In the last decades, several European health systems have abandoned their vertically integrated health care in favour of some form of managed competition (MC), either in a centralised or decentralised format. However, during a pandemic, MC may put health systems under additional strain as they are designed to follow some form of ‘organisational self-interest’, and hence face reduced incentives for both provider coordination (e.g. temporary hospital close down, change in the case-mix), and information sharing. We illustrate our argument using evidence for the Covid-19 pandemic outbreak in Italy during March and April 2020, which calls for the development of ‘coordination mechanisms’ at times of a health emergency.

As of November 2020, the United States leads the world in confirmed coronavirus disease 2019 (COVID-19) cases and deaths. Over the past 10 months, the United States has experienced three peaks in new cases, with the most recent spike in November setting new records. Inaction and the lack of a scientifically informed, unified response have contributed to the sustained spread of COVID-19 in the United States. This paper describes major events and findings from the domestic response to COVID-19 from January to November 2020, including on preventing transmission, COVID-19 testing and contact tracing, ensuring sufficient physical infrastructure and healthcare workforce, paying for services, and governance. We further reflect on the public health response to-date and analyse the link between key policy decisions (e.g. closing, reopening) and COVID-19 cases in three states that are representative of the broader regions that have experienced spikes in cases. Finally, as we approach the winter months and undergo a change in national leadership, we highlight some considerations for the ongoing COVID-19 response and the broader United States healthcare system. These findings describe why the United States has failed to contain COVID-19 effectively to-date and can serve as a reference in the continued response to COVID-19 and future pandemics.

The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.

This paper explores policy mechanisms behind New Zealand's remarkable track record of cost containment in public pharmaceutical spending, contrasting with most other advanced economies. We drew on a review of official policy documents and 28 semi-structured expert interviews. We found that decision making in pricing and reimbursement policy was dominated by a small group of managers at the Pharmaceutical Management Agency (PHARMAC), the country's drug reimbursement and Health Technology Assessment Agency, who negotiated pharmaceutical prices on behalf of the public payer. In formal negotiation over patented pharmaceutical prices these managers applied an array of pricing strategies, most notably, ‘bundling’ consisting of discounted package deals for multiple pharmaceuticals, and ‘play-off tenders’, whereby two or more pharmaceutical companies bid for exclusive contracts. The key pricing strategy for generic drugs, in contrast, was ‘blind-tenders’ taking the form of an annual bidding process for supply contracts. An additional contextual condition on bargaining over pharmaceutical prices was an indirect strategy that involved the cultivation of the PHARMAC's ‘negotiation leverage’. We derived two cost containment mechanisms consisting in the relationship between pricing strategy options and various reimbursement actors. Our findings shed light on aspects of the institutional design of drug reimbursement that may promote the effective use of competitive negotiations of pharmaceutical prices, including specific pricing strategies, by specialist public payer institutions. On this basis, we formulate recommendations for countries seeking to develop or reform policy frameworks to better meet the budgetary challenge posed by pharmaceutical expenditure.

Canada's experience with the coronavirus disease-2019 (COVID-19) pandemic has been characterized by considerable regional variation, as would be expected in a highly decentralized federation. Yet, the country has been beset by challenges, similar to many of those documented in the severe acute respiratory syndrome outbreak of 2003. Despite a high degree of pandemic preparedness, the relative success with flattening the curve during the first wave of the pandemic was not matched in much of Canada during the second wave. This paper critically reviews Canada's response to the COVID-19 pandemic with a focus on the role of the federal government in this public health emergency, considering areas within its jurisdiction (international borders), areas where an increased federal role may be warranted (long-term care), as well as its technical role in terms of generating evidence and supporting public health surveillance, and its convening role to support collaboration across the country. This accounting of the first 12 months of the pandemic highlights opportunities for a strengthened federal role in the short term, and some important lessons to be applied in preparing for future pandemics.

One of the main governance decisions that policymakers need to make is whether to implement public services via centralized or decentralized forms. As Costa et al. discuss in their article, when public services are implemented via competing systems, service providers contend to provide good services with the ultimate objective of gaining market quota. This is known as managed competition (MC), as the authorities will have to manage the panoply of public and private organizations offering the service. The alternative is to manage the service more centrally, in what it is identified as vertical integration. As the authors describe, several governments around the globe have abandoned their vertical integrated models in favour of decentralized models. This is the case, as the authors recall, for most health services in Europe. While there is an emerging body of evidence suggesting that decentralized MC outperforms vertically integrated models both in terms of efficiency and in terms of service quality, little is known on how these systems react under different circumstances. This means, for example, how these systems can cope with a sudden increase in their service demands.

