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Most research on health care equity focuses on accessing services, with less attention given to how revenue is collected to pay for a country's health care bill. This article examines the progressivity of revenue collection among publicly funded sources: income taxes, social insurance (often in the form of payroll) taxes, and consumption taxes (e.g., value-added taxes). We develop methodology to derive a qualitative index that rates each of 29 high-income countries as to its progressivity or regressivity for each of the three sources of revenue. A variety of data sources are employed, some from secondary data sources and other from country representatives of the Health Systems and Policy Monitor of the European Observatory on Health Systems and Policies. We found that countries with more progressive income tax systems used more income-based tax brackets and had larger differences in marginal tax rates between the brackets. The more progressive social insurance revenue collection systems did not have an upper income cap and exempted poorer persons or reduced their contributions. The only pattern regarding consumption taxes was that countries that exhibited the fewest overall income inequalities tended to have least regressive consumption tax policies. The article also provides several examples from the sample of countries on ways to make public revenue financing of health care more progressive., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Gestational diabetes mellitus and overweight are associated with an increased likelihood of complications during birth and for the newborn baby. These complications lead to increased immediate and long-term healthcare costs as well as reduced health and well-being in women and infants. This protocol presents the health economic evaluation to investigate the cost-effectiveness of Bump2Baby and Me (B2B&Me), which is a health coaching intervention delivered via smartphone to women at risk of gestational diabetes., Methods and Analysis: Using data from the B2B&Me randomised controlled trial, this economic evaluation compares costs and health effects between the intervention and control group as an incremental cost-effectiveness ratio. Direct healthcare costs, costs of pharmaceuticals and intervention costs will be included in the analysis, body weight and quality-adjusted life-years for the mother will serve as the effect outcomes. To investigate the long-term cost-effectiveness of the trial, a Markov model will be employed. Deterministic and probabilistic sensitivity analysis will be employed., Ethics and Dissemination: The National Maternity Hospital Human Research and Ethics Committee was the primary approval site (EC18.2020) with approvals from University College Dublin HREC-Sciences (LS-E-20-150-OReilly), Junta de Andalucia CEIM/CEI Provincial de Granada (2087-M1-22), Monash Health HREC (RES-20-0000-892A) and National Health Service Health Research Authority and Health and Care Research Wales (HCRW) (21/WA/0022). The results from the analysis will be disseminated in scientific papers, through conference presentations and through different channels for communication within the project., Trial Registration Number: ACTRN12620001240932., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Demographic changes in all industrialized countries have led to a keen interest in extending working lives for older workers. To achieve this goal, it is essential to understand the patterns of retirement and specifically what characterizes individuals who continue to work beyond retirement age. Thus, the aim of this paper was to contribute to the international body of empirical knowledge about individuals who continue in the workforce after retirement age. We present evidence from Denmark and examine what characterizes individuals who continue in the workforce after retirement age and investigate the likelihood of continued work after retirement age while controlling for a set of socio-economic and lifestyle factors., Methods: The study population consisted of 5,474 respondents to the Copenhagen Aging and Midlife Biobank (CAMB) 2021 survey, divided into two groups. The first group included subjects (n = 1,293) who stayed longer in the workforce even though they had the possibility to retire. The second group consisted of subjects who had retired full-time at the time of the survey (n = 4,181). Survey data was linked to register data to provide a broader dataset. In order to investigate the heterogeneity between the two groups in terms of important socio-economic, work-related and health-related variables, t-test, Mann-Whitney U (Wilcoxon Rank) test, and chi-square tests were employed. Further, to examine the probability of an individual working after retirement age a logit model with step-wise inclusion was utilized., Results: Overall, individuals who continue to work even though they could retire tend to be wealthier, healthier, and males compared to individuals who are retired full-time. Further, there are more older workers who have partners and are co-habitants than retirees. The likelihood of continuing in the workforce past retirement age is affected by several work-related factors as well as life-style factors. The likelihood of working past retirement age decreases by years spent in the workforce (marginal effect of -0.003), if you have a partner (-0.080) and if your partner is outside of the workforce (marginal effect of -0.106). The likelihood increases by health (marginal effect of -0.044 of moving from excellent/very good health to good health or to fair/poor health, physical working capability (marginal effect of -0.083 of moving from no/some problems to severe problems or cannot work at all) and income (marginal effect of 0.083 from moving from the lowest income-quantile to higher quantiles)., Conclusion: These results are in line with the previous literature and suggest the importance of designing retirement policies that tailor the transition toward retirement according to specific characteristics of both the individual and the segment of occupation., (© 2024. The Author(s).)

This analysis of the Danish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Population health in Denmark is good and improving, with life expectancy above the European Union (EU) average but is, however, lagging behind the other Nordic countries. Denmark has a universal and tax-financed health system, providing coverage for a comprehensive package of health services. Notable exclusions to the benefits package include outpatient prescription drugs and adult dental care, which require co-payment and are the main causes of out-of-pocket spending. The hospital sector has been transformed during the past 15 years through a process of consolidating hospitals and the centralization of medical specialties. However, in recent years, there has been a move towards decentralization to increase the volume and quality of care provided outside hospitals in primary and local care settings. The Danish health care system is, to a very high degree, based on digital solutions that health care providers, citizens and institutions all use. Ensuring the availability of health care in all parts of Denmark is increasingly seen as a priority issue. Ensuring sufficient health workers, especially nurses, poses a significant challenge to the Danish health system's sustainability and resilience. While a comprehensive package of policies has been put in place to increase the number of nurses being trained and retain those already working in the system, such measures need time to work. Addressing staffing shortages requires long-term action. Profound changes in working practices and working environments will be required to ensure the sustainability of the health workforce and, by extension, the health system into the future., (World Health Organization 2024 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

Background: Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality., Methods: A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined., Results: Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history., Conclusion: In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall., (© 2024. The Author(s).)

