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Hospitals worldwide are facing the same opportunities and threats: the demographics of an aging population; steady increases in chronic diseases and severe illnesses; and a steadily increasing demand for medical services with more intensive treatment for multi-morbid patients. Additionally, patients are becoming more demanding. They expect high quality medicine within a dignity-driven and painless healing environment.

The severe financial pressures that these developments entail oblige care providers to more and more cost-containment and to apply process reengineering, as well as continuous performance improvement measures, so as to achieve future financial sustainability. At the same time, regulators are calling for improved patient outcomes. Benchmarking and best practice management are successfully proven performance improvement tools for enabling hospitals to achieve a higher level of clinical output quality, enhanced patient satisfaction, and care delivery capability, while simultaneously containing and reducing costs.

This chapter aims to clarify what benchmarking is and what it is not. Furthermore, it is stated that benchmarking is a powerful managerial tool for improving decision-making processes that can contribute to the above-mentioned improvement measures in health care delivery. The benchmarking approach described in this chapter is oriented toward the philosophy of an input–output model and is explained based on practical international examples from different industries in various countries.

Benchmarking is not a project with a defined start and end point, but a continuous initiative of comparing key performance indicators, process structures, and best practices from best-in-class companies inside and outside industry.

Benchmarking is an ongoing process of measuring and searching for best-in-class performance:

• Measure yourself with yourself over time against key performance indicators

• Measure yourself against others

• Identify best practices

• Equal or exceed this best practice in your institution

• Focus on simple and effective ways to implement solutions

Measure yourself with yourself over time against key performance indicators

Measure yourself against others

Identify best practices

Equal or exceed this best practice in your institution

Focus on simple and effective ways to implement solutions

Comparing only figures, such as average length of stay, costs of procedures, infection rates, or out-of-stock rates, can lead easily to wrong conclusions and decision making with often-disastrous consequences. Just looking at figures and ratios is not the basis for detecting potential excellence. It is necessary to look beyond the numbers to understand how processes work and contribute to best-in-class results. Best practices from even quite different industries can enable hospitals to leapfrog results in patient orientation, clinical excellence, and cost-effectiveness.

Despite common benchmarking approaches, it is pointed out that a comparison without “looking behind the figures” (what it means to be familiar with the process structure, process dynamic and drivers, process institutions/rules and process-related incentive components) will be extremely limited referring to reliability and quality of findings.

In order to demonstrate transferability of benchmarking results between different industries practical examples from health care, automotive, and hotel service have been selected.

Additionally, it is depicted that international comparisons between hospitals providing medical services in different health care systems do have a great potential for achieving leapfrog results in medical quality, organization of service provision, effective work structures, purchasing and logistics processes, or management, etc.

There is a renewed interest among economists and policymakers in striking a perfect balance between the market, state, and the community for equitable and sustained development. Inclusive development is the need of the hour and healthcare cooperatives provide the perfect means to deliver that. The cooperatives can and should have an important role to play in this scenario. However, there is an important need to provide an enabling environment for the genesis and growth of Healthcare Cooperatives in India and to learn from the best models and practices across the world. The chapter discusses the effectiveness of healthcare cooperatives.

The Norwegian health care system is semi-decentralized. Primary care and long-term care (LTC) are the responsibilities of the municipalities. Specialist care is the responsibility of the central government and is organised through four Regional Health Authorities (RHA). Resource use, health outcomes and severity are the three main pillars for priority setting, regularly applied in reimbursement decisions for pharmaceuticals.

The sustainability of health care is challenged in Norway. The main factors are a growing elderly population with high need of complex, coordinated services, an increasing demand for newly approved drugs and advanced technology and a potential shortage of health care personnel.

We present recent trials and policy reforms in Norway aimed at improving care pathways combined with cost containment. Reforms in the pharmaceutical market, both with regard to market access and reimbursement (cost-effectiveness), and regulation of prices, have resulted in cost containment. The primary care sector awaits reform initiatives to recruit and retain physicians as general practitioners. No reform in the hospital sector has had cost containment as a main focus. The sector is characterized with low productivity growth, and expenditures that have increased more than the GDP growth. Waiting times are long, and coordination between sub-sectors of health care has been poor, although the Coordination reform of 2012 has alleviated some of the challenges related to intersectoral coordination. Still, the divided responsibility for health care between the central government and the municipalities creates tensions between national ambitions and local decisions in the financing and provision of health services.