The UK's relationship with the European Union (EU) is now embodied in two principal legal instruments: the EU–UK Trade and Cooperation Agreement, which formally entered into force on 1 May 2021; and the Withdrawal Agreement, with its Protocol on Ireland/Northern Ireland, which continues to apply. Using a ‘building blocks’ framework for analysis of national health systems derived from the World Health Organisation, this article examines the likely impacts in the UK of this legal settlement on the National Health Service (NHS), health and social care. Specifically, we determine the extent to which the trade, cooperation and regulatory aspects of those legal measures support positive impacts for the NHS and social care. We show that, as there is clear support for positive health and care outcomes in only one of the 17 NHS ‘building blocks’, unless mitigating action is taken, the likely outcomes will be detrimental. However, as the legal settlement gives the UK a great deal of regulatory freedom, especially in Great Britain, we argue that it is crucial to track the effects of proposed new health and social care-related policy choices in the months and years ahead.

Australia suffered two waves of the coronavirus disease 2019 pandemic in 2020: the first lasting from February to July 2020 was mainly caused by transmission from international arrivals, the second lasting from July to November was caused by breaches of hotel quarantine which allowed spreading into the community. From a second wave peak in early August of over 700 new cases a day, by November 2020 Australia had effectively eliminated community transmission. Effective elimination was largely maintained in the first half of 2021 using snap lockdowns, while a slow vaccination programme left Australia lagging behind comparable countries. This paper describes the interventions which led to Australia's relative success up to July 2021, and also some of the failures along the way.

Since the outbreak of the COVID-19 pandemic, discussions about the capabilities of health and social systems to control and contain infectious diseases have been reignited. In Resilient Managed Competition During Pandemics: Lessons from the Italian Experience, Costa-Font, Turatti and Levaggi ask whether or not institutional differences between the managed competition (MC) systems in three of Italy's regions may have affected their performance – and hence, population health outcomes – during the pandemic. Fuchs (2000) previously argued that institutional arrangements not only ‘matter’, but also sometimes ‘matter a great deal’ (p. 149, emphasis in original) and this may be particularly true in emergencies.

Aotearoa New Zealand went ‘hard’ and ‘early’ in its response to COVID-19 and has been highly successful in limiting the spread and impact of the virus. The response has ramped up over time, and has included various levels of: border control; advice on hygiene, physical distancing and mask wearing; advice to remain at home if unwell; and testing and tracing. A four-level Alert Level framework has guided key actions at different levels of risk. Strong leadership from the Prime Minister, Minister of Finance, and Director-General of Health and high levels of community co-operation have supported the response. The country is most vulnerable at its borders, where arrangements have been of concern; advice on testing and the wearing of masks has changed over time; while the use and distribution of personal protective equipment has also been of concern. The country overall was not well prepared for a pandemic, but policy-making has been nimble. Key challenges for 2021 include swiftly rolling out a vaccine, catching up on delayed health care, and deciding how and when the border can reopen. The economic, and associated social, challenges will last many years.

Despite denials of politicians and other advisors, trade-offs have already been apparent in many policy decisions addressing the coronavirus disease 2019 pandemic and its social and economic consequences. Here, we illustrate why it is important, from a wellbeing perspective, to recognise such trade-offs, and provide a framework, based on the economic concept of ‘marginal analysis’, for doing so. We illustrate its potential through consideration of optimising the balance between reducing the reproductive rate (R) of the virus and further opening of the economy. The framework accommodates both perspectives in the health-vs-economy debate whereby, depending on where we are within the marginal analysis framework, either health issues are allowed to dominate or, below some threshold of R and/or background level of infection, health and economic considerations can be traded off against each other. Given the inevitability of such trade-offs, the framework exposes crucial questions to be addressed, such as: the critical value of R and/or background infection, above which health considerations predominate, and which may vary from jurisdiction to jurisdiction; and the value of lives forgone resulting from the small increases in R and/or background infection levels that may have to be tolerated as the economy is gradually opened.

In Ireland, the coronavirus disease 2019 (COVID-19) pandemic has led to a total of 230,599 cases of infection as on 20 March 2021, and 4323 deaths. Although the Irish hospital network has not been overwhelmed, it has faced pressures, with a total of 13,313 persons hospitalised, including 1402 admitted to the intensive care unit. Out of caution, in spring 2020, in anticipation of possible surges in hospitals in light of international experience, the Irish government reached an agreement with private hospitals to access their capacity for three months to alleviate pressure on the public system, as part of its comprehensive response to the pandemic. This piece analyses the agreement with private hospitals, based on the legally binding Heads of Terms of the agreement, which were signed by the parties, along with publicly reported details from media reports and Oireachtas (parliamentary) committee hearings. We argue that although the new relationship could, in theory, have paved the way to the nationalisation of the whole hospital system, in fact, the experiment is best interpreted as a lost opportunity to integrate and simplify Ireland's hospital system.

The UK, and England in particular, has suffered egregiously poor outcomes in managing the Covid-19 pandemic. This short perspective points to the explanation in terms of both current British politics and the public health policy inheritance. Boris Johnson's Premiership was born in an opportunistic assertion of British exceptionalism, and Johnson's initial, fate-tempting reaction to the novel Coronavirus set the UK on the wrong path. Furthermore, the gradual erosion of professionalism in (especially health) policy-making over almost four decades, and the hollowing-out of the health protection infrastructure, both facilitated and accentuated a toxic approach to managing Covid-19.