The English National Health Service: 1979--2005

Determinants of intention with remote health management service among urban older adults: A Unified Theory of Acceptance and Use of Technology perspective

Background

Although older adults health management systems have been shown to have a significant impact on health levels, there remains the problem of low use rate, frequency of use, and acceptance by the older adults. This study aims to explore the significant factors which serve as determinants of behavioral intention to use the technology, which in turn promotes actual use.

Methods

This study took a total of 402 urban older adults over 60 years to explore the impact of the use behavior toward remote health management (RHM) through an online questionnaire. Based on the Unified Theory of Acceptance and Use of Technology (UTAUT), the author adds four dimensions: perceived risk, perceived value, perceived interactivity and individual innovation, constructed an extended structural equation model of acceptance and use of technology, and analyzed the variable path relationship.

Results

In this study, the factor loading is between 0.61 and 0.98; the overall Cronbach's Alpha coefficients are >0.7; The composite reliability ranges from 0.59 to 0.91; the average variance extraction ranges from 0.51 to 0.85, which shows the good reliability, validity, and discriminant validity of the constructed model. The influencing factors of the behavioral intention of the older adults to accept the health management system are: effort expectation, social influences, perceived value, performance expectation, perceived interactivity and perceived risk. Effort expectation has a significant positive impact on performance expectation. Individual innovation positively impacts performance expectation and perceived interactivity. Perceived interactivity and behavioral intention have a significant positive effect on the use behavior of the older adults, while the facilitating conditions have little effect on the use behavior.

Conclusions

This paper constructs and verifies the extended model based on UTAUT, fully explores the potential factors affecting the use intention of the older adult users. According to the research findings, some suggestions are proposed from the aspects of effort expectation, performance expectation, perceived interaction and perceived value to improve the use intention and user experience of Internet-based health management services in older adults.

The shadows of waiting and care: on discourses of waiting in the history of the British National Health Service

Waiting is at the centre of experiences and practices of healthcare. However, we know very little about the relationship between the subjective experiences of patients who wait in and for care, health practitioners who 'prescribe' and manage waiting, and how this relates to broader cultural meanings of waiting. Waiting features heavily in the sociological, managerial, historical and health economics literatures that investigate UK healthcare, but the focus has been on service provision and quality, with waiting (including waiting lists and waiting times) drawn on as a key marker to test the efficiency and affordability of the NHS. In this article, we consider the historical contours of this framing of waiting, and ask what has been lost or occluded through its development. To do so, we review the available discourses in the existing literature on the NHS through a series of 'snapshots' or key moments in its history. Through its negative imprint, we argue that what shadows these discourses is the idea of waiting and care as phenomenological temporal experiences, and time as a practice of care. In response, we begin to trace the intellectual and historical resources available for alternative histories of waiting - materials that might enable scholars to reconstruct some of the complex temporalities of care marginalized in existing accounts of waiting, and which could help reframe both future historical accounts and contemporary debates about waiting in the NHS.

Service use and costs in adolescents with pain and suicidality: a cross-sectional study

Background

Persistent/recurrent pain for more than three months and suicidality (suicide and self-harm related thoughts and behaviours) are serious and co-occurring health problems in adolescence, underscoring the need for targeted support. However, little is known about service use and costs in adolescents with pain-suicidality comorbidity, compared to those with either problem alone. This study aimed to shed light on service use and costs in adolescents with pain and/or suicidality, and the role of individual and school characteristics.

Methods

We analysed cross-sectional, pre-intervention data from a large cluster randomised controlled trial, collected between 2017 and 2019 on a representative sample of 8072 adolescents (55% female; aged 11-15 years; 76% white) in 84 schools in the UK. We explored service use settings, covering health, social, educational settings, and medication for mental health problems over three months. Data were analysed using descriptive statistics and two-part hurdle models to obtain odds ratios (ORs) and incident rate ratios (IRRs).

Findings

9% of adolescents reported comorbidity between pain and suicidality, 11% only suicidality, 13% only pain, and 66% neither pain nor suicidality. Approximately 55% of adolescents used services, especially general practitioner visits, outpatient appointments for injuries and contacts with a school nurse or pharmacist. Compared to adolescents with neither pain nor suicidality: (i) adolescents with pain (OR 3.79, 95% CI 2.63-5.48), suicidality (1.68, 1.12-2.51), and pain-suicidality comorbidity (2.35, 1.26-4.41) were more likely to use services and (ii) if services were used, they were more likely to have higher total costs (Pain: IRR 1.25, 95% CI 1.11-1.42; Suicidality: 1.27, 1.11-1.46; Comorbidity: 1.57, 1.34-1.85).

