Regional International Organizations and Health: A Framework for Analysis.

CONTEXT: Regional international organizations (RIOs), from the South African Development Community (SADC) to the European Union (EU), are organizations that promote cooperation among countries in a specific region of the world. Asking what RIOs do to health and health policy by looking only at their formal health policies can understate their effects (e.g., a free trade agreement with no stated health goals can affect health policy) and overstate their effects (as with agreements full of ambition that did not deliver much). METHODS: We adopt a "three-faces" framework that identifies RIOs' direct health policies, the effects of their trade and market policies, and their effects on health via fiscal governance of their member states to better capture their health impact. We tested the usefulness of the framework by examining the Association of Southeast Asian Nations, EU, North American Free Trade Agreement, SADC, and the Union of South American Nations. FINDINGS: All RIOs had some impact on health systems and policies, and, in many cases, the principal policies were not identified as health policy. CONCLUSIONS: Such a framework will be useful in understanding the effects of RIOs on health systems and policies because it captures indirect and even unintended health effects in a way that permits development of explanatory theories.

Termites of Solidarity in the House of Austerity: Undermining Fiscal Governance in the European Union.

European Union (EU) fiscal governance, especially the European Semester, is an ambitious new governance architecture involving surveillance and discipline, across both Eurozone and non-Eurozone member state policies, in pursuit of fiscal rigor. It is the most recent of several attempts to expand EU powers over member state policy with the goal of austere budgeting, and one that has led to remarkable claims of authority by the EU over member state health policies as detailed as medical school admissions and the role of primary care. It is expected that it would be resisted not just by those who object to an EU role in the organization and delivery of health care but also by those who object to a particular austere approach to health policy. How well is it working? Using two waves of interviews and documentary analysis, and health as a policy case study, the authors document three key techniques that opponents use to undermine the semester's governance architecture: broadening goals, expanding the scope of conflict, and disputing and nuancing indicators. The result is that opponents of a narrow fiscal governance agenda are again successfully undermining the narrow focus of the semester.

What Is EU Public Health and Why? Explaining the Scope and Organization of Public Health in the European Union.

Public health is notoriously difficult to define, and that is the case for public health in the European Union as much as other political systems. In this article, the authors try to identify the actual scope and meaning of public health as it is institutionalized in the EU political system. Using a mixture of historical policy and legal analysis, the authors show how the evolution of the institutional space called public health in the EU has been shaped by the EU's distinctive constitutional nature, its focus on regulation, and the legacy of its focus on market making as well as the preferences of its political leaders. The European Union does have an increasingly large space named "public health," in which health ministers, the health directorate-general, and invocation of its public health treaty article 168 can be found, as well as a much broader and older area of activities justified by the need to manage adverse health consequences of market-making policies in other areas such as labor standards and agriculture. The COVID-19 crisis of 2020 not only led to a strengthening of EU public health but also showed that the EU is one of the many political systems in which the legal and bureaucratic domain of public health is far smaller than the actual issues affecting the public's health.

Power and Purchasing: Why Strategic Purchasing Fails.

Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness. CONTEXT: Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing. METHODS: We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years. FINDINGS: No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry. CONCLUSIONS: Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.

Brexit is just a symptom: the constitutional weaknesses it reveals have serious consequences for health.

Brexit has direct and indirect negative health consequences, whether from economic damage or from the political paralysis and distraction from public health that it has created. Brexit is a public health problem in its own right, as other literature has shown-but, we argue, it is also a symptom of deeper problems in the governance of the United Kingdom. In particular, the combination of executive dominance, partisanship and opacity that give rise to the constitutional casualism of the Brexit decisions has already affected public health policy and will continue to do so unless addressed.

Do parties make a difference? A review of partisan effects on health and the welfare state.

BACKGROUND: Do political parties matter to health? Do they affect population health either directly or through welfare states' social policies and the eligibility, affordability and quality of health systems? And if they do, how? These are crucial questions if we are to understand health politics or shape public health policy, particularly given the changing landscape of political parties, party dominance in the executive and the mediating influence of the legislature. METHODS: Using a systematic approach, this review examines 107 peer-reviewed articles and books published after 1978 focusing on high-income countries asking the overarching question: Do political parties matter to health and the welfare state? RESULTS: The literature relating parties to health directly was surprisingly thin, thus, the welfare state was used as a 'proxy' variable. An overwhelming majority of the literature sample suggests that Left parties are inclined to expand the welfare state without cutting benefits, while the Right does not expand and tends to reduce benefits. There was an inflection in the 1980s when Left parties shifted from expansion to maintaining the status quo. CONCLUSION: Considering current health trends in the form of measles outbreaks, the 'Deaths of Despair', the rise of previous eradicated infectious diseases and the declining health expectancy rates in some Western countries as well as the rise of Populist Radical Right parties in office we question the current partisanship thesis that political parties matter less and less.

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978-2017.

