives. The authors contend that current policy discourse around private capital lacks sufficient nuance and risks obscuring more fundamental drivers of cost growth, particularly reimbursement design. They call for a more balanced dialogue and additional research to better understand how consolidation, payment policy, and SOC decision-making interact, concluding that policymakers should prioritise incentives that support clinically appropriate care in lower-cost settings.

This paper contributes to this special issue by exploring the act of capitulation to populist authoritarianism, focusing on American universities under Donald Trump’s second administration. Despite threats to funding and autonomy, especially around health-related issues, many universities capitulated. Yet, while universities might be seen as especially vulnerable due to their dependence on federal funds and international students, we show that actors with far greater power exhibited similar behaviour. Elements of the legal profession enabled authoritarian legalism, while corporations, once defenders of democratic norms, largely retreated into silence or complicity. Drawing on contemporary and historical examples, we situate these responses within broader patterns of democratic backsliding. Institutions are shown to be vulnerable to legal manipulation, financial coercion, and ideological alignment. Yet, resistance persists. Some universities have fought back through litigation, and judges have blocked unconstitutional orders despite personal risk. The paper reframes institutions not as passive structures but as active agents that can either resist or enable authoritarianism. It argues that democratic commitment is not inherent but must be cultivated and defended. Ultimately, democracy requires ongoing engagement, ethical leadership, and a willingness to bear short-term costs for long-term preservation.

Strong health system governance requires effective stewardship of private actors operating within health systems and ensuring that their activities align with a government’s strategic health goals. Financialisation, defined as the expanding role of financial actors, instruments, and ideas, has been identified as a potential opportunity, but also challenge to health systems and their governance. There is a need to comprehensively understand how financialisation impacts both health systems and their governance. We initiated a critical interpretative synthesis of literature theorising financialisation of health systems or health system governance. A search was conducted to identify English-language, peer-reviewed and grey articles that (1) contains definitions or conceptual frameworks of financialisation; and (2) relates this concept to health systems or health-system governance. We found that articles defined financialisation as a transformative process characterised by the advent of private investors and financial instruments within health systems. We identified several emergent themes in the literature, such as the role of profits and competition in financialised health systems. Finally, most articles addressed potential challenges that financialisation raises for health system governance, especially accountability and transparency challenges. We conclude by considering how future research might address the remaining gaps within the literature.

The role of different forms of inequality in Populist Radical Right (PRR) voting, such as income and health inequalities, is not examined consistently. Therefore we conducted a scoping review aiming to examine whether and why income and health inequalities are associated with PRR voting in Europe. We systematically searched Web of Science, Scopus and ScienceDirect for publications between 2015 and 2024. Eleven studies were ultimately included in our review. Data were extracted and analysed qualitatively. We identified seven studies that support an association between income inequality in PRR voting, while two studies did not find evidence for this relationship. Although no studies examined the role of health inequalities, we found two studies that suggest a role for welfare policies and life dissatisfaction. The overall results offer a more comprehensive understanding of how income inequality is related to PRR voting, highlighting perceived risks of economic, social or cultural loss. Our findings tie theories on social hierarchies to theories on PRR voting. While social hierarchies can lead to health problems related to anxiety and stress, more research is needed to analyse whether and how pre-existing health inequalities contribute to the rise of social hierarchies, institutional distrust and PRR voting.

Health Technology Assessment (HTA) is an essential tool for transparent decision-making and prioritisation of resources routinely used in many high-income countries. The use of HTA in resource allocation is now gaining traction in several Low- and Middle-Income Countries too. India is one such country that has taken critical steps to integrate HTA into its policymaking framework. We explore the potential role of Adaptive (aHTA) as a screening measure and a more flexible approach to optimising the capacity of HTA. Adaptive HTA, as ‘a structured approach to identify and conduct the optimised full HTA analysis’, offers a pragmatic way to balance the need for swift decision-making with methodological rigour. We examined the value aHTA brings to decision-makers based on the Indian experiences in conducting aHTA and further discussed the challenges involved in its methodology and implementation. Institutionalising aHTA is proposed as both a tool for topic prioritisation and optimising the full HTA for timely decision-making, integrated within the broader HTA ecosystem in India. Given the evolving nature of aHTA methods and processes, we propose that there is a need to: standardise aHTA methodologies and develop reference cases which benchmark a set of guiding principles, methodological, and reporting standards.

