Commentary: Global Comparisons of Physician Associations

The authors reflect on their own work in relation to the articles in this special section on physician organizations, and they make four observations. First, association-government power relations shift after countries introduce universal health insurance, but they are by no means diminished. In France, Germany, and Japan, physicians' economic interests are explicitly considered against broader health system goals, such as providing affordable universal insurance. In low- and middle-income countries (LMICs), physician organizations do not share power in the same way. Second, in higher-income countries, fragmentation may occur along specialty or generalist lines, and some physicians are unionized. Generally speaking, physician influence over reimbursement policy is reduced because of organizational fragmentation. Third, associations develop as legitimate voices for physicians, but their relationship to other professions differs in higher-income countries. Associations in LMICs form coalitions with other health professionals. Finally, although German state physician associations have a key implementation role, in most countries, state and federal policy roles seem relatively defined. Global comparison of the LMICs and other countries suggests power, unity, legitimacy, and federal roles are tied closely to the stage of health system development.