Interpretation

In our study, adolescents with pain and suicidality reported increased contact with health, social, and educational services, which could provide an opportunity for suicide prevention. Given the diversity of identified settings, multi-sector suicide prevention strategies are paramount.

Funding

Wellcome Trust [WT104908/Z/14/Z; WT107496/Z/15/Z]; Stiftung Oskar-Helene-Heim.

Balancing Equity and Efficiency in the Allocation of Health Resources-Where Is the Middle Ground?

The notion of equity in health service delivery has been embodied in several of the Global Sustainable Development Goals (SDGs), especially the aspiration for universal health coverage (UHC). At the same time, escalating healthcare costs amidst dwindling resources continue to ignite discussions on the efficiency aspect of healthcare delivery at both operational and system levels. Therefore, health planners and managers have had to grapple with balancing the two, given limited resources and sophisticated population health needs. Undoubtedly, the concepts of equity and efficiency have overarching importance in healthcare. While efficiency dictates an 'economical' use of the limited healthcare resources, equity advocates their fair and ethical use. Some have leaned on this to argue that one has to be forgone in search of the other. In search of a 'middle ground', this paper explores the conceptual underpinnings of equity and efficiency in the context of healthcare resource allocation with some empirical examples from high-income and low- and middle-income settings. We conclude by arguing that equity and efficiency are, and ought to be, treated as complementary rather than conflicting considerations in distributing health resources. Each could be pursued without necessarily compromising the other-what matters is an explicit criterion of what will be 'equitable' in ensuring efficient allocation of resources, and on the other hand, what options will be considered more 'efficient' when equity objectives are pursued. Thus, equity can be achieved in an efficient way, while efficiency can drive the attainment of equity.

A "liberalização" do Serviço Nacional de Saúde da Inglaterra: trajetória e riscos para o direito à saúde

Resumo: A recente reforma do Serviço Nacional de Saúde (NHS) inglês por meio do Health and Social Care Act de 2012 introduziu mudanças importantes na organização, gestão e prestação de serviços públicos de saúde na Inglaterra. O objetivo deste estudo é analisar as reformas do NHS no contexto histórico de predomínio de teorias neoliberais desde 1980 e discutir o processo de "liberalização" do NHS. São identificados e analisados três momentos: (i) gradativa substituição ideológica e teórica (1979-1990) - transição da lógica profissional e sanitária para uma lógica gerencial/comercial; (ii) burocracia e mercado incipiente (1991-2004) - estruturação de burocracia voltada à administração do mercado interno e expansão de medidas pró-mercado; e (iii) abertura ao mercado, fragmentação e descontinuidade de serviços (2005-2012) - fragilização do modelo de saúde territorial e consolidação da saúde como um mercado aberto a prestadores públicos e privados. Esse processo gradual e constante de liberalização vem levando ao fechamento de serviços e à restrição do acesso, comprometendo a integralidade, a equidade e o direito universal à saúde no NHS.

Do maximum waiting times guarantees change clinical priorities for elective treatment? Evidence from Scotland

The level and distribution of patient waiting times for elective treatment are a major concern in publicly funded health care systems. Strict targets, which have specified maximum waiting times, have been introduced in the NHS over the last decade and have been criticised for distorting existing clinical priorities in scheduling hospital treatment. We demonstrate the usefulness of conditional density estimation (CDE) in the evaluation of the reform using data for Scotland for 2002 and 2007. We develop a modified goodness of fit test to discriminate between models with different numbers of bins. We document a change in prioritisation between different patient groups with longer waiting patients benefiting at the expense of those who previously waited less. Our results contribute to understanding the response of publicly funded health systems to enforced targets for maximum waiting times.