This paper examines how financial actors enter and reshape healthcare systems, building new, often transnational, social, technical, and financial infrastructures for organising and providing care. We use the concept of assetization – the transformation of ‘things’ into rent-generating assets for investors – to explore how financial actors appear within healthcare. Drawing on empirical case studies from England, Canada, and the Netherlands, we show how assetization unfolds differently across national contexts, shaped by political cultures, regulatory environments, and institutional legacies. Rather than deploying uniform strategies, financial actors respond strategically to systemic frictions and perceived crises, positioning themselves as problem-solvers and embedding investor logic into healthcare provision. As such, assetization is an active process that constructs new infrastructures facilitating future investment and normalising financial presence in healthcare. By tracing how an emerging investor logic reshapes the conditions that allow financial actors to turn healthcare into an asset across different socio-political and institutional contexts, and by tracing the mechanisms through which this logic is articulated and enacted, this paper reveals how care is increasingly integrated into broader circuits of financialization. In doing so, we raise critical questions about the evolving governance, valuation, and organisation of healthcare under expanding financial influence, pointing towards a future research agenda

Health system integration has been actively promoted in recent years as a promising approach to defragmentize the current delivery framework of health services and contain costs. Yet, integration often faces significant barriers from the bureaucratic sphere. Successful integration is hardly due to good technical design alone; rather, it is often explained by how the policy dimension of the reform is managed. This study embraces a policy sciences perspective to explain the micro policy dynamics of health system integration reforms in a fragmented health system. Engaging the policy entrepreneurship literature, it investigates the county medical conglomeration innovations that have flourished in China in the past few years. Two pioneer counties were selected for in-depth case studies. Qualitative methods were extensively used in data analysis. Analytical attention was specifically focused on how a small team of local policy entrepreneurs championed the reforms amidst multiple constraints. The analysis revealed the varying momentum of policy entrepreneurs and the distinctive reform pathways across the two cases. A certain degree of similarity was also observed in their use of entrepreneurial strategies to promote integration reforms. Importantly, close vertical integration combined with a bundled global budget was adopted in both cases, and this model was subsequently diffused to other localities.

This paper explores changes in the commissioning, contracting and provision of NHS-funded cataract surgery in England over the last decade, focusing on the growing role of independent sector providers (ISPs). In recent years, there has been a dramatic rise in NHS-funded cataract surgery (from almost 417,000 cases in 2018/19 to about 650,000 in 2023/24) with the ISP share increasing from 22 to 57 per cent. A mixed-methods approach was employed, combining quantitative analysis of over 4.6 million NHS-funded hospital admissions for cataract surgery (2013–2024) and qualitative interviews with senior NHS and ISP stakeholders. Interviews were analysed using reflexive thematic analysis. The shift to ISPs was largely unplanned, driven by long NHS waiting lists, favourable payment tariffs, and low barriers to entry for new providers. ISPs’ involvement has contributed to reduced waiting times and improved productivity, potentially due to specialised infrastructure and incentive structures. However, concerns exist about contract management, service quality, and value for money. The study highlights the need for improved service commissioning, tariff reform, stronger contractual oversight, and effective monitoring to ensure quality and value. These findings have broader implications for healthcare systems balancing competition, patient choice, and public–private delivery models in elective care.

China’s recent expansion of Home- and Community-Based Services (HCBS) may influence fertility intentions among women of childbearing age. Using data from the China Labor-force Dynamics Survey (CLDS, 2014–2018) and a multi-period difference-in-differences (DID) design, we examine the effect of HCBS reforms on women’s fertility expectations and explore the channels through which these reforms operate. Our results show that HCBS expansion significantly reduces fertility intentions, with an average decline of approximately 0.12 children per woman. The effect is stronger among women with siblings, those who already have children, rural residents, and women in their prime childbearing years (aged 25–34 years). Mechanism analysis indicates that this reduction is mediated by increased perceived community safety, greater participation in pension insurance, and higher economic satisfaction. These findings suggest that elderly care policies can shape reproductive decisions, highlighting the need for integrated strategies that address both ageing and fertility concerns in China.

Premarital screening policies are increasingly adopted to prevent hereditary disorders in populations with high consanguinity. In Oman, a Middle Eastern country with significant sickle cell disease prevalence, the shift toward mandatory premarital screening emerged through a strategic policy process influenced by cultural, tribal, and religious values. In this context, premarital screening offers a critical opportunity for early detection and informed reproductive decision-making. This paper provides an explanatory analysis of the agenda-setting process that enabled the formal adoption of compulsory premarital screening for genetic disorders, using Kingdon’s Multiple Streams Framework (MSF) as an analytical lens. The analysis demonstrates how hereditary blood disorders, in particular Sickle cell disease (SCD), transitioned from a socially normalised condition to a recognised public health and socioeconomic problem, and how a technically feasible and ethically sensitive policy solution was advanced. Oman’s case illustrates how preventive health policies targeting socially sensitive issues can gain traction through stream convergence, and incremental reframing.

