Adapting the welfare state : privatisation in health care in Denmark, England and Sweden

Defence date: 12 June 2010Examining Board: Jens Blom-Hansen (Aarhus Univ), Pepper Culpepper (EUI), Bo Rothstein (Univ. Gothenborg), Sven Steinmo (EUI) (Supervisor)First made available online on 8 April 2019This dissertation deals with the following question: In the past decades some of the countries most dedicated to the universal public welfare state have privatised many of their welfare service provisions. Why is this so? The dissertation takes a close look at privatisation policies in health care in Denmark, Sweden and England in order to figure out how and why the private health care sector has expanded rapidly in recent years. Health care services in Denmark, Sweden and England provide good examples of welfare state service privatisation because these three countries have spent decades building up universal public health care systems that offer free and equal access to all citizens - and these programmes are very popular. In this dissertation I find that the most common explanations for welfare state reform fail to explain these changes: Privatisation policies are not the result of partisan politics, instead they are supported by Social Democratic / Labour parties and in some cases the unions as well. Privatisation is not the result of pressures for fiscal retrenchment; in fact, public health care funding has increased in all three countries over the past decade. Neither is privatisation the straight forward result of new right wing ideas. Certainly, new ideas play a role in this change, but it is difficult to sustain the argument that ideas alone have been the cause of privatisation in these three health care systems. Finally, it has been debated whether privatisation is the result of pressure from EU legislation. This explanation does not hold either for the basic reason of timing. The policies leading to privatisation in Denmark, England and Sweden were all implemented before the European debate over health care services started. Instead, I suggest that privatisation in health care in Denmark, Sweden and England can best be understood as the product of policy makers puzzling over important policy problems (Heclo, 1972). I call this an adaptive process. In this analysis I show that privatisation is the result of several interconnected attempts to adapt health care systems to a changing context. By taking a long historical view of the changes in health care systems, it becomes evident that the changes towards privatisation do not occur overnight or as a result of a ‘punctuated equilibrium’. Rather, the increasing privatisation in health care is the accumulated effect of several small step policy changes, which, over time, result in rising levels of privatisation. Some scholars have suggested that neo-liberal policies, such as privatisation of service provision, will ultimately lead to the end of the welfare state. In this study, I come to a different conclusion. Rather than undermine the welfare state, privatisation in health care may help the welfare state survive. Privatisation can be seen as a way of adapting welfare state services to a changing political context

Policymaking without policy choice: the rise of private health insurance in Denmark

Policymaking and policy outcomes are not necessarily the result of a carefully designed process but can result from intertwined political and institutional dynamics that are often difficult to predict from the outset. This article examines such a policy process, the dramatic rise in the uptake of private health insurance (PHI) in Denmark. In a comprehensive welfare state, founded on the principle of universalism, its success is puzzling. The explanation suggested here is that the rise in PHI is an example of policymaking without policy choice. The article reviews the intended and unintended effects concerning equality in health care and public finance. It also notes that the introduction of a private alternative to the universal health care system has not weakened the support for the public services. An electronic version of this article can be accessed via the internet at http://journals.cambridge.or

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Late Classical and Hellenistic Art

Late classical and Hellenistic art in Etruscan culture between 450 and 250 BC

The Danish-American Research Exchange (DARE): a cross-sectional study of a binational research education program

BackgroundMost medical educational programs emphasize clinical observation or clinical skill acquisition, fewer focus upon research. The Danish-American Research Exchange (DARE) program, sponsored by the Lundbeck Foundation, is unique in that the medical student initiates biomedical research collaboration between Danish and US medical institutions. To achieve this, Danish medical students (DARE students) conduct binational mentored research projects while based in the United States for 10 months. In addition, DARE students are introduced to interdisciplinary thinking about how to develop ultra-low-cost healthcare interventions through the '$10 Challenge'.MethodsWe conducted a cross-sectional study of DARE alumni over five consecutive years (2015-2020, n = 24). Research metrics included completion of a research project, primary authorship, and co-authorship of publications. The number of publications, prior to and after the DARE program were enumerated. For the first four cohorts, graduation from medical school and acceptance or intention to enter a joint MD-PhD program also were assessed. Two focus groups were conducted using constructivist grounded theory. Discussions were transcribed, redacted, and coded using Dedoose software.ResultsDARE Medical students were 31.2 years (range 24-35), the majority were women (67%;16/24). The majority (17/24;71%) completed a first author publication in a peer-reviewed journal with a median of 3.9 per DARE alumnus. DARE alumnus reported increased proficiency in biostatistics, epidemiology, coding and public speaking as well as stronger research qualities in creativity, critical thinking, comfort in approaching scientist in both the US and Denmark (p < 0.001 for all). Qualitative key themes included: increased confidence, a deepening of research inquiry and linkage to a research network.ConclusionsPreliminarily, this study suggests that medical students can initiate binational collaboration in medicine. Benefits include research productivity, intention to pursue academic medical careers, as well as positive impacts on motivation. This medical student-initiated research model lays the groundwork for using this model across other country pairs to promote binational collaboration