In this chapter, we focus on the major reforms intended to ensure the sustainability of health care in Denmark between 2000 and 2020 and the evidence for the effectiveness of these reforms. We take a broad definition of sustainability and include reforms that aimed to improve the productivity of the health care sector both in terms of increasing activity for the same set of inputs and in terms of improving the quality of care. A characterisation of the Danish health care system as having gone through evolution rather than revolution (Pedersen, Christiansen, & Bech, 2005) is, with one exception, still true today, and reforms have been relatively few. As we demonstrate there is a relative lack of formal evaluations of these reforms.

In the first decade of the period, the majority of new policy measures aimed to increase the quantity of care provided by the health care sector. With the introduction of diagnosis-related groups (DRGs) to measure hospital activity, a wave of reforms created a stronger link between activity and hospital reimbursement, and introduced additional incentives for increasing activity, alongside requirements for increased technical efficiency. A centralisation reform in 2007 reduced the number of administrative units and saw the beginning of a development that would also lead to fewer hospital units. Procurements of medicines were professionalised, and a national council was established to consider the use of expensive hospital medicine.

In the second-half of the period, policy makers began questioning whether increased activity was always for the better, and slowly began experimenting with initiatives that would shift the focus to the quality and appropriateness of care. As in many other countries, this move occurred in the light of a realisation of a shift in the demographic structure of the country and the change this was expected to create for the future demand for health care.

Although some empirical evidence exists, it is striking that few of the changes to the health care sector has been subject to formal academic evaluation – especially when considering the availability of high quality nationwide micro data. We point to a number of important lessons that could be drawn from the Danish experiences.

However, the greatest potential for research into the sustainability of health care in the Danish setting is probably still to be realised by taking advantage of the possibilities of linking micro data on individuals' health care utilisation, schooling outcomes and labour supply, with the possibility of following individuals across decades. For example, Danish micro data make it possible to follow newborns in 1990 until they reach adulthood and simultaneously follow their parents from adulthood until they reach 60 years of age where the prevalence of chronic diseases begins to show.

For health services researchers and health services management educators, chronicling the unfolding of a country's implementation of national health insurance (NHI) is once in a lifetime opportunity. Rarely, do researchers have the opportunity to observe the macro and micro changes associated with turning a country's health care delivery system 180 degrees. Accordingly, we report on the first decade of Taiwan's changing delivery system and selected adaptations of health care management, providers and patients.

We present a description and analysis of the current reforms in the French system of “assurance maladie”, or its health insurance system, particularly as they bear on quality at the hospital level. The measurement and management of quality play a significant role in the reform, thus providing a particularly timely example for health care policy makers, researchers, and managers. We discovered several lessons from the French experience. First, the issue of workload influenced thinking about how best to build a given indicator, and led to careful evaluation of the added value of additional data collection. In some cases the indicators are actually more of a screen or filter than an actual assessment of quality, with particularly high or low values signaling the need for further investigation rather than serving as assessments per se. Second, the development and implementation of quality indicators (QIs) demand the involvement of professionals in the process. Third, process indicators seemed to be more useful than outcome indicators. Fourth, expectations for quality management should be aligned with feasibility and with the reality of measurement system. For example, the workload is closely tied to the state of the hospital data collection systems (indicators selection). Lastly, the twin objectives of quality improvement and accountability do not necessarily mesh easily or well.

This chapter provides an assessment of the sustainability of Ireland's health care system. It starts by describing the historical development of the Irish system and identifying key features of the current system that raise potential challenges for sustainability. It then provides an analysis of recently compiled and up-to-date data on trends in health care expenditures. A number of specific demand and supply side challenges to sustainability are then described and discussed. This is followed by an examination of recent and current reforms to the health care system, focussing on their likely impact on sustainability, as well as a discussion of how health economics has and can inform policy, practice and debate. We also discuss the potential implications of the COVID-19 pandemic for the Irish system.