OBJECTIVES: To examine whether the Health System Reforms delivered the promise of being a coherent and mutually supporting reform programme; to identify the underlying programme theory of the reform programme; to reflect on whether lessons have been learned. METHODS: Documentary analysis mapping the implicit and explicit programme theories about how the reforms intended to achieve its goals and outcomes. Semi-structured interviews with policy-makers to further understand the programme theory. RESULTS: The Health System Reforms assumed a 'one size fits all' approach to policy implementation with little recognition that some contexts can be more receptive than others. There was evidence of some policy evolution and rebalancing between the reform streams as policy-makers became aware of some perverse incentives and unforeseen consequences. Later elements aimed to restore balance to the system. CONCLUSIONS: The Health System Reforms do not appear to comprise a coherent and mutually supportive set of levers and incentives. They appear unbalanced with the centre of gravity favouring suppliers over commissioners. However, recent reform changes have sought to redress this imbalance to some extent, suggesting that lessons have been learned and policies have been adapted over time.
OBJECTIVES: To examine whether the Health System Reforms delivered the promise of being a coherent and mutually supporting reform programme; to identify the underlying programme theory of the reform programme; to reflect on whether lessons have been learned. METHODS: Documentary analysis mapping the implicit and explicit programme theories about how the reforms intended to achieve its goals and outcomes. Semi-structured interviews with policy-makers to further understand the programme theory. RESULTS: The Health System Reforms assumed a 'one size fits all' approach to policy implementation with little recognition that some contexts can be more receptive than others. There was evidence of some policy evolution and rebalancing between the reform streams as policy-makers became aware of some perverse incentives and unforeseen consequences. Later elements aimed to restore balance to the system. CONCLUSIONS: The Health System Reforms do not appear to comprise a coherent and mutually supportive set of levers and incentives. They appear unbalanced with the centre of gravity favouring suppliers over commissioners. However, recent reform changes have sought to redress this imbalance to some extent, suggesting that lessons have been learned and policies have been adapted over time.