The paradox of non-evidence based, publicly funded complementary alternative medicine in the English National Health Service: An explanation

Despite the unproven effectiveness of many practices that are under the umbrella term 'complementary alternative medicine' (CAM), there is provision of CAM within the English National Health Service (NHS). Moreover, although the National Institute for Health and Care Excellence was established to promote scientifically validated medicine in the NHS, the paradox of publicly funded, non-evidence based CAM can be explained as linked with government policy of patient choice and specifically patient treatment choice. Patient choice is useful in the political and policy discourse as it is open to different interpretations and can be justified by policy-makers who rely on the traditional NHS values of equity and universality. Treatment choice finds expression in the policy of personalised healthcare linked with patient responsibilisation which finds resonance in the emphasis CAM places on self-care and self-management. More importantly, however, policy-makers also use patient choice and treatment choice as a policy initiative with the objective of encouraging destabilisation of the entrenched healthcare institutions and practices considered resistant to change. This political strategy of system reform has the unintended, paradoxical consequence of allowing for the emergence of non-evidence based, publicly funded CAM in the NHS. The political and policy discourse of patient choice thus trumps evidence based medicine, with patients that demand access to CAM becoming the unwitting beneficiaries.

Changes in healthcare professional work afforded by technology: The introduction of a national electronic patient record in an English hospital

This article considers changes in healthcare professional work afforded by technology. It uses the sociology of professionals’ literature together with a theory of affordances to examine how and when technology allows change in healthcare professional work. The study draws from research into the introduction of a national electronic patient record in an English hospital. We argue that electronic patient record affords changes through its materiality as it interacts with healthcare professional practice. Its affordances entail some level of standardisation of healthcare professional conduct and practice, curtailment of professional autonomy, enlargement of nurses’ roles and redistribution of clinical work within and across professional boundaries. The article makes a contribution to the growing literature advocating a cultural approach to the study of technological affordances in organisations and to studies that explore healthcare professional practice in conjunction with the materiality of technology. Two main lines of argument are developed here. First, that technological affordances do not solely lie with the materiality of technology nor with individual perceptions, but are cultivated and nurtured within a broader cultural–institutional context, in our case a professional context of use. Second, that technological affordance of change is realised when healthcare professionals’ (individual and collective) perceptions of technology (and of its materiality) fit with their sense of (professional) self. In this respect, the article shows the extent to which the materiality of technology plays out with professional identity and frames the level and extent to which technology can and cannot afford restructuring of work and redistribution of power across professional groups.

"Fact" and "fiction": enlivening health care education

PURPOSE

This paper aims to demonstrate how close analysis of cultural narratives can be employed as effective pedagogical tools in the explication and critique of specific workplace issues relevant to health management education.

DESIGN/METHODOLOGY/APPROACH

Two narratives have been selected to illustrate this point: the apparently "fictional" UK-based medical television drama series Bodies (2005-2006) and the apparently "factual" report of an Australian state government public inquiry into acute health care, the Garling Report.

FINDINGS

Through their demonstration of how analyses of selected segments of these texts can be used in health management education, the authors conclude that the comparative analyses of ostensibly "fictional" and "factual" narratives allow for analysis and critique of the inadequacies of new public management (NPM) applied to the health care industry, leading to a greater understanding of wider ideological effects on public perceptions.

PRACTICAL IMPLICATIONS

The authors argue that these understandings enliven students' learning experiences, and that such comparative analyses should be applied more widely across health management education to develop students' critical skills and openness to exploring alternative models.

ORIGINALITY/VALUE

Comparative analysis of cultural texts is novel in health care education, and allows for the interrogation of ideology and its effects.

Using small-area variations to inform health care service planning: what do we 'need' to know?

RATIONALE, AIMS AND OBJECTIVES

Allocating resources on the basis of population need is a health care policy goal in many countries. Thus, resources must be allocated in accordance with need if stakeholders are to achieve policy goals. Small area methods have been presented as a means for revealing important information that can assist stakeholders in meeting policy goals. The purpose of this review is to examine the extent to which small area methods provide information relevant to meeting the goals of a needs-based health care policy.

METHODS

We present a conceptual framework explaining the terms 'demand', 'need', 'use' and 'supply', as commonly used in the literature. We critically review the literature on small area methods through the lens of this framework.

RESULTS

'Use' cannot be used as a proxy or surrogate of 'need'. Thus, if the goal of health care policy is to provide equal access for equal need, then traditional small area methods are inadequate because they measure small area variations in use of services in different populations, independent of the levels of need in those populations.

CONCLUSIONS

Small area methods can be modified by incorporating direct measures of relative population need from population health surveys or by adjusting population size for levels of health risks in populations such as the prevalence of smoking and low birth weight. This might improve what can be learned from studies employing small area methods if they are to inform needs-based health care policies.