Background: The COVID-19 pandemic necessitated wide-ranging adaptations to the organisation of health systems, and primary care is no exception. This article aims to collate insights on the role of primary care during the pandemic. The gained knowledge helps to increase pandemic preparedness and resilience., Methods: The role of primary care during the pandemic in five European countries (Austria, Denmark, France, Hungary, Italy) was investigated using a qualitative approach, namely case study, based on document analysis and semi-structured interviews. In total, 31 interviews were conducted with primary care providers between June and August 2022. The five country case studies were subjected to an overarching analysis focusing on successful strategies as well as gaps and failures regarding pandemic management in primary care., Results: Primary care providers identified disruptions to service delivery as a major challenge emerging from the pandemic which led to a widespread adoption of telehealth. Despite the rapid increase in telehealth usage and efforts of primary care providers to organise face-to-face care delivery in a safe way, some patient groups were particularly affected by disruptions in service delivery. Moreover, primary care providers perceived a substantial propagation of misinformation about COVID-19 and vaccines among the population, which also threatened patient-physician relationships. At the same time, primary care providers faced an increased workload, had to work with insufficient personal protective equipment and were provided incongruous guidelines from public authorities. There was a consensus among primary care providers that they were mostly sidelined by public health policy in the context of pandemic management. Primary care providers tackled these problems through a diverse set of measures including home visits, implementing infection control measures, refurbishing used masks, holding internal meetings and relying on their own experiences as well as information shared by colleagues., Conclusion: Primary care providers were neither well prepared nor the focus of initial policy making. However, they implemented creative solutions to the problems they faced and applying the learnings from the pandemic could help in increasing the resilience of primary care. Attributes of an integrated health system with a strong primary care component proved beneficial in addressing immediate effects of the pandemic., (© 2023. BioMed Central Ltd., part of Springer Nature.)

We assessed challenges that the COVID-19 pandemic presented for mental health systems and the responses to these challenges in 14 countries in Europe and North America. Experts from each country filled out a structured questionnaire with closed- and open-ended questions between January and June 2021. We conducted thematic analysis to investigate the qualitative responses to open-ended questions, and we summarized the responses to closed-ended survey items on changes in telemental health policies and regulations. Findings revealed that many countries grappled with the rising demand for mental health services against a backdrop of mental health provider shortages and challenges responding to workforce stress and burnout. All countries in our sample implemented new policies or initiatives to strengthen mental health service delivery - with more than two-thirds investing to bolster their specialized mental health care sector. There was a universal shift to telehealth to deliver a larger portion of mental health services in all 14 countries, which was facilitated by changes in national regulations and policies; 11 of the 14 participating countries relaxed regulations and 10 of 14 countries made changes to reimbursement policies to facilitate telemental health care. These findings provide a first step to assess the long-term challenges and re-organizational effect of the COVID-19 pandemic on mental health systems in Europe and North America., (Copyright © 2023. Published by Elsevier B.V.)

Health systems internationally face demands to deliver care that is better coordinated and integrated. The health system financing and delivery model may go some, but not all the way in explaining health system fragmentation. In this paper, we consider the road to care integration in two countries with Beveridge style health systems, England and Denmark, that are both ranked as highly Integrated systems in Toth's health integration index. We use the SELFIE framework to compare the policies and reforms that have affected care integration over the past 30 years in the two countries. The countries both started their reform path by reforming to introduce choice and competition, but did so in different ways that set them on different pathways. Nevertheless, after two decades, the countries ended the period with largely similar structures that emphasised the creation of a cross-sectoral governance structure. In the relatively centralised England, by introducing decentralised Integrated Care Systems, and in the relatively decentralised Denmark with a centralising element in the form of new Health Clusters.

Introduction: Denmark and Sweden initially adopted different responses to the COVID-19 pandemic although the two countries share many characteristics. Denmark responded swiftly with many mandatory restrictions. In contrast, Sweden relied on voluntary restrictions and a more "relaxed" response during the first wave of the pandemic. However, increased rates of COVID-19 cases led to a new approach that involved many more mandatory restrictions, thus making Sweden's response similar to Denmark's in the second wave of the pandemic., Aim: The aim was to investigate and compare the extent to which the populations in Denmark and Sweden considered the COVID-19 restrictions to be acceptable during the first two waves of the pandemic. The study also aimed to identify the characteristics of those who were least accepting of the restrictions in the two countries., Materials and Methods: Cross-sectional surveys were conducted in Denmark and Sweden in 2021. The study population was sampled from nationally representative web panels in the two countries, consisting of 2,619 individuals from Denmark and 2,633 from Sweden. The questionnaire captured key socio-demographic characteristics. Acceptability was operationalized based on a theoretical framework consisting of seven constructs and one overarching construct., Results: The respondents' age and gender patterns were similar in the two countries. The proportion of respondents in Denmark who agreed with the statements ("agree" alternative) that captured various acceptability constructs was generally higher for the first wave than the second wave of the pandemic. The opposite pattern was seen for Sweden. In Denmark, 66% in the first wave and 50% in the second wave were accepting of the restrictions. The corresponding figures for Sweden was 42% (first wave) and 47% (second wave). Low acceptance of the restrictions, defined as the 25% with the lowest total score on the seven acceptability statements, was associated with younger age, male gender and lower education levels., Conclusion: Respondents in Sweden were more accepting of the restrictions in the second wave, when the country used many mandatory restrictions. In contrast, respondents in Denmark were more accepting of the restrictions in the first wave than in the second wave, implying an increased weariness to comply with the restrictions over time. There were considerable socio-demographic differences between those who expressed low acceptance of the restrictions and the others in both countries, suggesting the importance of tailoring communication about the pandemic to different segments of the population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Nilsen, Seing, Sekhon, Kallemose, Tjørnhøj-Thomsen, Stefánsdóttir, Vrangbæk, Andersen and Kirk.)

