From social rights to the market: neo-liberalism and the knowledge economy

Public higher education has a long history, with its growth associated with mass higher education and the extension of a social right to education from secondary schooling to university education. Following the rise in student numbers since the 1970s, the aspiration to higher education has been universalized, although opportunities remain structured by social background. This paper looks at changing policies for higher education in the UK and the emergence of a neoliberal knowledge regime. This subordinates higher education to the market and shifts the burden of paying for degree courses onto students. It seeks to stratify institutions and extend the role of for-profit providers. From a role in the amelioration of social inequality, universities are now asked to participate actively in the widening inequalities associated with a neoliberal global market order

Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies

Background: Recent high-profile reports into serious failings in the quality of hospital care in the NHS raise concerns over the ability of trust boards to discharge their duties effectively. Objectives: Our study aimed to generate theoretically grounded empirical evidence on the associations between board governance, patient safety processes and patient-centred outcomes. The specific aims were as follows: (1) to identify the types of governance activities undertaken by hospital trust boards in the English NHS with regard to ensuring safe care in their organisation; (2) in foundation trusts, to explore the role of boards and boards of governors with regards to the oversight of patient safety in their organisation; (3) to assess the association between particular hospital trust board oversight activities and patient safety processes and clinical outcomes; (4) to identify the facilitators and barriers to developing effective hospital trust board governance of safe care; and (5) to assess the impact of external commissioning arrangements and incentives on hospital trust board oversight of patient safety. Methods: The study comprised three distinct but interlocking strands: (1) a narrative systematic review in order to describe, interpret and synthesise key findings and debates concerning board oversight of patient safety; (2) in-depth mixed-methods case studies in four organisations to assess the impact of hospital board governance and external incentives on patient safety processes and outcomes; and (3) two national surveys exploring board management in NHS acute and specialist hospital trusts in England, and relating board characteristics to whole-organisation outcomes. Results: A very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance. Our analysis of the symbolic aspects of board activities highlights the role and differences in local processes of organising the governance of patient safety. Most boards do allocate considerable amount of time to discussing patient safety and quality-related issues and were using a wide range of hard performance metrics and soft intelligence to monitor its organisation with regard to patient safety. Although the board of governors is generally perceived to be well-meaning, they were also considered to be being largely ineffective in helping to promote and deliver safer care for their organisations. We did not find any statistically significant relationship between board attributes (self-reported) and processes and any patient safety outcome measures. However, we did find a significant relationship between two dimensions of the Board Self-Assessment Questionnaire and two specific-and-related national staff survey organisational ‘process’ measures: (1) staff feeling safe to raise concerns about errors, near-misses and incidents and (2) staff feeling confident that their organisation would address their concerns, if raised. We also found that contracting and external financial incentives appeared to play only a relatively minor role in incentivising quality and safety improvement. Conclusions: Our research is the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS and the key findings should be used to influence the design of future governance arrangements as well as the training and support of board. Funding: The National Institute for Health Research Health Services and Delivery Research programme

High Out-Of-Pocket Medical Spending Among the Poor and Elderly in Nine Developed Countries

Objective: The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each. Data Source: The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending. Study Design: Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation\u27s population, as well as subpopulations within it, with high OOP expenditures. Principal Findings: The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses. Conclusions: For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes. © Health Research and Educational Trus

Participatory and incremental development in an African local government accounting reform

Despite significant donor funding, government accounting reforms seeking transparent and effective management of public resources often fail or have limited success, especially in Africa, prompting questions about donors? implementation approach and calls for studies of successful reforms. This paper investigates a local government accounting reform in Benin supported by a German development agency ? perceived as successful due to the participatory, pragmatic and incremental approach reinforced by conditionalities in the face of neo-patrimonial leadership

Politics at the Cutting Edge: Intergovernmental Policy Innovation in the Affordable Care Act

In the eight years since the passage of the Patient Protection and Affordable Care Act (ACA), state governments have remained critical sites of contention over the law. Intense partisan conflict over ACA implementation has raised questions about traditional theories of intergovernmental relations, which posit that federal–state cooperation depends largely on policy design. Yet, few studies have examined how partisanship, as well as other important factors, shape state policy innovations under the ACA. This article examines the ACA’s State Innovation Models (SIM) initiative. SIM is specifically geared towards incentivizing states to experiment with new models of payment and delivery that can improve health outcomes and/or reduce health-care costs. Drawing on a combination of quantitative and qualitative evidence, we find that states’ participation in SIM is shaped by partisanship, administrative capacity, and state policy legacies. Our findings have implications for future efforts at intergovernmental health reforms