Investment specificity, vertical integration and market foreclosure

In this paper we consider the impact of vertical integration on a retailer's choices of product variety and specific, brand-supporting investment. In an incomplete contract environment, vertical merger encourages investment in integrated supply, and foreclosure of non-integrated manufacturers. Anti-competitive as opposed to efficiency interpretations depend delicately on a trade-off between the benefits of supplier-specific rather than generally applicable retailer investment, and the value of multi-product rather than single product retailing. Where retailers compete, it is shown that vertical integration implements competition reducing, product differentiating investment strategies.incomplete contracts,vertical integration,monopolization

Tackling disinvestment in health care services

Rising levels of demand due to ageing populations and increases in long term conditions (White 2007), increased levels of expectation amongst patients and inflationary pressure caused by the rising cost of new technologies are amongst the explanations for the funding shortfalls in government funded health systems across the world (Newhouse 1992). The challenge facing these health systems has also been intensified by the worldwide economic downturn. Within health systems, efforts have been made to increase productivity and efficiency and to control costs without reducing quality (Garner and Littlejohns 2011) but the scale of the task necessitates further action (Donaldson et al. 2010). Beyond productivity and efficiency gains the next logical step for decision makers is disinvestment in cost-ineffective services, prioritisation of funding for one service over another or what Prasad (2012) refers to as ‘medical reversal’. The aims of this study were to explore the experiences of budget holders within the English National Health Service (NHS) in their attempts to implement programmes of disinvestment, and to consider factors which influence the success (or otherwise) of this activity. This paper begins with clarification of terminology and a summary of the current state of knowledge with regard to health service disinvestment, before presenting and discussing findings. The research suggests that disinvestment activity is varied across organisations and ranges from ‘invest to save’ schemes through to ‘true disinvestment.’ Although the majority of interviewees accept that disinvestment is necessary most had made little progress at the time of interview beyond ‘picking the low hanging fruit’. Interviewees identify a number of determinants of disinvestment such as: local/national relationships, co-ordination/ collaboration and; professional understanding and support

Priority setting during the COVID-19 pandemic: going beyond vaccines

Development of vaccines is a major breakthrough in the fight against the SARS-CoV-2 virus. Much attention has been paid to how to prioritise between patient groups for vaccination and how to ensure equity, especially in low-income countries, but there are other important decisions that need to be made. These decisions include: (a) choosing between the various vaccines that will become available, (b) continuing to invest in other aspects of the COVID-19 response and (c) balancing the COVID-19 response with the need to invest in other healthcare that has suffered during the pandemic. Although these decisions are inherently difficult, principles of good priority setting can be helpful; these principles include: evidence-based and transparent decision-making, participation of stakeholders and a focus on the implementation of decisions

What is a ‘National’ ‘Health’ ‘Service’? A keyword analysis of policy documents leading to the formation of the UK NHS

This paper explores the keywords of ‘National’, ‘Health’ and Service’ in the road to the NHS in 1948. It uses a form of Qualitative Content Analysis to analyse key documents in the period leading to the ‘Appointed Day’ when the NHS was created in 1948. In terms of ‘national’, most documents favoured Local Authorities, with ‘National’ coming rather late in the day. For ‘health’, most of the documents ‘talk’ of a broad or ‘positive’ health, but they lack any specific details, and seem to focus on a narrower curative medical service. Finally, most proposals relating to ‘service’ are based on insurance and a ‘90% service’, with the free and universal (100%) service arriving rather late in the period. Clearly, the three keywords could be combined in many ways, resulting in many possible types of NHS. However, bringing them together suggests that it was probably only with Beveridge onwards that the three keywords of national, health and service (citizenship) combined to form Bevan's NHS

Lonely at the top and stuck in the middle? The ongoing challenge of using cost-effectiveness information in priority setting Comment on “Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden”

The topic of how cost-effectiveness information informs priority setting in healthcare remains important to both policy and practice. This commentary considers the study carried out by Eckard and colleagues in Sweden. In it we distinguish between the conditions at national and local levels and put forward some recommendations for research into local priority setting in particular

Realist Synthesis of the International Theory and Evidence on Strategies to Improve Childhood Vaccination in Low- and Middle-Income Countries: Developing Strategies for the Nigerian Healthcare System

