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Journal Article


Leadership and Governance in Seven Developed Health Systems

The Issue

According to the World Health Organization, a government’s responsibility for its health care system has three components: setting population health goals, assessing progress toward those goals, and ensuring accountability. In a Commonwealth Fund–supported study, researchers use this model to compare the leadership and governance arrangements in seven nations with advanced health systems: Australia, England, Germany, the Netherlands, Norway, Sweden, and Switzerland.

What the Study Found

Approaches to health system governance and leadership vary substantially. While there is some consensus around broad goals—such as ensuring the quality and safety of health services—the seven nations take varying approaches in setting priorities to reach them. They are in general agreement about the need to measure health system performance. On the other hand, the nations take widely different approaches to holding health system actors accountable. For example, the Netherlands relies on health care markets, in which patients or insurers exert pressure on providers to uphold standards of care, and England appears to be moving in this direction. By contrast, Norway has more direct control through four regional health authorities that set health plans’ terms and contracts.


The researchers suggest that a blended approach to accountability—including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control—is likely to be most effective. They conclude that further challenges for the governance and leadership of these health systems are “setting realistic priorities based on sustainable financing, performance monitoring that encourages rather than stifles innovation, and designing accountability mechanisms that strengthen rather than undermine professional responsibility.”

Publication Details



P. C. Smith, A. Anell, R. Busse et al., “Leadership and Governance in Seven Developed Health Systems,” Health Policy, published online Jan. 19, 2012.