Preliminary Programme

The international collection of statistics about health systems became, in the course of the 20th century, a sophisticated industry informing policy-making and public debate. This paper asks how and why this practice began, what challenges were involved in developing and standardising different metrics, and whether political agendas lay behind apparently neutral data-gathering exercises. The first section is empirical, describing the work of organisations such as the League of Nations Health Organisation and the International Labour Organisation in the 1930s, then, in the postwar period the WHO, the World Bank and the Organisation of Economic Co-operation and Development. The second section examines the choices of metrics for comparing national health systems, beginning with basic indicators of provision, utilisation and financing, then moving to the more politically sensitive measures such as health outcomes, dignity and satisfaction. The final section suggests examples of where these health system statistics were marshalled in political argumentation. My argument is that they were invoked for rhetorical purposes in debates, between those who favoured ‘vertical’, technical and disease-focused programmes, and those championing redistributive and universalist action on health services.
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The Swedish version of private health insurance is characterised by providing rapid access to healthcare. An increasing number of Swedish health facilities use different queuing systems for publicly and privately funded patients, where the latter get faster access to care than the former. The phenomenon – known as VIP lanes – has been politically controversial because it challenges the pillars of the Health Act, which says that ‘Those who have the greatest need for healthcare shall be given priority’. How did that happen? With a continuous support of publicly funded and equally accessed healthcare not only among the citizens but also in the rhetoric of all political parties, the rapid rise of private health insurance seems to be quite unexpected. However, some understanding can be gained from ‘the path dependency of an idea’ according to which the Scandinavian model rests upon values (universalism, solidarity, decommodofication) so important to so many that policy-makers justify their proposals for reform by making reference to those values. The overall policy remains the same, but institutions are altered by shifts beneath the general policy level, something that scholars within an agent-centred version strand of historical institutionalism have called layering, drift, and conversion. On a more direct level, there is a contested but largely underresearched connection between private delivery and private funding of healthcare. The rapid rise of private health insurance in Sweden would not have been possible without the substantial privatization of delivery on all levels of healthcare from the 1990s and onwards. This is so because public providers do not welcome patients with private health insurance. The insurance companies are thus dependent on the emergence of a large and country-wide net of private providers on all care levels. If there was not a country-wide net of private providers (and there was not before 2000), the insurance companies would have nowhere to send their customers. However, it is not only that insurance companies are dependent on privately delivered healthcare. The dependency is mutual and the private providers can actually become increasingly dependent on the insurance companies. First, it is about spreading the risks. It is risky for profit-making private providers to put all their trust in the agreements with the county councils and their publicly funded patients. Second, and perhaps more important, the private providers earn more money on patients with private health insurance. This is so because the county councils can guarantee a large flow of patients while insurance companies cannot. Therefore, the insurance companies must pay more for each patient. The purpose of the paper is to dig deeper into the underresearched and sometimes contested interplay between private delivery and private funding of healthcare. In this context, I make a thorough investigation of all the actors involved and try to answer questions such as: Do the insurance companies pay more for each patient? Do the private providers see it as spreading risks when they cooperate with the insurance companies? Are the insurance companies dependent on private providers of healthcare? (Show less)

Spain passed its first compulsory health insurance in the 1940s, under a dictatorship and without public funding. Under these circumstances, the health insurance lacked universal coverage, offered very limited benefits, and was paid for by workers and employers. In addition, some agreements between public and private sectors were needed to manage health coverage, given the lack of public infrastructure and the shortage of public funds. Collaboration between the private and public sectors was diluted by the end of the dictatorship, when there was an attempt to establish a social security system similar to other European countries. However, the lack of public resources and the dictatorship’s lack of interest in establishing a welfare state led to a meagre social security system. During the early years of democracy, a long discussion on the health system to be established in Spain was initiated. Right-wing parties intended to promote the signing of agreements with private healthcare; left-wing parties sought to establish a national health system. The socialist victory in 1982 resulted in the establishment of this second model. At last, after long debates in Parliament, the first General Public Health Law was passed in Spain in 1986.
This paper aims to analyse how the health system was shaping up in Spain under dictatorship and democracy. This analysis is accompanied by a reconstruction of the series of major variables affecting the performance of the Public Health System (hospitals and clinics, beds, medical and health staff) and private provision between 1942 and 1986. Finally, international comparison helps us understand how the Franco dictatorship conditioned the configuration and characteristics of the health system in Spain. (Show less)

The discipline and practice of health economics was strengthened in the post-war period in different ways in the UK and the USA. There were increased opportunities for employment within academic institutions and government departments; dedicated societies and study groups were formed, and distinctions made relative to associated areas such as medical decision science (US) and Operational Research (UK). This expanded group of practitioners also developed new evaluation techniques, moving health economics from a theoretical focus to applied policy formation within health systems. The primary ones developed in the 1960s and 1970s were Cost Benefit Analysis, Cost Effectiveness Analysis, QALYS, DRGs. This paper explores the parallel but very different genesis and development of these analytical techniques in the US and the UK. The second half of the paper will explore new hypotheses on the importation of US health economics expertise to the UK NHS: to what extent was this personality driven, or facilitated by relationships between economists and medical practitioners? Why does the ‘transatlantic drift’ of expertise in the 1970s and 1980s appear to be mainly west to east? (Show less)

China used to be a role model in organizing primary care focused health services at low cost, but its health system has been increasingly hospital-centric. The paper traces the balance between hospitals and primary care in China back to early historical periods and examines the changes that led to the current situation. The first section provides an overview of data available for analyzing China’s health system since 1949, and also tries to discuss the reliability and availability of such data. The second part discusses the long-term change in the balance between primary care and hospitals, starting from the very beginning of state-wide health care system under the newly established communist regime, to the system that built on the Barefoot Doctors during the Cultural Revolution, and finally to one that emphasis development of medical establishment and technology. The final section links these changes to changing policies during the Cultural Revolution and in the Reform and Opening-up era. My argument is that the reforms during the Cultural Revolution were strong enough to create the foundation of primary care yet also contained weaknesses that led to the focus of health system shifting back to hospitals. (Show less)