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in-person, semi-structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision-making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.

What Is the Affordable Care Act a Case of? Understanding the ACA through the Comparative Method.

International comparisons of US health care are common but mostly focus on comparing its performance to peers or asking why the United States remains so far from universal coverage. Here the authors ask how other comparative research could shed light on the unusual politics and structure of US health care and how the US experience could bring more to international conversations about health care and the welfare state. After introducing the concept of casing-asking what the Affordable Care Act (ACA) might be a case of-the authors discuss different "casings" of the ACA: complex legislation, path dependency, demos-constraining institutions, deep social cleavages, segmentalism, or the persistence of the welfare state. Each of these pictures of the ACA has strong support in the US-focused literature. Each also cases the ACA as part of a different experience shared with other countries, with different implications for how to analyze it and what we can learn from it. The final section discusses the implications for selecting cases that might shed light on the US experience and that make the United States look less exceptional and more tractable as an object of research.

Lessons for the United States From Single-Payer Systems.

US political debates often refer to the experience of "single-payer" systems such as those of Canada and the United Kingdom. We argue that single payer is not a very useful category in comparative health policy analysis but that the experiences of countries such as Canada, the United Kingdom, Spain, Sweden, and Australia provide useful lessons. In creating universal tax-financed systems, they teach the importance of strong, unified governments at critical junctures-most notably democratization. The United States seems politically hospitable to creating such a system.The process of creation, however, highlights the malleability of interests in the health care system, the opportunities for creative coalition building, and the problems caused by linking health care finance and reform. In maintaining these systems, keeping the middle class supportive is crucial to avoiding universal health care that is essentially a program for the poor.For a technical term from the 1970s, "single-payer health care" has proved to have remarkable political power and persistence. We argue it is not a very useful term but the lessons from such systems can be valuable for those contemplating movement toward universal health coverage in the United States.

What will Donald Trump's presidency mean for health? A scorecard.

US Presidents make their mark on health, for better or worse. Donald Trump campaigned on a populist platform to "make America great again". While the actual policies his administration will pursue-and the priority he will place on each of them-remain in many ways uncertain, both his statements and his nominations for key government posts suggest that his presidency could have profound implications for health. His proposal to repeal and replace the Affordable Care Act with a "better reform", his stance on reproductive rights, and his approaches to other areas, such as science policy and climate change, coupled with his stated intention to put "America first" are creating anxiety and uncertainty about America's domestic health policies and its global leadership role in areas such as security and development. We propose criteria on which the global health community can judge the success or failure of a Trump presidency, based on a selection of the 17 Sustainable Development Goals that apply to health.

Labour politics as public health: how the politics of industrial relations and workplace regulation affect health.

There are three main areas of social and economic policy that influence health: the welfare state, industrial organization (unions), and labor regulation. Public health literature and analysis traditionally focuses on the taxing and spending of the welfare state. This paper presents highlights from the extensive literature in political economy in order to argue that industrial relations and workplace regulation are political and crucial to public health. The routes by which they influence public health include wage inequality, workplace health and safety, political engagement and investment in human capital. The magnitude of impact can be impressive: the United Kingdom's taxation and spending have about as much redistributive impact as that of Sweden, but that is not enough to compensate for the inequality produced by the UK's liberal labor market. The trend across wealthy countries has been to weaker unions and less workplace regulation and we can see this as a likely cause of public health problems and health inequalities into the future.

Political parties matter: the impact of the populist radical right on health.

This paper presents the basic political science consensus on parties and their impact on policy, then turns to focus on the impact of the populist radical right (PRR) parties on policy, what PRR parties have done to implement their views and whether they make a difference. Three effects on policy were established: 1) they de-emphasize the issue, preferring to focus on migration, crime and security rather than health and welfare and 2) they prefer to pursue exclusionary policies. 3) it is not clear whether they increase or decrease benefits for the "native" populations they claim to represent. In short PRR parties make a difference whether to migrants or conservative governments, this party group matters.

Policy, politics and public health.

If public health is the field that diagnoses and strives to cure social ills, then understanding political causes and cures for health problems should be an intrinsic part of the field. In this article, we argue that there is no support for the simple and common, implicit model of politics in which scientific evidence plus political will produces healthy policies. Efforts to improve the translation of evidence into policy such as knowledge transfer work only under certain circumstances. These circumstances are frequently political, and to be understood through systematic inquiry into basic features of the political economy such as institutions, partisanship and the organization of labour markets.

Devolution and health in the UK: policy and its lessons since 1998.