Background: The COVID-19 pandemic highlighted the fragmented nature of governmental policy decisions in Europe. However, the extent to which COVID-19 vaccination policies differed between European countries remains unclear. Here, we mapped the COVID-19 vaccination policies that were in effect in January 2022 as well as booster regulations in April 2022 in Austria, Denmark, England, France, Germany, Ireland, Italy, the Netherlands, Poland, and Spain., Methods: National public health and health policy experts from these ten European nations developed and completed an electronic questionnaire. The questionnaire included a series of questions that addressed six critical components of vaccine implementation, including (1) authorization, (2) prioritization, (3) procurement and distribution, (4) data collection, (5) administration, and (6) mandate requirements., Results: Our findings revealed significant variations in COVID-19 vaccination policies across Europe. We observed critical differences in COVID-19 vaccine formulations authorized for use, as well as the specific groups that were provided with priority access. We also identified discrepancies in how vaccination-related data were recorded in each country and what vaccination requirements were implemented., Conclusion: Each of the ten European nations surveyed in this study reported different COVID-19 vaccination policies. These differences complicated efforts to provide a coordinated pandemic response. These findings might alert policymakers in Europe of the need to coordinate their efforts to avoid fostering divergent and socially disruptive policies., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Bjelle Roberts reports a relationship with Merck Sharp and Dohme that includes: employment. Isabelle Durand-Zaleski reports a relationship with Pfizer that includes: consulting or advisory., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aims: The aim of the SCIENCE trial was to investigate whether a single treatment with direct intramyocardial injections of adipose tissue-derived mesenchymal stromal cells (CSCC&#95;ASCs) was safe and improved cardiac function in patients with chronic ischaemic heart failure with reduced ejection fraction (HFrEF)., Methods and Results: The study was a European multicentre, double-blind, placebo-controlled phase II trial using allogeneic CSCC&#95;ASCs from healthy donors or placebo (2:1 randomization). Main inclusion criteria were New York Heart Association (NYHA) class II-III, left ventricular ejection fraction (LVEF) <45%, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels >300 pg/ml. CSCC&#95;ASCs or placebo (isotonic saline) were injected directly into viable myocardium. The primary endpoint was change in left ventricular end-systolic volume (LVESV) at 6-month follow-up measured by echocardiography. A total of 133 symptomatic HFrEF patients were included. The treatment was safe without any drug-related severe adverse events or difference in cardiac-related adverse events during a 3-year follow-up period. There were no significant differences between groups during follow-up in LVESV (0.3 ± 5.0 ml, p = 0.945), nor in secondary endpoints of left ventricular end-diastolic volume (-2.0 ± 6.0 ml, p = 0.736) and LVEF (-1.6 ± 1.0%, p = 0.119). The NYHA class improved slightly within the first year in both groups without any difference between groups. There were no changes in 6-min walk test, NT-proBNP, C-reactive protein or quality of life the first year in any groups., Conclusion: The SCIENCE trial demonstrated safety of intramyocardial allogeneic CSCC&#95;ASC therapy in patients with chronic HFrEF. However, it was not possible to improve the pre-defined endpoints and induce restoration of cardiac function or clinical symptoms., (© 2023 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

This contribution examines the responses of five health systems in the first wave of the COVID-19 pandemic: Denmark, Germany, Israel, Spain and Sweden. The aim is to understand to what extent this crisis response of these countries was resilient. The study focuses on hospital care structures, considering both existing capacity before the pandemic and the management and expansion of capacity during the crisis. Evaluation criteria include flexibility in the use of existing resources and response planning, as well as the ability to create surge capacity. Data were collected from country experts using a structured questionnaire. Main findings are that not only the total number but also the availability of hospital beds is critical to resilience, as is the ability to mobilise (highly) qualified personnel. Indispensable for rapid capacity adjustment is the availability of data. Countries with more centralised hospital care structures, more sophisticated concepts for providing specialised services and stronger integration of the inpatient and outpatient sectors have clear structural advantages. A solid digital infrastructure is also conducive. Finally, a centralised governance structure is crucial for flexibility and adaptability. In decentralised systems, robust mechanisms to coordinate across levels are important to strengthen health care system resilience in pandemic situations and beyond.

Chronic diseases are major causes of death and reduction in the quality of life worldwide, and their prevalence is expected to rise due to changing demographics. Disease management programmes (DMPs) have been presented as a policy response to challenges of care coordination for such chronic diseases. This paper investigates the implementation of DMPs in a National Health Care system in the Nordic region using type II diabetes as an example. DMPs are detailed descriptions of the sequence and responsibilities for diagnostic, treatment, rehabilitation and prevention procedures. The paper applies a systemic implementation perspective to provide detailed analysis of implementation progress, issues and concerns. The implementation analysis shows that the framework of DMP has facilitated the development of new practices and attention to the roles that each of the stakeholders are playing within the service delivery. Many new initiatives contribute to improved coordination and overall management of the Type 2 diabetes (T2DB) population. Yet, there are also several cross-cutting challenges that are affecting the implementation process.

