The organisation of health services tends to reflect the values and priorities of each population. However, as we discussed in 2006), which influence the way the patient citizen (PC) expresses its demands for healthcare. As discussed in Chapter 4, the constitutional design of a country – including the electoral rules, the division of powers and the role of the judiciary – adds additional veto players into the health system reform process, and often extra ‘checks and balances’ that are not always in the interest of the PC. At the core of those institutions lie the mechanisms of accountability (to the PC) and representation (of the view of the PC). That is, a well-functioning democracy would be one where healthcare decisions are the expression of the PC’s demands. Such demands are typically revealed through electoral processes (which turn heterogeneous preferences into political mandates), as we discuss later in Chapter 6. However, as a first step to understand how health policy choices are made, we discuss whether and how democratic decision-making, unlike other political collective decision-making systems, affects the health system.