Market competition, ownership, payment systems and the performance of health care providers - a panel study among Finnish occupational health services providers

Many health care reforms rely on competition although health care differs in many respects from the assumptions of perfect competition. Finnish occupational health services provide an opportunity to study empirically competition, ownership and payment systems and the performance of providers. In these markets employers (purchasers) choose the provider and prices are market determined. The price regulation of public providers was abolished in 1995. We had data on providers from 1992, 1995, 1997, 2000 and 2004. The unbalanced panel consisted of 1145 providers and 4059 observations. Our results show that in more competitive markets providers in general offered a higher share of medical care compared to preventive services. The association between unit prices and revenues and market environment varied according to the provider type. For-profit providers had lower prices and revenues in markets with numerous providers. The public providers in more competitive regions were more sensitive to react to the abolishment of their price regulation by raising their prices. Employer governed providers had weaker association between unit prices or revenues and competition. The market share of for-profit providers was negatively associated with productivity, which was the only sign of market spillovers we found in our study.

Markets and targets in the English National Health Service: is there a role for behavioral economics?

Over the past twenty years, the emphasis of reform attempts to improve efficiency within the English National Health Service (NHS) has oscillated between markets and targets. Both strategies are informed by standard economic theory but thus far have achieved varying degrees of success. Behavioral economics is currently in vogue and offers an alternative (or, in some cases, a complement) to standard economic theory on what motivates human behavior. There are many aspects to behavioral economics, but space constraints allow just three to be considered here: identity, loss aversion, and hyperbolic discounting. An attempt is made in this article to speculate on the extent to which these three concepts can explain the success or otherwise of the NHS market and target policies of the last two decades, and some suggestions are offered as to how policies might be usefully designed in the future. Arguably the key points are that people are more likely to be motivated if they identify with the ethos of the policy; the threat of losses will often provoke more of a response than the promise of gains; and the "immediate moment" matters enormously to individuals, so policies that require human action should be designed to make that moment as enjoyable (or as pain free) as possible.

Paying for hospital care: the experience with implementing activity-based funding in five European countries

Following the US experience, activity-based funding has become the most common mechanism for reimbursing hospitals in Europe. Focusing on five European countries (England, Finland, France, Germany and Ireland), this paper reviews the motivation for introducing activity-based funding, together with the empirical evidence available to assess the impact of implementation. Despite differences in the prevailing approaches to reimbursement, the five countries shared several common objectives, albeit with different emphasis, in moving to activity-based funding during the 1990s and 2000s. These include increasing efficiency, improving quality of care and enhancing transparency. There is substantial cross-country variation in how activity-based funding has been implemented and developed. In Finland and Ireland, for instance, activity-based funding is principally used to determine hospital budgets, whereas the models adopted in the other three countries are more similar to the US approach. Assessing the impact of activity-based funding is complicated by a shortage of rigorous empirical evaluations. What evidence is currently available, though, suggests that the introduction of activity-based funding has been associated with an increase in activity, a decline in length of stay and/or a reduction in the rate of growth in hospital expenditure in most of the countries under consideration.

Health care financing in Asia: key issues and challenges

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.

Healthcare policy tools as determinants of health-system efficiency: evidence from the OECD

This paper assesses which policy-relevant characteristics of a healthcare system contribute to health-system efficiency. Health-system efficiency is measured using the stochastic frontier approach. Characteristics of the health system are included as determinants of efficiency. Data from 21 OECD countries from 1970 to 2008 are analysed. Results indicate that broader health-system structures, such as Beveridgian or Bismarckian financing arrangements or gatekeeping, are not significant determinants of efficiency. Significant contributors to efficiency are policy instruments that directly target patient behaviours, such as insurance coverage and cost sharing, and those that directly target physician behaviours, such as physician payment methods. From the perspective of the policymaker, changes in cost-sharing arrangements or physician remuneration are politically easier to implement than changes to the foundational financing structure of the system.

Public health care providers and market competition: the case of Finnish occupational health services

BACKGROUND

As reforms in publicly funded health systems rely heavily on competition, it is important to know if and how public providers react to competition. In many European countries, it is empirically difficult to study public providers in different markets, but in Finnish occupational health services, both public and private for-profit and non-profit providers co-exist. We studied possible differences in public providers' performance (price, intensity of services, service mix-curative medical services/prevention, productivity and revenues) according to the competitiveness of the market.