Objective: Despite aims of equal access to treatment and care in the Nordic countries, marked socioeconomic inequality in the development of type 2 diabetes (T2D) complications persists. The study purpose was to estimate the associations of individual socioeconomic position and deprivation at the general practitioner (GP) level with referrals to T2D rehabilitation.Research Design and Methods: In 2015-2018, 3390 people affiliated with 432 primary GPs living in the municipality of Copenhagen were identified through registry data as newly diagnosed with T2D. Of these, 656 (19%) individuals were referred to municipal rehabilitation services in 2015-2021. Individual socioeconomic position was measured by education, income, and employment. The Danish Deprivation Index (DADI) was used as a measure of GP-level deprivation., Results: Patients were more likely to be referred to municipal rehabilitation if they had low vs. high income (hazard ratio (HR) 2.87 [women], 1.64 [men]), were not employed vs. employed (HR 1.95 [women], 1.23 [men]) and were affiliated with GPs with a low vs. very high level of deprivation (HR 7.63 [women], 4.30 [men]). The results suggest that GPs practice proportionate universalism by allocating treatment to lower socioeconomic individuals in likely higher need of care. However, the overall HR for referrals was lower among GPs with more deprived patient populations, indicating unequal treatment of all citizens, which conflicts with the aims of general universal health care. Inequality in rehabilitation healthcare services must be further addressed and investigated to prevent exacerbating health disparities., (© 2022 Published by Elsevier Ltd.)

This study aimed to investigate the potential protective role of baseline resources and capabilities for experiencing challenges to emotional well-being and perceived access to and quality of diabetes care during the COVID-19 pandemic in a Danish type 2 diabetes population (N = 1608). We investigated how differences in self-efficacy, well-being capability, socioeconomic status, health status, and perceptions of diabetes care measured before the COVID-19 pandemic were related to experiences of well-being and diabetes management challenges during the pandemic. The study is based on a survey conducted shortly before the pandemic (autumn 2019) and a follow-up survey during the pandemic (autumn 2020), which included questions about impacts of the pandemic. We used this longitudinal data to quantitatively investigate in regression analyses how self-reported baseline indicators of chronic care access and quality (PACIC), self-efficacy (GSE), health (EQ VAS), and well-being capability (ICECAP-A), and registry-based socioeconomic indicators were associated with the probability of reporting negative impacts on emotional wellbeing and diabetes management. Results showed that respondents with higher baseline general self-efficacy and higher well-being capability scores, who more often considered care well-organised and were in better health before the pandemic, were less likely to report pandemic-related negative impacts on emotional well-being. Considering diabetes care well organised before the pandemic was associated with a lower probability of adverse impacts on diabetes care. The results thus broadly confirmed that several indicators of higher levels of baseline resources and capabilities were associated with a lower probability of reporting negative impacts of the pandemic. However, some variation in predictors was observed for general well-being outcomes, compared to diabetes-care specific challenges, and findings on socioeconomic status as indicated by education were mixed., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care., (Copyright © 2021. Published by Elsevier B.V.)

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Chronic diseases are highly important for the future level and distribution of health and well-being in western societies. Consequently, it seems pertinent to assess not only efficiency of chronic care but also its impact on health equity. However, operationalisation of health equity has proven a challenging task. Challenges include identifying a relevant and measurable evaluative space. Various schools of thought in health economics have identified different outcomes of interest for equity assessment, with capabilities as a proposed alternative to more conventional economic conceptualisations. The aim of this paper is to contribute to the conceptualisation of health equity evaluation in the context of chronic disease management. We do this by firstly introducing an equity enquiry framework incorporating the capabilities approach. Secondly, we demonstrate the application and relevance of this framework through a content analysis of equity-related principles and aims in national chronic disease management guidelines and the national diabetes action plan in Denmark. Finally, we discuss how conceptualisations of equity focused on capabilities may be used in evaluation by scoping relevant operationalisations. A promising way forward in the context of chronic care evaluation may emerge from a combination of concepts of capabilities developed in economics, health sciences and psychology.

