Finding the levers, finding the courage: lessons from cost containment in North America

"Learning" is broader and more complex than simply the orderly acquisition of new knowledge. At least as important is the evolution of the background of assumptions and beliefs held by the community, or its principal decision makers, and implicit in its institutions and policies. These may bear only a loose relation to evidence or knowledge narrowly defined. The pressures of cost escalation over the past twenty years, and the attempts at containment in the U.S. and Canada, have added substantially to our knowledge of how the health care system works. Containment is possible, and the successful mechanisms, thus far, are quite specific. But the results of these attempts and (in the U.S.) the continued escalation have also significantly shifted the broader set of assumptions in the community about appropriate priorities and policies in health care. Attitudes towards physician supply, variations in practice patterns, capitated practice, and for-profit organization, for example, have changed radically, although the supporting evidence has not. But cost pressures have created an audience which wants to hear, whose background assumptions provide a different "fit" for the evidence.     

The Contours and Limits of Environmental Remediation Under the Treaty on the Prohibition of Nuclear Weapons

Netherlands International Law Review - The entry into force of the Treaty on the Prohibition of Nuclear Weapons (TPNW) in January 2021 has sparked analysis of the so-called ‘positive...     

Direct investment and industrial concentration

Cross‐national comparison of industrial concentration is considered here in terms of two hypotheses. The ‘technology/market size’ hypothesis [Merhav, 1969] predicts greater concentration in less developed countries than in the larger markets of developed countries. The ‘miniature replica’ hypothesis predicts that, when the degree of foreign ownership is high, industries in less developed countries may be less concentrated than their counterparts in advanced countries. Most cross‐national comparisons of firm size distributions support a predominance of ‘technology/market size’ effects. In this paper, data from the pharmaceutical industry in Brazil and other less developed countries are used to suggest that under certain conditions ‘miniature replica’ effects may prevail.     

Rail Franchises,Competition and Public Service

The use of franchises to deliver rail services has raised major problems. Franchises restrict competition in the market, whilst competitive bidding for franchises has met with difficulties, notably in relation to risk transfer and the recent use of short‐term contracts that have not been awarded competitively. Further, franchise agreements are detailed and highly stipulative and do not achieve the flexibility and opportunities for innovation originally intended. This reflects an underlying lack of trust resulting from the arrangements adopted on privatisation. By contrast, in Sweden regional services have been procured through contracts with limited risk transfer, and in Italy provision of services has been entrusted to a dominant operator with comparatively limited detailed service specifications; both seem to have been more successful. For the future in the UK, possibilities include greater use of competition, a return to public ownership, regionalisation, and the use of concessions with limited risk transfer to secure stability.