Whose system is it, anyway? Political economy and the contested space of health reform

Health systems are often discussed as problems of design: the optimal benefit package, the efficient payment mechanism, and the well-calibrated means test. Yet comparative health policy points to a more demanding conclusion. Health systems are not simply designed; they are contested. They are shaped through conflict among governments, industries, professions, investors, and citizens whose interests often diverge, and whose relative power determines what reform can be imagined, enacted, and sustained (Friebel and Wallenburg, Reference Friebel and Wallenburg2024). The six articles in this issue of Health Economics, Policy and Law span tobacco regulation in Europe, fraud enforcement and HIV prevention in the United States, hospital reform in China, and long-term care in England and the Netherlands. Taken together, they show that health systems and their reforms are politised and form political economies that are continuously negotiated. They ask: when health systems are reformed, whose system is being remade, and whose interests does reform ultimately serve?