Healthcare inequities are often investigated empirically as associations between socio-economic characteristics and differences between observed healthcare utilisation and estimates of needs-based utilisation. However, the concept of 'need' is tricky to operationalise and utilisation may be contingent on inequities arising at an earlier stage. In this study, we apply a unique combination of register and survey data collected in 2019 to assess equity in opportunities to access treatment for patients with recently diagnosed type 2 diabetes. In the study of this population (N = 1864) we escape the challenge of estimating needs by arguing that need can be approximated from treatment guidelines within a nationwide framework of disease management programmes. Furthermore, instead of observed utilisation we use patient reports on whether they have been offered treatment as a measure of opportunities to access multiple components of care, that is, we focus on possible inequalities arising prior to possible utilisation inequalities. 'Healthcare gaps' are computed as the discrepancy between an index of guideline recommended treatments and patients' perceived offers of treatments, thus providing a novel take on the 'healthcare deprivation profiles' approach to the study of healthcare inequalities. Using this method, we explore and document inequalities along multiple dimensions of familiar socio-economic factors (income, education, occupation) as well as self-reported barriers to access. We also provide supporting evidence that healthcare gaps, as measured in our study, are associated with poorer quality of care, and that those who experience large gaps are more likely to be disadvantaged in terms of self-reported difficulties in relation to key self-care aspects. We conclude that even in a health system with comprehensive universal coverage, healthcare inequity can arise already at the stage of offering access to preventive treatment. The results warrant further research into the causes, consequences and remedies of such inequities., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Gestational diabetes (GDM) impacts 8-18% of pregnancies and greatly increases both maternal and child risk of developing non-communicable diseases such as type 2 diabetes and obesity. Whilst lifestyle interventions in pregnancy and postpartum reduce this risk, a research translation gap remains around delivering implementable interventions with adequate population penetration and participation. Impact Diabetes Bump2Baby is an implementation project of an evidence-based system of care for the prevention of overweight and obesity. Bump2Baby and Me is the multicentre randomised controlled trial investigating the effectiveness of a mHealth coaching programme in pregnancy and postpartum for women at high risk of developing GDM., Methods: Eight hundred women will be recruited in early pregnancy from 4 clinical sites within Ireland, the UK, Spain, and Australia. Women will be screened for eligibility using the validated Monash GDM screening tool. Participants will be enrolled from 12 to 24 weeks' gestation and randomised on a 1:1 basis into the intervention or control arm. Alongside usual care, the intervention involves mHealth coaching via a smartphone application, which uses a combination of synchronous and asynchronous video and text messaging, and allows for personalised support and goal setting with a trained health coach. The control arm receives usual care. All women and their children will be followed from early pregnancy until 12 months postpartum. The primary outcome will be a difference in maternal body mass index (BMI) of 0.8 kg/m 2 at 12 months postpartum. Secondary maternal and infant outcomes include the development of GDM, gestational weight gain, pregnancy outcomes, improvements in diet, physical activity, sleep, and neonatal weight and infant growth patterns. The 5-year project is funded by the EU Commission Horizon 2020 and the Australian National Health and Medical Research Council. Ethical approval has been received., Discussion: Previous interventions have not moved beyond tightly controlled efficacy trials into routine service delivery. This project aims to provide evidence-based, sustainable support that could be incorporated into usual care for women during pregnancy and postpartum. This study will contribute evidence to inform the early prevention of non-communicable diseases like obesity and diabetes in mothers and the next generation., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001240932 . Registered on 19 November 2020., (© 2021. The Author(s).)

Background: Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts., Methods: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms., Results: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments)., Conclusion: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care., Competing Interests: Conflict of interests None., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Aims/hypothesis: High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities., Methods: Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40-59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension., Results: Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity., Conclusions/interpretation: In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Social distancing measures have been a key component in government strategies to mitigate COVID-19 globally. Based on official documents, this study aimed to identify, compare and analyse public social distancing policy measures adopted in Denmark and Sweden regarding the coronavirus from 1 March 2020 until 1 October 2020. A key difference was the greater emphasis on laws and executive orders (sticks) in Denmark, which allowed the country to adopt many stricter policy measures than Sweden, which relied mostly on general guidelines and recommendations (sermons). The main policy adopters in Denmark were the government and the Danish Parliament, whereas the Public Health Agency issued most policies in Sweden, reflecting a difference in political governance and administrative structure in the two countries. During the study period, Sweden had noticeably higher rates of COVID-19 deaths and hospitalizations per 100,000 population than Denmark, yet it is difficult to determine the impact or relative effectiveness of sermons and sticks, particularly with regard to broader and longer-term health, economic and societal effects.

Type 2 diabetes mellitus represents a multi-dimensional challenge for European and global societies alike. Building on an iterative six-step disease management process that leverages feedback loops and utilizes commodity digital tools, the PDM-ProValue study program demonstrated that integrated personalized diabetes management, or iPDM, can improve the standard of care for persons living with diabetes in a sustainable way. The novel "iPDM Goes Europe" consortium strives to advance iPDM adoption by (1) implementing the concept in a value-based healthcare setting for the treatment of persons living with type 2 diabetes, (2) providing tools to assess the patient's physical and mental health status, and (3) exploring new avenues to take advantage of emerging big data resources., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Physician turnover is a concern in many health care systems globally. A better understanding of physicians' reasons for leaving their job may inform organisational policies to retain key personnel. The aim of this study was to investigate hospital physicians' intention to leave their current job, and to investigate if such intentions are associated with how physicians assess their leaders and the organisational context., Methods: Data was derived from a survey of 971 physicians working in public hospitals in Norway in 2016. The data was analysed using descriptive statistics and multivariate analysis., Results: We found that 21.0% of all hospital physicians expressed an intention to leave their current job for another job. An additional 20.3% of physicians had not made up their mind whether to stay or leave. Physicians' perceptions of their leaders and the organisational context influence their intention to leave their hospital. Respondents who perceived their leaders as professional-supportive had a significantly lower probability of reporting an intention to leave their job. The analysis suggests that organisational context, such as department mergers, weigh in on physicians' considerations about leaving their current job. Social climate and commitment are important reasons why physician stay., Conclusions: A professional-supportive leadership style may have a positive influence on retention of physicians in public hospitals. Further research should investigate how retention of physicians is associated with performance related to organisational and leadership style.