The Danish-American Research Exchange (DARE): a cross-sectional study of a binational research education program

Abstract Background Most medical educational programs emphasize clinical observation or clinical skill acquisition, fewer focus upon research. The Danish-American Research Exchange (DARE) program, sponsored by the Lundbeck Foundation, is unique in that the medical student initiates biomedical research collaboration between Danish and US medical institutions. To achieve this, Danish medical students (DARE students) conduct binational mentored research projects while based in the United States for 10 months. In addition, DARE students are introduced to interdisciplinary thinking about how to develop ultra-low-cost healthcare interventions through the ‘$10 Challenge’. Methods We conducted a cross-sectional study of DARE alumni over five consecutive years (2015–2020, n = 24). Research metrics included completion of a research project, primary authorship, and co-authorship of publications. The number of publications, prior to and after the DARE program were enumerated. For the first four cohorts, graduation from medical school and acceptance or intention to enter a joint MD-PhD program also were assessed. Two focus groups were conducted using constructivist grounded theory. Discussions were transcribed, redacted, and coded using Dedoose software. Results DARE Medical students were 31.2 years (range 24–35), the majority were women (67%;16/24). The majority (17/24;71%) completed a first author publication in a peer-reviewed journal with a median of 3.9 per DARE alumnus. DARE alumnus reported increased proficiency in biostatistics, epidemiology, coding and public speaking as well as stronger research qualities in creativity, critical thinking, comfort in approaching scientist in both the US and Denmark (p < 0.001 for all). Qualitative key themes included: increased confidence, a deepening of research inquiry and linkage to a research network. Conclusions Preliminarily, this study suggests that medical students can initiate binational collaboration in medicine. Benefits include research productivity, intention to pursue academic medical careers, as well as positive impacts on motivation. This medical student-initiated research model lays the groundwork for using this model across other country pairs to promote binational collaboration

The Danish-American Research Exchange (DARE): a cross-sectional study of a binational research education program

Abstract Background Most medical educational programs emphasize clinical observation or clinical skill acquisition, fewer focus upon research. The Danish-American Research Exchange (DARE) program, sponsored by the Lundbeck Foundation, is unique in that the medical student initiates biomedical research collaboration between Danish and US medical institutions. To achieve this, Danish medical students (DARE students) conduct binational mentored research projects while based in the United States for 10 months. In addition, DARE students are introduced to interdisciplinary thinking about how to develop ultra-low-cost healthcare interventions through the ‘$10 Challenge’. Methods We conducted a cross-sectional study of DARE alumni over five consecutive years (2015–2020, n = 24). Research metrics included completion of a research project, primary authorship, and co-authorship of publications. The number of publications, prior to and after the DARE program were enumerated. For the first four cohorts, graduation from medical school and acceptance or intention to enter a joint MD-PhD program also were assessed. Two focus groups were conducted using constructivist grounded theory. Discussions were transcribed, redacted, and coded using Dedoose software. Results DARE Medical students were 31.2 years (range 24–35), the majority were women (67%;16/24). The majority (17/24;71%) completed a first author publication in a peer-reviewed journal with a median of 3.9 per DARE alumnus. DARE alumnus reported increased proficiency in biostatistics, epidemiology, coding and public speaking as well as stronger research qualities in creativity, critical thinking, comfort in approaching scientist in both the US and Denmark (p < 0.001 for all). Qualitative key themes included: increased confidence, a deepening of research inquiry and linkage to a research network. Conclusions Preliminarily, this study suggests that medical students can initiate binational collaboration in medicine. Benefits include research productivity, intention to pursue academic medical careers, as well as positive impacts on motivation. This medical student-initiated research model lays the groundwork for using this model across other country pairs to promote binational collaboration

Additional file 3 of The Danish-American Research Exchange (DARE): a cross-sectional study of a binational research education program

Additional file 3: Supplemental Table 1. Qualitative data from DARE medical student alumni collected at two focus group meetings. Appendix 1. References for publications of DARE Fellows and Alumni, 2015-2020, Cohorts 1-5

Additional file 3 of The Danish-American Research Exchange (DARE): a cross-sectional study of a binational research education program

Additional file 3: Supplemental Table 1. Qualitative data from DARE medical student alumni collected at two focus group meetings. Appendix 1. References for publications of DARE Fellows and Alumni, 2015-2020, Cohorts 1-5