The mixed legacy of managed competition: between policy and practice

About 25 years ago, managed competitionalso termed 'the internal market' and 'regulated competition', depending on the institutional characteristics and regulatory mechanisms that were highlightedwas introduced as a response to growing waiting lists and political concerns about the sustainability of health systems.Moving forward on the waves of new public management, and stretching from Australia to Columbia, and from the United Kingdom to South Africa, many health systems introduced some form of managed competition.Among other aspects, this would hold together the conflicting aims of efficiency and equity, combining 'public' security with 'private' market innovation and cost reduction.In this special issue of Health Economics, Policy and Law, edited by Josefa Henriquez, Shuli Brammli-Greenberg, Francesco Paolucci, and Maria Trottmann, we aim to provide insights into the impact of managed competition as a policy instrument.To what extent have countries been successful in realising its full potential?And what might that potential look like in evolving health systems, where new challenges are emerging ever since?The special issue starts with an editorial by the editorial team, comparing the countries featured (i.e.Columbia, New Zealand, Ireland, Australia, the United States, Chile, South Africa, and the United Kingdom), highlighting and discussing their institutional characteristics that impact the (im)possibilities and challenges to achieving a managed competition model.The editorial is followed by two theory-informed papers in which Trottmann et al. ( 2023) and Henriquez et al. ( 2024) present a theoretical framework and analytical model that explains the central features of the regulated competition model, emphasising the conditions that should be met to enable managed competition and to identify possible competition failures.In the subsequent papers, countries are held up to these standards.The paper of Van den Heever (2024) shows that in South Africa, the managed competition model has only been partially introduced.It assesses the existing regulatory framework and the resulting market outcomes against the preconditions for a complete system of regulated competition as argued by theory.Also, the other papers describe the challenges to bring theory in practice, besides initial or only partial successes.Berardi et al. (2024), for example, discuss how in Australia structural deficiencies exist in public-private partnerships, which makes it difficult to deliver high-quality and accessible care for all.Ellis et al. (2024) points out the complex nature of the US health system and the programmes in which it has been introduced as a governing principle (i.e. the Affordable Care Act, Medicaid managed care organisations, and Medicare Advantage plans).They argue that the differences between these systems as well as their lack of