Aims: Ischaemic heart failure (IHF) patients have a poor prognosis even with current guideline-derived therapy. Intramyocardial injections of autologous or allogeneic mesenchymal stromal cells might improve cardiac function leading to better clinical outcome., Methods: The SCIENCE (Stem Cell therapy in IschEmic Non-treatable Cardiac diseasE) consortium has initiated a Horizon 2020 funded multicentre phase II study in six European countries. It is a double-blind, placebo-controlled trial testing the safety and efficacy of allogeneic Cardiology Stem Cell Centre Adipose-derived Stromal Cells (CSCC&#95;ASC) from healthy donors or placebo in 138 symptomatic IHF patients. Main inclusion criteria are New York Heart Association class II-III, left ventricular ejection fraction < 45% and N-terminal pro-B-type natriuretic peptide levels > 300 pg/mL. Patients are randomized in a 2:1 pattern to receive intramyocardial injections of either CSCC&#95;ASC or placebo. CSCC&#95;ASC and placebo treatments are prepared centralized at Rigshospitalet in 5 mL vials as an off-the-shelf product. Vials are distributed to all clinical partners and stored in nitrogen vapour tanks ready to be used directly after thawing. A total of 100 × 10 6 CSCC&#95;ASC or placebo are injected directly into viable myocardium in the infarct border zone using the NOGA XP system (BDS, Cordis, Johnson & Johnson, USA). Primary endpoint is a centralized core-laboratory assessed change in left ventricular end-systolic volume at 6-month follow-up measured by echocardiography. The trial started in January 2017, 58 patients were included and treated until July 2018., Conclusion: The SCIENCE trial will provide clinical data on efficacy and safety of intramyocardial cell therapy of allogeneic adipose-derived stromal cells from healthy donors in patients with IHF., (© 2019 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Introduction: Community health centres accommodating different professional groups are expected to improve inter-sectoral collaboration between primary care providers. This study aimed to identify what has been done to support inter-sectoral collaboration between municipal professionals and general practitioners in health centres, and to explore the interactions that emerge between these professionals at the operational level., Methods: The study was a multi-site qualitative study carried out in four municipal health centres in a Danish region. The study was based on documents and qualitative interviews with general practitioners, and municipal professionals and administrators in each of the health centres. A content analysis was conducted., Results: The study found that little attention had been given to the organizational prerequisites for enhanced inter-sectoral collaboration in the health centres. Even though some health centres had employed coordinators, these did not play a significant role as facilitators of collaboration partly due to a lack of political and managerial attention. At the operational level, inter-sectoral collaboration was limited to ad hoc interactions between professionals. Although these interactions could be useful, they did not evolve into more systematic forms of collaboration., Conclusion: The gap between policy visions and actual implementation efforts found in this study suggests that a more active and focused engagement from the political-administrative level is needed if the visions of increased inter-sectoral collaboration in health centres are to be realised., Competing Interests: The authors have no competing interests to declare.

Demographic transitions in Europe accentuate the need to develop innovative solutions for healthy ageing. One increasingly popular policy approach is co-production between local governments and voluntary community associations (VCOs) to promote activities for health and wellbeing among older adults. While co-production has been studied from the perspective of local governments there is limited knowledge regarding how voluntary associations perceive their conditions. This study aims to fill this gap using survey data from voluntary associations in Denmark. The investigation is based on an electronic survey (n = 263) of VCOs engaged in activities relevant for healthy ageing in three Danish municipalities. The survey addressed 13 issues and potential problems within four categories - ''members and volunteers', 'economics, 'media and the public' and '´politics and the local government'. The paper presents a relatively positive picture of the potentials in municipal-VCO collaboration. However, we also find that a sizeable number of VCOs point to problems and obstacles particular in regards to recruitment of members and economics. While the municipalities in our study have all developed strategies to support VCOs and to promote coproduction it seems that there are deficits in the implementation of the strategies. This leads us to conclude that municipalities must pay close attention to the issues and conditions for VCOs in order to succeed with their policy initiatives in this area., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Denmark implemented a major reform of the administrative and political structure in 2007 when the previous 13 counties were merged into five new regions and the number of municipalities was reduced from 271 to 98. A main objective was to create administrative units that were large enough to support a hospital structure with few acute hospitals in each region and to centralize specialized care in fewer hospitals. This paper analyses the reorganization of the somatic hospital sector in Denmark since 2007, discusses the mechanisms behind the changes and analyses hospital performance after the reform. The reform focused on improving acute services and quality of care. The number of acute hospitals was reduced from about 40-21 hospitals with new joint acute facilities, which include emergency care wards. The restructuring and geographical placement of acute hospitals took place in a democratic process subject to central guidelines and requirements. Since the reform, hospital productivity has increased by more than 2 per cent per year and costs have been stable. Overall, indicators point to a successful reform. However, it has also been criticized that some people in remote areas feel "left behind" in the economic development and that hospital staff are under increased workload pressure. Concurrent with the centralization of hospitals municipalities strengthened their health service with an emphasis on prevention and health promotion., (Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: What is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies., Methods: The review was based on a methodological approach inspired by the British EPPI-Centre's methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality., Results: Our review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals., Conclusions: The paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

The issue of integrated care and inter-sectoral collaboration is on the health policy agenda in many countries. Yet, there is limited knowledge about the effects of the different policy instruments used to achieve this. This paper studies co-location as a driver for cross-sectoral collaboration with general practitioners (GPs) acting as coordinators in a municipal health centre. The purpose of the health centre, which is staffed by health professionals from municipal, regional and private sectors, is to provide primary health services to the citizens of the municipality. Co-locating these professionals is supposed to benefit e.g., elder citizens and patients with chronic diseases who frequently require services from health professionals across administrative sectors. Methodologically, the analysis is based on qualitative data in the form of semi-structured interviews with the health professionals employed at the health centre and with administrative managers from municipal and regional government levels. The study finds that co-location does not function as a driver for cross-sectoral collaboration in a health centre when GPs act as coordinators. Cross-sectoral collaboration is hampered by the general practitioners' work routines and professional identity, by organisational factors and by a lack of clarity concerning the content of collaboration with regard to economic and professional incentives.

