Control and performance of health care systems. A comparative analysis of 19 OECD countries

Int J Health Plann Manage. Jul-Sep 2008;23(3):235-57. doi: 10.1002/hpm.946.


This paper performs an empirical comparison of health systems. Health systems are seen as networks of delegation relationships among principals and agents, subject to agency problems. Following the institutional economics approach, a health system's efficiency is considered to be determined by the existence and treatment of agency problems. Agency problems can be controlled by mechanisms built into the health system, or can also be controlled by an external actor, for example, the government, either by using the instruments available or by conducting institutional reforms. To explain differences in the amenability of a country's health system to external governmental control, I combine the veto player approach and the incentives for societal actors to exert influence, into the concept of indirect veto players: the more indirect veto players exist, the less external control will be exercised.I derive indicators capturing both forms of control and perform a comparison of health systems based on institutional and performance data. Using data reducing methods, I identify two dimensions of control underlying the institutional setting of the health system and three dimensions of health system performance. The relationships found between control and performance confirm the hypotheses derived from the adopted theoretical approach.

Publication types

  • Comparative Study

MeSH terms

  • Delivery of Health Care / organization & administration*
  • Democracy
  • Efficiency, Organizational*
  • Humans
  • Internationality*
  • Societies