This article explores possible connections between health crises, economic policy choices, and the rise of populist movements, drawing on evidence from the interwar period. It considers how differing policy responses to the Great Depression may have been associated with contrasting trajectories in both public health and political developments. In Germany, the adoption of austerity measures in the early 1930s appears to have coincided with worsening economic conditions, declining health indicators, and growing electoral support for far-right movements. By contrast, expansionary initiatives introduced under the New Deal in the U.S. were likely accompanied by strengthened social protections, improvements in health outcomes, and what some observers have interpreted as a mitigation of pressures toward political radicalisation. Taken together, these historical experiences offer insights into contemporary developments, where perceived inadequacies in responding to intertwined health and economic crises could potentially contribute to eroding institutional trust and increasing receptiveness to populist narratives.

This paper examines Health System Resilience (HSR) through a political science lens, arguing that the capacity of health systems to become resilient is shaped not only by technical capabilities and available resources but also by the political theories underpinning health systems and health policy. While HSR has gained prominence in health research as a concept, its integration with political theories remains limited – particularly within political science literature. Drawing on a scoping review, the paper finds that political dimensions – such as governance and leadership, institutional path dependency, and power dynamics – are rarely and unevenly addressed in the literature. Most sources adopt a fragmented view of policy and politics, infrequently identifying the Political Determinants of Health (PDoH) systematically or analysing them through robust political theory. As a result, resilience is often depoliticised and treated as a managerial issue rather than a contested political process. In light of these findings, the paper proposes new opportunities to scrutinise how HSR is shaped by the interplay of actors, ideas, and institutions. In doing so, it contributes to developing a political science of health that fosters stronger interdisciplinary engagement. The paper calls on political scientists to engage more proactively with public health scholarship to support politically informed and more effective resilience strategies.

Private investment in residential long-term care has surged around the world. Growing evidence shows that this is changing the institutional logic and the inner workings of the sector, prioritising the financial interests of asset holders above those of other stakeholders (eg. clients, care professionals and regulators). We know little about how policy makers and regulators are responding to private investment and profit-making in the long-term care sector. This paper addresses that gap by analysing policies prompting the growth of private investment and profit-making in residential long-term care, the emerging power struggles in some cases between asset holders and other stakeholders in long-term care, the controversies that have arisen and the concomitant responses of regulators and policy makers in Ontario (Canada), Lombardy (Italy), the Netherlands and England (United Kingdom). We show that the institutional context (eg. legal frameworks, policies and regulations) shapes controversies concerning quality, accessibility and affordability of care, and argue that regulators and policymakers in the constituencies we studied are responding reactively to such controversies rather than proactively anticipating and preventing unwanted effects. Our analysis provides policymakers with valuable insights regarding the regulation and governance of private investment and profit-making in the residential long-term care sector.

Joint clinical assessments (JCAs) under the European Union (EU) Regulation 2021/2282 on health technology assessment (HTA-R) and its implementing regulations have been linked to various implementation challenges. However, legal implications of practically relevant issues have mostly remained unexplored. This study investigated potential legal implications of disparities regarding patient population, intervention, comparator, and outcomes (PICOs) in JCAs from respective member states (MSs), and of managing conflicts of interest (CoIs) of experts involved in a JCA. Moreover, we discussed potential consequences for patient access. JCA reports are not legally binding for MS; PICO disparities can underpin the required justification for their non-consideration at national level. Legal action against negative reimbursement decisions due to unjustified non-consideration falls under national jurisdiction. Furthermore, too strict CoI management might leave perspectives of MSs with fewer experts and thus a higher chance of CoI occurrence unheard, requiring corresponding expert elicitation at national level. These implications might lead to an increased workload for health technology developers and national HTA bodies, potentially fostering marketing strategies and access delays. Thorough scoping processes and prioritising the need for a JCA’s scientific excellence could facilitate more streamlined national HTA procedures and accelerated patient access.

We study private equity involvement (or lack thereof) in the long-term care (LTC) sector and its recent developments in the United States, Ireland and Poland. Based on the similarities and differences across these countries’ LTC systems, which can be treated as ideal types of the variety in typical models of LTC systems, we develop a systematic approach to the analysis of private equity engagement in the sector. Specifically, we define the comparison criteria as follows: the debates about the role and place of private equity in LTC; the extent of private equity investments in LTC; the reasons for private equity entry into the LTC sector; the business strategies of private equity firms; the regulations relative to private equity in LTC. Our case study comparison demonstrates that policy responses to population aging and care needs are deeply political processes, leading to a variety of solutions shaped by institutional legacies, cultural contexts, and the power dynamics between states, markets, and civil society.