This article presents the results of a systematic review of international studies on economic and quality effects of contracting out published in the period from 2000 to 2014. We conducted a comprehensive search of the literature and identified 49 relevant studies. There are three main findings of the systematic review: (1) cost savings documented in international contracting out literature have been decreasing over time; (2) cost savings have been much greater in technical services than in social services; and (3) economic effects have been twice as large in Anglo-Saxon countries compared with other countries. With regard to measuring the effect of contracting out on service quality, which is a vital component of any service delivery arrangement, very few studies assess this issue in a comprehensive manner. There is also a significant lack of studies that include measures of transaction costs, thereby making it difficult to evaluate the impact of contracting out on overall costeffectiveness of public service delivery. We conclude that generalization of effects from contracting out should be made with caution and are likely to depend, among other things, on the transaction costs characteristics of the service, the market situation and the institutional/regulatory setting.

The past decades have witnessed an upsurge in governments' use of contracting out as a means of reforming and privatizing public service delivery. This development has to a large extent been driven by efficiency and cost-effectiveness concerns, but may also result in important changes in the working conditions and work environment for the personnel in public organizations. In this article, we present the findings from a systematic review of studies documenting the consequences of contracting out for employees. The review is based on 26 empirical studies published between 2000 and 2012. We find both positive and negative effects for employees documented in the literature, although with a predominance of negative effects, including reductions in the workforce and other changes in the workforce composition such as the replacement of experienced employees with younger workers, poorer working conditions, lower salaries, fewer benefits and reduced job satisfaction. We conclude that poorer conditions for the public service personnel are well documented as a short term consequence of contracting out, while more studies covering a longer time-span are needed in order to assess whether the predominantly negative effects are transitory or will persist over time.

Denmark implemented a major reform of the administrative and political structure in 2007 when the previous 13 counties were merged into five new regions and the number of municipalities was reduced from 271 to 98. A main objective was to create administrative units that were large enough to support a hospital structure with few acute hospitals in each region and to centralize specialized care in fewer hospitals. This paper analyses the reorganization of the somatic hospital sector in Denmark since 2007, discusses the mechanisms behind the changes and analyses hospital performance after the reform. The reform focused on improving acute services and quality of care. The number of acute hospitals was reduced from about 40-21 hospitals with new joint acute facilities, which include emergency care wards. The restructuring and geographical placement of acute hospitals took place in a democratic process subject to central guidelines and requirements. Since the reform, hospital productivity has increased by more than 2 per cent per year and costs have been stable. Overall, indicators point to a successful reform. However, it has also been criticized that some people in remote areas feel "left behind" in the economic development and that hospital staff are under increased workload pressure. Concurrent with the centralization of hospitals municipalities strengthened their health service with an emphasis on prevention and health promotion.

BackgroundWhat is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies.MethodsThe review was based on a methodological approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality.ResultsOur review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.ConclusionsThe paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Further integration of the public value literature with other strands of literature within Public Administration necessitates a more specific classification of public values. This article applies a typology linked to organizational design principles, because this is useful for empirical public administration studies. Based on an existing typology of modes of governance, we develop a classification and test it empirically, using survey data from a study of the values of 501 public managers. We distinguish among seven value dimensions (the public at large, rule abidance, balancing interests, budget keeping, efficient supply, professionalism, and user focus), and we find systematic differences between organizations at different levels and with different tasks, indicating that the classification is fruitful. Our goal is to enable more precise analyses of value conflicts and improve the integration between the public value literature and other parts of the Public Administration discipline.

Industrialised countries face similar challenges for improving the performance of their health system.Nevertheless the nature and intensity of the reforms required are largely determined by each country's basic social security model. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of health care system which underlie these differences? Have recent reforms been effective?Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms.Keywords: Health system, Beveridge, Bismarck, reforms, performance JEL Classification: I18, 057. RésuméPour améliorer la performance de leur système de santé, les pays industrialisés relèvent des défis assez semblables. Néanmoins, la nature et l'intensité des réformes exigées sont en grande partie déterminées par le modèle de protection sociale mis en oeuvre dans chaque pays. Examinant les principales différences de cette performance dans cinq pays, cet article compare leur expérience récente de réforme à partir de trois questions majeures : Y a-t-il des différences systématiques de performance entre les systèmes de type beveridgien et bismarckien ? Quels sont les principaux paramètres du système de soins à l'origine de ces différences ? Les réformes récentes ont-elles été efficaces ?Nos résultats ne suggèrent pas qu'un système-type est invariablement meilleur qu'un autre. L'hétérogénéité de la conception organisationnelle et de la gouvernance tant à l'intérieur qu'à travers ces systèmes explique en partie leurs écarts. Une attention insuffisante à ces différences structurelles peut expliciter le succès limité d'un certain nombre de réformes récentes.

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitt's suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice.

IntroductionInsights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, and discuss them in relation to interorganisational network theory.Policy practiceThe policy initiatives to improve collaboration between primary and secondary healthcare in Denmark and Sweden include legislation and agreements aiming at clarifying areas of responsibility and defining requirements, creation of links across organisational boarders. In Denmark many initiatives have been centrally induced, while development of local solutions is more prominent in Sweden. Many Danish initiatives target the administrative level, while in Sweden initiatives are also directed at the operational level. In both countries economic incentives for collaboration are weak or lacking, and use of sanctions as a regulatory mean is limited.Discussion and conclusionDespite a variety of policy initiatives, lacking or poorly developed structures to support implementation function as barriers for coordination. The two cases illustrate that even in two relatively coherent health systems, with regional management of both the hospital and general practice sector, there are issues to resolve in regard to administrative and operational coordination. The interorganisational network literature can provide useful tools and concepts for interpreting such issues.