Background: Childhood vaccination coverage rates in low- and middle-income countries (LMICs) vary significantly, with some countries achieving higher rates than others. Several attempts have been made in Nigeria to achieve universal vaccination coverage but with limited success. This study aimed to analyse strategies used to improve childhood vaccine access and uptake in LMICs in order to inform strategy development for the Nigerian healthcare system.Methods: A realist synthesis approach was adopted in order to elucidate the contexts and mechanisms wherewith these strategies achieved their aim (or not). Nine databases were searched for relevant articles and 27 articles were included in the study. Programme theories were generated from the included articles, and data extraction was carried out paying particular attention to context, mechanism and outcomes configurations.Results: Interventions used in LMICs to improve vaccination coverage were categorised as follows: communication/educational, reminder-type, incentives, social mobilisation, provider-directed strategies, health service integration and multi-pronged strategies. The strategies that appeared most likely to be effective in the health contexts of contemporary Nigeria include communication and educational interventions; employing informal change agents, and; monitoring and evaluation to strengthen communication. The programme theories for the use of reminders, social mobilisation, staff training and supportive supervision were observed in practice, and these strategies were generally successful within some contexts. By contrast, the use of monetary incentives in Nigeria is not supported by the evidence, although further research and evaluation is required. The integration of other interventions with routine immunisation (RI) to improve uptake was more effective when the perceived value of the other program was high. Adoption of multi-pronged interventions for hard to reach communities was beneficial. However, caution should be exercised because of varying levels of published evidence in respect of each intervention type and a relative lack of the rich description required to conduct a full realist analysis.Conclusion: This paper adds to the evidence base on the adaption of strategies to improve vaccine access and uptake to the context of LMICs

Incomplete contracts, control rights and integration decisions in economic organisations.

This thesis comprises an introduction and four distinct chapters. Its central theme is the role played by the allocation of asset ownership rights in motivating asset-specific investment, when contracts are incomplete. Chapter 1 considers the debt financing of an entrepreneurial project. To encourage asset-specific investment and loan repayment, debt structure should minimise both (voluntary) strategic default and liquidation following (unavoidable) liquidity default. Liquidation incentives are critical and shown to depend crucially on creditor characteristics. In general, borrowing from multiple creditors with contrasting attributes is found optimal. The benefits of borrowing from a creditor also undertaking project trade are explored. In Chapter 2 the relationship between asset ownership and investment specificity is examined. Asset control encourages efficient, asset-specific investment by owners. However, lock-in fears lead non-owners to choose widely applicable but less effective investment. The interactions between asset ownership, firms' technology choices and workers' investments are considered. In particular, it is found that the costs and benefits of individual integration decisions are sensitive to overall industry structure. The specificity framework is extended in Chapter 3 to model a retailer's product choice. Vertical merger encourages investment in integrated supply and foreclosure of non-integrated manufacturers. An anti-competitive as opposed to an efficiency interpretation depends delicately on the trade-off between the benefits of supplier-specific investment and multi-product retailing. Where retailers compete, it is shown that vertical integration implements effective competition-reducing differentiation strategies. In Chapter 4 vertical integration, through the incentive effects of asset ownership, is shown to amount to a specialisation decision. The attractions of encouraging investment in input as opposed to final good production depend on the effectiveness of investment at each manufacturing stage, and the scale benefits of input sales to generally rivalrous downstream firms. These benefits are sensitive to downstream competitive pressures, yielding a potentially non-monotonic relationship between competition and integration

Is the NHS underfunded?:Three approaches to answering the question

The adequacy of funding for the National Health Service (NHS) is a perennial issue1,2 and one that has become particularly prominent in recent years.3 The way ‘underfunding’ is understood influences perceptions about how much resource is needed and where it ought to be channelled. This in turn has profound implications for patients, citizens and staff. In this article, we examine what it means to claim that health systems are underfunded and whether this applies to the contemporary NHS. We identify three main approaches to studying the issue and uncover the value judgements inherent in each approach. We argue that there is evidence to support the current claim of underfunding and conclude by suggesting future avenues for addressing this critical issue, both in the UK and elsewhere