HEALTHDOX: Mapping Three Decades of Health Reform in Europe

How have three decades of health reform changed Europe’s health systems, and what have these changes meant for citizens? This was the question at the heart of HEALTHDOX – The Paradox of Health State Futures, an international research project that ran from 2015 to 2018 and whose first comprehensive dataset of European health reforms continues to generate new research today.

HEALTHDOX started from a puzzle. European integration and globalisation seemed to push tax-funded National Health Service (NHS) systems towards the contributions-based Social Health Insurance (SHI) model. Yet NHS-type systems might be better placed to contain the costs of population ageing and to keep the support of increasingly diverse populations. If so, the direction of reform and the needs of future welfare states could be pulling against each other – the “paradox” in the project’s title. To examine it, the project studied health reforms since 1990, in relation to health inequalities and public attitudes towards the health system.

HEALTHDOX was one of 15 transnational research projects in the NORFACE Welfare State Futures programme. Backed by the NORFACE partner research councils, the Swedish Research Council for Health, Working Life and Welfare (Forte) and the European Commission, the programme invested around €18 million in comparative research on the challenges facing European welfare states.

Who was involved

The project was coordinated by Ellen M. Immergut at Humboldt-Universität zu Berlin (later, European University Institute) and brought together teams from five additional Countries. The teams were led by Mare Ainsaar at the University of Tartu in Estonia, Camilla Devitt at Trinity College Dublin in Ireland, Karen M. Anderson at Radboud University Nijmegen in the Netherlands, and Maria Asensio at the University of Lisbon in Portugal. Sweden was represented by two teams: Paula Blomqvist at Uppsala University and Maria Oskarson at the University of Gothenburg. Diana Burlacu, Tamara Popic, Andra Roescu, Simone M. Schneider, Ave Roots, and Björn Rönnerstrand joined the project as Post-docs.

The six partner Countries were also the project’s in-depth case studies. They were chosen to cover the main types of European health systems: NHS-type systems (Ireland, Portugal, Sweden), social health insurance (SHI) systems (Germany, the Netherlands), and a post-communist system (Estonia).¹

Alongside these cases, the team carried out a comparative review of the remaining EU member states (all except Malta) and 9 non-EU Countries (the UK, Norway, Switzerland, Albania, Serbia, Montenegro, North Macedonia, Bosnia and Herzegovina, and Kosovo), combining quantitative data from national and international sources with qualitative research.²

Project outputs

HEALTHDOX left two major resources for researchers and policy makers, along with a growing body of articles.

• A handbook. Health Politics in Europe: A Handbook, edited by Ellen M. Immergut, Karen M. Anderson, Camilla Devitt and Tamara Popic (Oxford University Press, 2021). Its 46 chapters cover core issues of health inequalities and public opinion, overviews of each European region, and 35 Country-specific chapters authored by Country experts. Each Country chapter traces the political history, the current health system and the politics of health reform since 1989.
• A dataset. The HEALTHDOX Health Politics in Europe Dataset, an original record of three decades of health legislation across whole Europe, described in more details below.
• Research articles. Studies on health reform and partisanship, public opinion and health outcomes, published in leading journals in political science and health policy.

The health reform database

The HEALTHDOX Health Politics in Europe Dataset records the healthcare reforms enacted in European Countries from 1989 to 2019. It was compiled by Ellen M. Immergut, Diana Burlacu, Andra Maria Roescu, Mirko Wegemann, Tamara Popic and Guergana Stolarov-Demuth, and is available in open access in Cadmus, the research repository of the European University Institute (EUI). Most comparative health research measures reform indirectly, through spending or health outcomes. The HEALTHDOX dataset instead records legislative outputs of health reforms. For each measure, it documents:

• the date and number of the law, decree or legislative proposal;
• its name in the national language and in English;
• link to the text of the law;
• the dates of passage and entry into force;
• a description of its main provisions.