Denmark is a small Northern European country with an extensive welfare state and a strong commitment to maintaining a universal healthcare system. Like the other countries in the Nordic region, Denmark has a long tradition of democratically governed local and regional governments with extensive responsibilities in organizing welfare state services. The Danish healthcare system has demonstrated an ability to increase productivity, while at the same time maintaining a high level of patient satisfaction. Ongoing reforms have contributed to these results, as well as a firm commitment to innovation and coordination. Regions and municipalities in Denmark are governed by directly elected democratic councils. The Danish case is thus an example of democratic decentralization, but within a framework of national coordination and fiscal control. In spite of the difference in size and historical traditions there are also many similarities between Canada and Denmark, particularly in terms of health and social policy goals and aspirations, and in terms of the commitment to a comprehensive, universal healthcare system. These similarities provide interesting opportunities for comparison.

Objectives: To evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP., Methods: On the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information., Results: At the end of the study period (2007-2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional--as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed., Conclusions: Our study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

The commentary discusses key issues for assessment of performance management within health care. It supports the ambition to develop more realistic understandings of performance management based on insights from behavioral economics as suggested by Adam Oliver. However, it also points to several pitfalls and potential risks to consider when doing so. The commentary concludes that this is a promising field, but further research is needed to support the development of policy instruments.

Purpose: The purpose of this paper is to investigate different types of patient involvement in Denmark, and to discuss the potential implications of pursuing several strategies for patient involvement simultaneously., Design/methodology/approach: The paper presents a preliminary framework for analysis of patient involvement in health care. This framework is used to analyze key governance features of patient involvement in Denmark based on previous research papers and reports describing patient involvement in Danish health care., Findings: Patient involvement is important in Denmark at the rhetorical level, and many policies and initiatives have been introduced. All three governance forms (voice, choice and co-production) are used. However, there are important barriers and limitations in translating the rhetoric into practice, and potential synergy and negative synergy effects can be identified when pursuing the strategies at the same time., Research Limitations/implications: Because of the chosen research approach, the research results may lack generalizability. Therefore, researchers are encouraged to test the proposed framework further., Practical Implications: The paper includes implications for the development of patient involvement in health care., Originality/value: This paper fulfills a need to study different types of patient involvement and to develop a theoretical framework for characterizing and analyzing such involvement strategies.

Denmark, Finland and Sweden have experienced two major recessions during the last 25 years. The adjustments to the earlier crisis in the late 1980s (Denmark) and early 1990s (Finland and Sweden) resembled the policies in many other European countries during the present crisis. The analysis of relationship of deep economic crises and growth period between them to the health system policies and institutions in the three countries from the 1980s to 2013 is based on a categorisation of reactions to external shocks as path conforming or path breaking. The results of the empirical long-term trends show that the reactions to deep recessions have been mainly temporary adjustments and acceleration of changes already prepared before economic crisis. The economic crisis in the three countries has not been 'good enough' to enable paradigmatic changes in the Nordic public, decentralised and equity-oriented health systems. Changes such as the slow privatisation in care funding and production and the adoption of new management practices indicate an ongoing paradigmatic change related to longer-term societal, ideological and political developments rather than directly to economic crises or growth.

Introduction: In 2007, a substantial reform changed the administrative boundaries of the Danish health care system and introduced health care agreements to be signed between municipal and regional authorities. To assess the health care agreements as a tool for coordinating health and social services, a survey was conducted before (2005-2006) and after the reform (2011)., Theory and Methods: The study was designed on the basis of a modified version of Alter and Hage's framework for conceptualising coordination. Both surveys addressed all municipal level units (n = 271/98) and a random sample of general practitioners (n = 700/853)., Results: The health care agreements were considered more useful for coordinating care than the previous health plans. The power relationship between the regional and municipal authorities in drawing up the agreements was described as more equal. Familiarity with the agreements among general practitioners was higher, as was the perceived influence of the health care agreements on their work., Discussion: Health care agreements with specific content and with regular follow-up and systematic mechanisms for organising feedback between collaborative partners exemplify a useful tool for the coordination of health and social services., Conclusion: There are substantial improvements with the new health agreements in terms of formalising a better coordination of the health care system.

Aims: To provide a preliminary answer to the question of whether the economic incentives introduced by the municipal co-financing of hospital services work as intended in the reform., Methods: This study is based on 30 statistical cross-section linear regressions, OLS, using data from Statistics Denmark (Statistikbanken) and the Municipal Financial Accounts. Supplemented by data from a survey study from municipal health managers in all municipalities of the country., Results: Despite the favourable conditions presented by the design of our analysis, it is not possible to demonstrate a clear link between local efforts and number of admissions from the municipalities., Conclusions: The study does not support one of the fundamental theoretical assumptions behind the municipal co-financing introduced in the 2007 structural reform in Denmark. While the study failed to establish systematic links between municipal public health efforts and hospitalisation levels, it appears from other studies that municipalities are in fact increasing their activities in public health. This presents a theoretical puzzle and we present several possible explanations for further empirical work.

