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Leadership and governance in seven developed health systems


  • Smith, Peter C.
  • Anell, Anders
  • Busse, Reinhard
  • Crivelli, Luca
  • Healy, Judith
  • Lindahl, Anne Karin
  • Westert, Gert
  • Kene, Tobechukwu


This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

Suggested Citation

  • Smith, Peter C. & Anell, Anders & Busse, Reinhard & Crivelli, Luca & Healy, Judith & Lindahl, Anne Karin & Westert, Gert & Kene, Tobechukwu, 2012. "Leadership and governance in seven developed health systems," Health Policy, Elsevier, vol. 106(1), pages 37-49.
  • Handle: RePEc:eee:hepoli:v:106:y:2012:i:1:p:37-49
    DOI: 10.1016/j.healthpol.2011.12.009

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    References listed on IDEAS

    1. Wismar, Matthias & Busse, Reinhard, 2002. "Outcome-related health targets--political strategies for better health outcomes: A conceptual and comparative study (part 2)," Health Policy, Elsevier, vol. 59(3), pages 223-241, March.
    2. J. Schreyögg & T. Stargardt & M. Velasco-Garrido & R. Busse, 2005. "Defining the “Health Benefit Basket” in nine European countries," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 6(1), pages 2-10, November.
    3. Nolte, Ellen & McKee, Martin, 2011. "Variations in amenable mortality—Trends in 16 high-income nations," Health Policy, Elsevier, vol. 103(1), pages 47-52.
    4. Veillard, Jeremy Henri Maurice & Brown, Adalsteinn Davidson & Barış, Enis & Permanand, Govin & Klazinga, Niek Sebastian, 2011. "Health system stewardship of National Health Ministries in the WHO European region: Concepts, functions and assessment framework," Health Policy, Elsevier, vol. 103(2), pages 191-199.
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    Cited by:

    1. Klink, Ab & Schakel, H. Christiaan & Visser, Sander & Jeurissen, Patrick, 2017. "The arduous quest for translating health care productivity gains into cost savings. Lessons from their evolution at economic scoring agencies in the Netherlands and the US," Health Policy, Elsevier, vol. 121(1), pages 1-8.
    2. Marmor, Theodore & Wendt, Claus, 2012. "Conceptual frameworks for comparing healthcare politics and policy," Health Policy, Elsevier, vol. 107(1), pages 11-20.
    3. Celia Dana BESCIU, 2013. "Personnel Satisfaction Study regarding the Emergency Medical Services’ Quality of Bucharest Hospitals," REVISTA ADMINISTRATIE SI MANAGEMENT PUBLIC, Faculty of Administration and Public Management, Academy of Economic Studies, Bucharest, Romania, vol. 2013(21), pages 71-83, December.
    4. Glenngård, Anna Häger, 2013. "Productivity and patient satisfaction in primary care—Conflicting or compatible goals?," Health Policy, Elsevier, vol. 111(2), pages 157-165.
    5. Okma, Kieke G.H. & Crivelli, Luca, 2013. "Swiss and Dutch “consumer-driven health care”: Ideal model or reality?," Health Policy, Elsevier, vol. 109(2), pages 105-112.


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