Reforms are coded by how they changed public-private mix in healthcare financing and provision. This includes measures to increase/decrease tax or mandatory contributory financing, out-of-pocket payment (OPP) or to increase/decrease private health insurance, number of private providers (doctors or hospitals), and healthcare benefits, as well as measure of patient rights. This makes it possible to compare reform trajectories across Countries and over time, and to link them to data on politics, public opinion and health. The first release also includes 61 data figures and 38 data tables drawing on Eurostat, the OECD, the European Social Survey, Eurobarometer, WHO and the Global Burden of Disease project, together with a guide to the data and sources and a codebook.

New research using the Healthdox data

The flagship article based on the database has just been published in the Journal of European Public Policy. In “Do parties and institutions still matter for healthcare? Multi-dimensional partisanship, veto points, and the legislative politics of healthcare”, in which Tamara Popic, Mirko Wegemann, Alexandru D. Moise and Ellen M. Immergut analyse 719 health reform laws passed in 33 European Countries between 1990 and 2019. The article challenges the view that healthcare has become a consensus issue where parties and institutions no longer matter. It finds that they still do, but differently for different sub-issues of health policy. Economically right-wing governments are more likely to pass privatisation laws, while socially conservative governments are more likely to introduce patient rights. Veto points such as second chambers, presidents, courts and referendums hinder privatisation, but they do not block patient rights legislation. Two further articles by Tamara Popic and Alexandru D. Moise use the data to study the consequences of privatisation for citizens:

• “A bitter aftertaste? The effects of privatisation reforms on evaluations of health systems across Europe”, Journal of European Public Policy, 2026. Combining the reform data with the European Social Survey for 30 Countries, it shows that citizens’ evaluations of their health system first improve after privatisation and then decline. People who rely most on healthcare react faster and for longer.
• “Political determinants of health: Healthcare privatization and population health in Europe”, Journal of Health Politics, Policy and Law 49(5), 2024. Covering 36 Countries from 1989 to 2019, it finds that privatisation is followed, typically after several years, by more people reporting poor health and unmet health needs. The effects are larger among people with lower income and education, which widens health inequalities.

Together, these studies show the value of measuring reform through legislation: they make it possible to trace how political choices travel from parliaments to health systems and back into citizens’ health and attitudes. The dataset remains openly available for new research.

1. In-depth case chapters: Ireland (Camilla Devitt); Portugal (Maria Asensio); Sweden (Paula Blomqvist and Ulrika Winblad); Germany (Ellen M. Immergut and Claus Wendt); the Netherlands (Karen M. Anderson and Ruud J. van Druenen); Estonia (Mare Ainsaar, Ave Roots, and Jüri Kõre).
2. Comparative cases: the UK (Jane Gingrich and Scott L. Greer); Denmark (Karsten Vrangbæk); Finland (Liina-Kaisa Tynkkynen, Meri Koivusalo, and Ilmo Keskimäki); Norway (Mi Ah Schoyen); Italy (Franca Maino and Federico Razetti); Spain (Elisa Chuliá); Greece (Ilias Kyriopoulos and Elias Mossialos); Cyprus (Mamas Theodorou and Kostas Athanasakis); Latvia (Edgars Eihmanis); Lithuania (Liubovė Murauskienė); France (Matthias Brunn and Patrick Hassenteufel); Belgium (Julia Lynch and Chris Vermorken); Luxembourg (Anja Leist); Austria (Carina Diesenreiter and Claus Wendt); Switzerland (Christian Rüefli); Hungary (Mária Éva Földes); Bulgaria (Guergana Stolarov-Demuth); Romania (Diana Burlacu and Alexandru Daniel Moise); Albania (Mirza Balaj); Montenegro (Natalija Perišić); North Macedonia (Simonida Kacarska and Neda Milevska Kostova); Bosnia and Herzegovina (Jasmin Hasić); Kosovo (Arta Uka); the former Yugoslavia (Tamara Popic and Natalija Perišić); the Czech Republic, Poland, Slovakia, Slovenia, Croatia, and Serbia (Tamara Popic).