MATERIALS AND METHODS

The Finnish Institute of Occupational Health (FIOH) collected data on clients, services and personnel for 1992, 1995, 1997, 2000 and 2004 from occupational health services (OHS) providers. Employers defray the costs of OHS and apply for reimbursement from the Social Insurance Institution (SII). The SII data was merged with FIOH's questionnaire. The unbalanced panel consisted of about 230 public providers, totalling 1,164 observations. Local markets were constructed from several municipalities based on commuting practices and regional collaboration. Competitiveness of the market was measured by the number of providers and by the Herfindahl index. The effect of competition was studied by ordinary least square regression analysis and panel models.

RESULTS

The more competitive the environment was for a public provider the higher were intensity, productivity and the share of medical care. Fixed panel models showed that these differences were not due to differences and changes in the competitiveness of the market. Instead, in more competitive markets public providers had higher unit prices and higher revenues.

Equity in health care: the Irish perspective

Equity is espoused in many national health policy statements but is a complex concept and is difficult to define. The way in which equity is defined in policy has implications for how the health-care system should be structured. Conflicts between different definitions of equity are identified in theory and policy. This paper discusses these issues, with specific focus on the equity principles underpinning the Irish health-care system. The complex mix of public and private funding in the Irish system brings the challenges in identifying (and achieving) equity objectives more sharply into view, and serves as a warning system for other countries.

The Irish 'health basket': a basket case?

The Irish health care system is typically described as complex and inequitable and yet the source of the complexity is difficult to identify. This paper examines and documents the way in which the structure of the Irish system is complicated when compared with other countries. Analysis is conducted in the context of the 'health basket' framework. A health basket describes which health care services, and which individuals, are covered by public funding, and to what extent. The Irish health basket is outlined along three dimensions of breadth, depth, and height, and compared with the health baskets of the United Kingdom, Canada, Australia, Sweden and France. Results indicate that it is in the combination of breadth and height that distinguishes the Irish basket from others. The majority of Irish health care services are run on a cost sharing basis; user fees are higher than in other countries particularly in primary care; and the structure of entitlement restrictions are complex. It is difficult to identify other countries in which all these factors operate within one system. In addition, the way in which the Irish health basket is delivered in practice introduces further complexities into the breadth and height of coverage.

Healthcare policies over the last 20 years: reforms and counter-reforms

The case argued in this article is that the last two decades have been characterised by distinct waves of healthcare reforms. The first, in the early 1990s, aimed to introduce more patients' choice and greater competition between the components of the healthcare system. The second, from 1995 to 2000, had the opposite aim of introducing greater integration and regulation. From 2000 onwards, the policy issue more in vogue has been the strengthening of patients' rights. Looking for the motives behind these reform strategies, this article aims to show how the ideological leaning of the governments in power affects the content of reform initiatives. The analysis presents evidence drawn from six OECD countries: France, Germany, the Netherlands, New Zealand, Sweden and UK.

The effects of increasing obesity on outcomes of vascular surgery

The aim of this study was to determine whether vascular patients are becoming progressively more obese and whether morbid obesity affects outcomes from vascular surgery. Data for the index vascular procedures of infrainguinal bypass, carotid endarterectomy, and abdominal aortic aneurysm (AAA) repair were collected in a computer database for 1996-2006. Body mass index (BMI) was stratified into <18.5 kg/m2 as underweight, >35 kg/m2 as morbidly obese, and other as control (18.5 < BMI < 35). The data were analyzed with respect to operation duration, length of stay, complication rates, and mortality rates. Results were adjusted for potential confounding variables, including mode of admission, diabetes, cardiac history, renal function, and smoking. A total of 1,317 patients were reviewed, and 1,105 cases were deemed suitable for analysis. The incidence of morbid obesity increased in a linear manner from 1.3% to 9% over the 10-year period. The operation duration was longer for morbidly obese subjects compared with normals. This was only statistically significant for AAA repair category, with a mean operating time of 158.4 +/- 65.5 min for patients with BMI <35 kg/m2 vs. 189.8 +/- 92.2 min for morbidly obese patients (p < 0.014). Infection rates were consistently higher in the morbidly obese group; however, this reached a statistically significant rate among AAA repair cases (43.5% [n = 16] vs. 34.8% [n = 159], p < 0.004). There were no significant differences in other complications, graft failure, length of stay, or mortality. Vascular patients are becoming progressively more obese. Procedures performed on morbidly obese subjects take longer, and these patients have higher rates of infectious complications. This is mainly attributable to AAA. This did not translate into poorer final outcomes in this study, although significant differences might emerge from a larger sample.