Despite the fact that Member States and many citizens of the EU like to keep healthcare a foremost national competence and the EU treaties state that Member States remain primarily responsible for the organization and delivery of health care services, the European Union (EU) has expanded its involvement in healthcare policy over the last twenty years. Based on interviews and document and literature analysis we show that the scope of EU involvement has widened from public health and access to care, to quality of care. In this paper we concentrate on the latter. Focusing on the recent EU initiatives regarding the quality systems of the Member States and the quality of services, this paper shows how the depth of EU interference has increased from sharing information to standardization and even to the first signs of enforcement. We argue that at this stage, reflection on the feasibility and desirability of the EU's involvement is clearly needed, also considering the differences in quality of care policies between and within EU Member States. Both arguments in favour and against further EU involvement are discussed in this paper., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitt's suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice., (© Cambridge University Press 2012)

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless, the nature and intensity of the reforms required are largely determined by each country's basic social security model. Most reforms in Beveridge-type systems have sought to increase choice and reduce waiting times while those in major Bismarck-type systems have focused on cost control by constraining the choice of providers. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of healthcare system, which underlie these differences? Have recent reforms been effective? Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms. Thus, while countries may share similar problems in terms of improving healthcare performance, adopting a 'copy-and-paste' approach to healthcare reform is likely to be ineffective.

The area of cancer care has received significant political attention in Denmark over the past decades. Colorectal cancer (CRC) has a relatively high burden of disease and high mortality. This paper describes the main initiatives to improve CRC treatment in Denmark. It highlights the introduction of national "cancer pathways" based on clinical guidelines. The pathways specify ideal patient pathways through the system and include standards for waiting times and care processes. The comprehensiveness and high quality of Danish patient registers will aid in the implementation. Yet a number of outstanding challenges are also identified. The most important include a shortage of nursing and medical specialists for cancer care, and issues of co-ordination between primary care, hospital care and follow-up services.

This paper analyses the introduction of a systemic standards based programme for governing medical performance in Denmark. The programme combines clinical, organisational, and patient related standards and measures, and contains both external evaluation and self-assessment based on standards. The substance of the programme is new compared to the previous decentralised or professionally driven state of affairs that was based on a largely voluntary introduction of clinical standards, combined with a case-by-case evaluation of malpractice incidents. The programme strengthens hierarchy-based forms of governance; these co-exist with salient components of network-based governance as well as some elements of market-based governance. Institutional and contextual factors are important in explaining why a systemic standards based programme emerged as a result of the policy negotiation processes. In particular, the programme reflects stronger governance ambitions from the government in response to claims of a relative decline in the quality of the regional health services. However, the actual design is mediated by institutionalised negotiation processes among the state, decentralised authorities, and health professionals.

Introduction: Insights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, and discuss them in relation to interorganisational network theory., Policy Practice: The policy initiatives to improve collaboration between primary and secondary healthcare in Denmark and Sweden include legislation and agreements aiming at clarifying areas of responsibility and defining requirements, creation of links across organisational boarders. In Denmark many initiatives have been centrally induced, while development of local solutions is more prominent in Sweden. Many Danish initiatives target the administrative level, while in Sweden initiatives are also directed at the operational level. In both countries economic incentives for collaboration are weak or lacking, and use of sanctions as a regulatory mean is limited., Discussion and Conclusion: Despite a variety of policy initiatives, lacking or poorly developed structures to support implementation function as barriers for coordination. The two cases illustrate that even in two relatively coherent health systems, with regional management of both the hospital and general practice sector, there are issues to resolve in regard to administrative and operational coordination. The interorganisational network literature can provide useful tools and concepts for interpreting such issues.

This article investigates the current use of Public-Private Partnerships (PPP) in the Danish health sector based on an initial discussion of theoretical approaches that analyze PPP. The empirical analysis concludes that PPP has been used very sparsely in the Danish health sector. There are few examples of large-scale partnership projects with joint investment and risk taking, but a number of smaller partnerships such as jointly owned companies at the regional level. When defining PPP more broadly, we can identify a long tradition for various types of collaboration between public and private actors in health care in Denmark. An analysis of the regulatory environment is offered as an explanation for the limited use of PPPs in Denmark. Major political and institutional actors at the central level differ in their enthusiasm for the PPP concept, and the regulatory framework is somewhat uncertain. A number of general issues and concerns related to PPPs are also discussed. It is suggested that a risk-based framework can be useful for mapping the potential and challenges for both private and public partners. Such a framework can be used to feed into game theoretical models of pros and cons for PPP projects. In general terms, it is concluded that more empirical research is needed for the assessment of the various risk factors involved in using PPPs in health care. Most PPPs are still very young, and the evidence on performance and broader governance issues is only just emerging. Ideally, such assessments should include comparisons with a purely public alternative.

Purpose: The paper aims to account for the substance of non-linear governance change by analysing the importance of sector-specific institutions and the pathways of governing they create., Design/methodology/approach: The analysis uses recent reforms of the governance of medical performance in four European countries as a case, adopting an inductively oriented approach to comparison. The governance of medical performance is a good case as it is both, closely related to redistributive policies, where the influence of institutions tends to be pertinent, and is subject to considerable policy pressures., Findings: The overall thrust of reforms is similar across countries, while there are important differences in relation to how individual forms of governance and the balance between different forms of governance are changing. More specifically, sector-specific institutions can account for the specific ways in which reforms redefine hierarchy and professional self-regulation and for the extent to which reforms strengthen hierarchy and affect the balance with other forms of governance., Originality/value: The recent literature on governance mainly focuses on mapping out the substance of non-linear change, whereas the development of explanations of the substance of governance change is less systematic. In the present paper, therefore, it is suggested coupling the notion of non-linear change with an analysis of sector specific institutions inspired by the historical institutionalist tradition to better account for the substance of non-linear governance change. Further, the analysis offers interesting insights into the complexity of redrawing boundaries between the public and the private in health care.