- Title
- Health systems reforms dynamics: implications for equity and efficiency
- Creator
- Berardi, Chiara
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2025
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- This thesis addresses the evolving dynamics of health system in response to global economic and health shocks and their implications for equity and efficiency, adopting a comparative perspective. It seeks to identify drivers of change, their impact on health system financing, and how transitions in financing contribute to outcomes like equity, efficiency, and population health. Governments worldwide have implemented similar reforms, leading to transformations in health system design that extend beyond the traditional public-private sector interface. In OECD countries, Universal Health Coverage involves a blend of mandatory government-based schemes and voluntary Private Health Insurance. Equity and efficiency issues might arise at their junction. However, the lack of a robust theoretical framework and empirical measures to comprehensively define mixed health systems and capture this evolving financing mix across countries and over time may present a significant challenge in assessing the link between health system design and performance. The economic analysis of the long-term dynamics of health system reforms is crucial for understanding the implications of these slow but continuous financing transitions. This thesis comprises four studies, two conceptual and two empirical. It investigates whether major crises in the 21st century induced similar reform waves in OECD countries between 1995 and 2022. It outlines the theoretical and methodological steps to measure health system financing and assesses their contribution to health outcomes and disparities across population groups. It evaluates the extent to which health systems achieve preconditions for efficiency and affordability. The analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward the re-centralization of health system governance to control public health resources. Similar reform waves implemented across countries have resulted in a slight trend of convergence in the financing mix adopted by countries over time. The mandatory-voluntary financing mix can result in inequitable and inefficient interactions between multiple overlapping funding sources, contributing to disparities in coverage access for vulnerable groups, which in turn may affect population health outcomes. Disparities in access are exacerbated by a lack of policy coherence as mandatory and voluntary schemes interact. Through a comparative perspective, the thesis contributes to a better understanding of reform dynamics and their impact on overarching and conflicting health system objectives. The studies included in this thesis theoretically and empirically define health systems financing to reflect their complexity, thereby enhancing the understanding of the impact of their design on critical societal outcomes such as equity and efficiency. To ensure a sustainable, efficient, and equitable health system, reforms are necessary to achieve long-term performance improvements. The thesis has the potential to inform health system reforms in increasingly mixed health system financing, which presently operate reactively or are based on budgetary goals rather than focusing on improving equity and efficiency. This is important to prevent unintended consequences, inform future financing reforms, and enhance health systems’ resilience in response to future shocks.
- Subject
- healthcare financing; economic crisis; pandemic; health policy
- Identifier
- http://hdl.handle.net/1959.13/1519467
- Identifier
- uon:57399
- Rights
- Copyright 2025 Chiara Berardi
- Language
- eng
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