Demand-driven care and hospital choice. Dutch health policy toward demand-driven care: results from a survey into hospital choice

In the Netherlands, current policy opinion emphasizes demand-driven health care. Central to this model is the view, advocated by some Dutch health policy makers, that patients should be encouraged to be aware of and make use of health quality and health outcomes information in making personal health care provider choices. The success of the new health care system in the Netherlands is premised on this being the case. After a literature review and description of the new Dutch health care system, the adequacy of this demand-driven health policy is tested. The data from a July 2005, self-administered questionnaire survey of 409 patients (response rate of 94%) as to how they choose a hospital are presented. Results indicate that most patients did not choose by actively employing available quality and outcome information. They were, rather, referred by their general practitioner. Hospital choice is highly related to the importance a patient attaches to his or her physician's opinion about a hospital. Some patients indicated that their hospital choice was affected by the reputation of the hospital, by the distance they lived from the hospital, etc. but physician's advice was, by far, the most important factor. Policy consequences are important; the assumptions underlying the demand-driven model of patient health provider choice are inadequate to explain the pattern of observed responses. An alternative, more adequate model is required, one that takes into account the patient's confidence in physician referral and advice.

Pharmaceutical pricing and reimbursement reforms in Greece

Pharmaceutical price regulation in Greece is centralized. The National Drug Organization (EOF) is the main regulatory authority functioning under the auspices of the Ministry of Health and Social Solidarity. In 2004, total pharmaceutical expenditure in Greece reached the level of 2.9 billion euro, of which 77.9% were public expenditure and the remaining 22.1% private. According to Organization for Economic Cooperation and Development (OECD) data the total per-capita expenditure on pharmaceutical care in Greece is among the lowest in Europe, representing 58% of the EU-12 average. In 1998, Greece introduced a reimbursement list, and the lowest reference pricing system among the 15 European Union member states with the purpose of controlling the growth of pharmaceutical expenditure. The measures proved to be ineffective since pharmaceutical expenditure, after a short-term reduction, continued to increase at similar rates to those before the introduction of price control mechanisms. The average annual increase of pharmaceutical expenditure in Greece over the period 1998-2003 was 7.9%, which is among the highest in the OECD countries (average 6.1%). New pharmaceutical legislation, no. 3457, was enacted on May 8th 2006, aiming at greater access to medicines, improvements to citizens' quality of life, effective and efficient utilization of health resources, transparency in public management, protecting public health, and maintaining long-term financial viability of the insurance system. The innovative aspect of the new legislation is the abolition of the positive list and the establishment of a rebate system granting the National Insurance Funds a rebate rate paid by the pharmaceutical companies. The purpose of this paper is twofold. First to assess the effectiveness of the positive list introduced in 1988 in Greece, using simple econometric models. Second to present the recent pharmaceutical reforms aimed at the introduction of a rebate system and establishing reimbursement pricing based on the average of the three lowest European prices.

Policy and regulatory responses to dual practice in the health sector

Physician dual practice is a widespread phenomenon which has implications for the equity, efficiency and quality of health care provision. Central to the analysis of physician dual practice is the trade-off between its benefits and costs, as well as the convenience of regulating it to undermine its adverse consequences. In this paper, we study and analyze different governmental responses to this activity. We find that internationally, there are wide variations in how governments tackle this issue. While some governments fully prohibit this practice, others regulate or restrict dual job holding with different intensities and regulatory instruments. The measures implemented include limiting the income physicians can earn through dual job holding, offering work benefits to physicians in exchange for their working exclusively in the public sector, raising public salaries, and allowing physicians to perform private practice at public facilities. We present the pros and cons of each of these alternatives and show how the health care market and institutional arrangements are crucial for the design and implementation of each of these strategies. The paper also identifies the need for empirical evidence on the effect of different government strategies on dual practice.

The Veterans Health Administration: an American success story?

The Veterans Health Administration (VHA) provides health care for U.S. military veterans. By the early 1990s, the VHA had a reputation for delivering limited, poor-quality care, which led to health care reforms. By 2000, the VHA had substantially improved in terms of numerous indicators of process quality, and some evidence shows that its overall performance now exceeds that of the rest of U.S. health care. Recently, however, the VHA has started to become a victim of its own success, with increased demands on the system raising concerns from some that access is becoming overly restricted and from others that its annual budget appropriations are becoming excessive. Nonetheless, the apparent turnaround in the VHA's performance offers encouragement that health care that is both financed and provided by the public sector can be an effective organizational form.