INTRODUCTION: Since devolution in 1998, the UK has had four increasingly distinct health systems, in England, Northern Ireland, Scotland and Wales. SOURCES OF DATA: Secondary literature and authors' own research since 1998. AREAS OF AGREEMENT: From a similar starting point, there has been a considerable distancing of the four health systems from each other in policies, priorities and organization. AREAS OF CONTROVERSY: The comparative efficiency and quality of the different systems as well as the wisdom of their greater or lesser reliance on integration and competition. GROWING POINTS: Better and more comparable public data would be useful, as would consideration of potential devolved lessons for UK policy. AREAS TIMELY FOR DEVELOPING FURTHER RESEARCH: Comparisons of organization and performance at levels more detailed than whole systems; analysis of the resilience and management of different systems in a context of budgetary austerity; analysis of the politics behind policy decisions.

Power to the people? An international review of the democratizing effects of direct elections to healthcare organizations.

Ensuring that publicly funded health systems are democratically accountable is an enduring challenge in policy and practice. One strategy for enhancing public officials' accountability is to elect members of the public to oversee their performance. Several countries have experimented with direct elections to healthcare organizations. The most directly comparable examples involve some Canadian regional health authorities, New Zealand district health boards, foundation trusts in England and health boards in Scotland. We propose three aspects of the process by which the democratizing effects of elections should be judged: authorization, accountability and influence. Evidence from these countries suggests that the democratization of health systems is a complex task, which cannot be completed simply by introducing elections. Copyright © 2015 John Wiley & Sons, Ltd.

The New Political Economy of Health Care in the European Union: The Impact of Fiscal Governance.

We argue that the political economy of health care in the European Union is being changed by the creation of a substantial new apparatus of European fiscal governance. A series of treaties and legal changes since 2008 have given the European Union new powers and duties to enforce budgetary austerity in the member states, and this apparatus of fiscal governance has already extended to include detailed and sometimes coercive policy recommendations to member states about the governance of their health care systems. We map the structures of this new fiscal governance and the way it purports to affect health care decision making.

Restricting Access to Health Care to Immigrants in Barcelona: A Mixed-Methods Study With Immigrants Who Have Experienced an Infectious Disease.

Austerity policies implemented in Spain in response to the ongoing economic crisis may have detrimental consequences for the health of immigrant populations and for public health in general. A mixed-methods study by the Public Health Agency of Barcelona and the University of Michigan indicates that the Real Decreto-ley 16/2012 (RDL) threatens the health of individuals and the population, especially in the case of infectious diseases. The study sought to determine the percentage of foreign-born persons with an infectious disease who had an Individual Health Card (IHC) prior to the RDL and to determine whether foreign-born persons with an infectious disease in Barcelona encountered problems accessing health care after the RDL. Results indicate that immigrants used the IHC to seek medical attention for infectious diseases and chronic conditions. Results also show that 66% of respondents, including 54% of unemployed respondents, 3% of respondents working without contracts, and those in informal employment (9%), may be at risk of losing at least part of their health coverage. Universal health care access in Spain has been crucial for the control of communicable diseases among immigrant populations. Reducing access to a significant percentage of the total population may have deleterious effects on public health.

Universal Health Coverage: A Political Struggle and Governance Challenge.

Universal health coverage has become a rallying cry in health policy, but it is often presented as a consensual, technical project. It is not. A review of the broader international literature on the origins of universal coverage shows that it is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics. On one hand, a variety of comparative research has shown that health coverage is associated with democratic political accountability. Democratization, and in particular left-wing parties, gives governments particular cause to expand health coverage. On the other hand, governance, the ways states make and implement decisions, shapes any decision to strive for universal health coverage and the shape of its implementation.

Health law and policy in the European Union.

From its origins as six western European countries coming together to reduce trade barriers, the European Union (EU) has expanded, both geographically and in the scope of its actions, to become an important supranational body whose policies affect almost all aspects of the lives of its citizens. This influence extends to health and health services. The EU's formal responsibilities in health and health services are limited in scope, but, it has substantial indirect influence on them. In this paper, we describe the institutions of the EU, its legislative process, and the nature of European law as it affects free movement of the goods, people, and services that affect health or are necessary to deliver health care. We show how the influence of the EU goes far beyond the activities that are most visible to health professionals, such as research funding and public health programmes, and involves an extensive body of legislation that affects almost every aspect of health and health care.

I'll be gone, you'll be gone: why American employers underinvest in health.

It has become increasingly common to hear a business case for wellness that emphasizes the benefits of having a healthy workforce. This is essentially the same as the case for employers to train their workers; training a worker and investing in the health of the worker both represent a productivity-enhancing investment in the worker by the firm. The problem is that the employer frequently fails to capture the returns on the investment. A healthier or better-skilled worker can command a higher wage and threaten to leave the firm making the investment. This risk of failing to capture the gains from investment produces underinvestment in skills and, by the same mechanism, should produce underinvestment in workforce wellness. We further divide wellness into positive and negative policies: Positive wellness is an investment, expenditure on the workforce in expectation of future increased returns, or perhaps better recruitment and retention. Negative wellness is an effort to reduce the wage bills associated with ill health with, for example, co-pays. Most stable and meaningful employer wellness programs are likely to be negative wellness programs that reduce the effective wages of the sick.