Rodrigo Moreno-Serra

Does progress towards universal health coverage improve population health

Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance.

Europe and central Asia's great post-communist social health insurance experiment: Aggregate impacts on health sector outcomes.

The post-Communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs regression-based generalizations of the difference-in-differences method on panel data from 28 countries for the period 1990-2004. We find that, controlling for any concurrent provider payment reforms, adoption of social health insurance increased national health spending and hospital activity rates, but did not lead to better health outcomes.

Towards improved measurement of financial protection in health

Christopher Millett and colleagues argue that new metrics are needed to better inform policy development on financial protection in health.

Can competition improve outcomes in UK health care? Lessons from the past two decades

UK governments of all political colours have sought to improve productivity in health care by introducing pro-competitive reforms in the National Health Service (NHS) during the last two decades. The first wave of reform operated from 1991 to 1997. The second wave was introduced in England only in the mid 2000s. In 2010, further reform in England, intended to increase the extent of competition, was proposed by the Coalition administration. But the effect of competition on productivity in health care and in particular on the quality of health care remains a contested issue. This paper reviews the evidence, focusing on robust and recent evidence, on the use of competition as a mechanism for improving quality. The consensus is that competition will increase quality in health care, but that institutional details matter. Given this, we end by discussing whether the current plans to make the buyers of care family doctors and other professionals and to allow some local price variation are likely to be beneficial in the UK context of full public funding for health care.

Broader health coverage is good for the nation's health: evidence from country level panel data.

Progress towards universal health coverage involves providing people with access to needed health services without entailing financial hardship and is often advocated on the grounds that it improves population health. The paper offers econometric evidence on the effects of health coverage on mortality outcomes at the national level. We use a large panel data set of countries, examined by using instrumental variable specifications that explicitly allow for potential reverse causality and unobserved country-specific characteristics. We employ various proxies for the coverage level in a health system. Our results indicate that expanded health coverage, particularly through higher levels of publicly funded health spending, results in lower child and adult mortality, with the beneficial effect on child mortality being larger in poorer countries.

In defence of our research on competition in England's National Health Service

2064 www.thelancet.com Vol 378 December 17/24/31, 2011 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ strongest support for the causation hypothesis may be revealed”. Indeed, Bradford Hill also lavished praise on Snow, who examined the causes of cholera outbreaks in London in what is regarded as the fi rst use of diff erencein-diff erence regression. This is the same strategy we used to test the eff ect of competition. No study is perfect, which is why we have peer review and open science. However, the fact that three studies by separate research teams produced consistent results strongly fortifi es our collective fi ndings. More work surely needs to be done to understand the changes competition has brought about in England. However, the way forward should be to look objectively to see what is driving our fi ndings, rather than dismissing the results out of hand because they confl ict with prior beliefs.

The Drivers of Public Health Spending: Integrating Policies and Institutions

This paper investigates the impact of policies and institutions on health expenditures for a large panel of OECD countries for the period 2000-10. We use a set of 20 policy and institutional indicators developed by the OECD characterising the main supply-side, demand-side, and public management, coordination and financing features of health systems. The impact of these indicators is tested alongside control variables related to demographic (dependency ratio) and non-demographic (income, prices and technology) drivers of health expenditures per capita. Overall, there is a reasonably good fit between the expected signs of the coefficients for the institutional indicators and the actual estimates. By integrating the role of policies and institutions, together with the other primary determinants, our analysis is able to explain most of the cross-country variation in public health expenditures. Les determinants des depenses publiques de sante : Le role des politiques et des institutions Ce papier analyse l’impact des politiques et des institutions sur les depenses de sante pour un large ensemble de pays de l’OCDE durant la periode 2000-10. Nous utilisons un groupe de 20 indicateurs politiques et institutionnels developpes par l’OCDE et qui caracterisent principalement l’offre, la demande, la gestion publique, la coordination et le financement des systemes de sante. L’incidence de ces indicateurs est evaluee conjointement avec des variables de controle en lien avec les determinants demographiques (taux de dependance) et non demographiques (revenu, prix et technologie) des depenses de sante par tete. Globalement, il existe une adequation satisfaisante entre les signes attendus des coefficients des indicateurs institutionnels et les estimations. En integrant le role des politiques et des institutions avec les autres determinants principaux, notre analyse reussit a expliquer la majorite de la variation entre pays des depenses publiques de sante.

Europe and Central Asia's Great Post-Communist Social Health Insurance Experiment: Impacts on Health Sector and Labor Market Outcomes

The post-communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs a regression-based generalization of the difference-in-differences method and instrumental variables on panel data from 28 countries for the period 1990-2004. The authors find that, controlling for any concurrent provider payment reforms, adoption of social health insurance increased national health spending and hospital activity rates, but did not lead to better health outcomes. The authors also find that adoption of social health insurance reduced employment in the economy as a whole and increased unemployment, although it did not apparently increase the size of the informal economy.

Competition could substantially benefit healthcare

In response to May’s concern that competition achieves relatively small gains,1 we have attempted some “back of the envelope” valuations of the gains from the choice and competition policy. Our research suggests that an average hospital’s all cause standardised mortality rate fell by 0.3% …

The Role of Policy and Institutions on Health Spending.

This paper investigates the impact of policies and institutions on health expenditures for a large panel of Organisation for Economic Co-operation and Development countries for the period of 2000-2010. A set of 20 policy and institutional indicators developed by the Organisation for Economic Co-operation and Development are integrated into a theoretically motivated econometric framework, alongside control variables related to demographic (dependency ratio) and non-demographic (income, prices and technology) drivers of health expenditures per capita. Although a large share of cross-country differences in public health expenditures can be explained by demographic and economic factors (around 71%), cross-country variations in policies and institutions also have a significant influence, explaining most of the remaining difference in public health spending (23%). Copyright