Mapping the scientific production on economic regulation and health systems

Mapeo de la producción científica sobre la regulación económica y los sistemas de salud

Mapeamento da produção científica sobre regulação econômica e sistemas de saúde

Natalia Carolina Cañar Muñoz ncanar@estudiante.uniajc.edu.co

Institución Universitaria Antonio José Camacho,, Colombia

Oscar Marino López-Mallama omarinolopez@admon.uniajc.edu.co

Institución Universitaria Antonio José Camacho, Colombia

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

Healthcare systems are dynamic and complex structures that are constantly evolving, linking multiple actors with diverse motivations who interact with each other (López-Mallama, 2023; Mantilla et al., 2023; López-Mallama et al., 2023) Its main objective is to guarantee the health of the population, protect their financial well-being, and offer accessible services, all under each country’s economic capacity (Andrade et al., 2024; Galvis et al., 2022; Pan American Health Organization (PAHO, 2020). To fulfill this purpose, health systems rely on four essential functions: stewardship, financing, resource generation, and service provision (Montaño & García-Perdomo, 2024; Centro de Estudios en Protección Social y Economía de la Salud [Proesa], 2020).

In addition to providing medical care to individuals and communities, health systems implement strategies that influence policies and actions in other sectors. These strategies aim to address the social, environmental, and economic determinants that impact health (Cotonieto-Martínez & Rodríguez-Terán, 2021; García & Esquer, 2024) From an economic perspective, these systems function within environments where market failures are evident, given the variety of actors and institutions involved in the sector’s planning, resource allocation, and regulation (Arellano, 2022). These actors interact within market, regulatory, and governance frameworks, giving rise to relationships of coordination, subordination, and participation (Tacumá & Tovar, 2021).

In the context of globalization and neoliberal economic policies —characterized by trade liberalization, reduced public spending, privatization, and the deregulation of economic inequalities— poverty and income inequality have increased, affecting equitable access to health services (Treacy, 2021). At the same time, public health faces challenges arising from demographic transition, marked by population aging and an increase in chronic noncommunicable diseases (UN. CEPAL, 2022; Pinilla et al., 2021). Similarly, the epidemiological transition has led to the development of programs to prevent and treat prevalent and emerging communicable diseases (Boucourt et al., 2022)

Studying health systems from the perspective of economic regulation allows us to analyze their macroeconomic impact on population health, productivity, and quality of life. At the microeconomic level, we can study the dynamics of agents and decision-making within the health ecosystem. These issues are closely linked to the third Sustainable Development Goal (SDG), which focuses on health and well-being. Specifically, it addresses universal coverage (target 3.8) and health financing (target 3.C) (Javier & Cuadros, 2022; Lomelí, 2020; United Nations, n.d.).

Although several studies have addressed economic regulation as a factor influencing the efficiency and equity of health systems, previous research, such as that by Rodriguez et al. (2024), Montaño and García-Perdomo, (2024), and Báscolo et al. (2024), have pointed out that there are gaps in our understanding of how health systems, especially in emerging economies, apply regulatory policies in the face of economic challenges. In this regard, the objective of this study is to analyze the state of scientific research on economic regulation and health systems using a bibliometric and qualitative approach based on the PRISMA-ScR statement. Through this analysis, we will identify the topics studied, the authors and agencies involved, and the emerging trends in this field (Nasrallah et al., 2022; Osorio et al., 2023; 2025).

To conduct this review, the procedures stipulated in the PRISMA-Scr statement for systematic literature reviews (Camacho-Castro & Monge-Olivarría, 2023; Cervantes et al., 2024; Page et al., 2021) were integrated with the bibliometric methods proposed by Donthu et al. (2021). These methods allow for the evaluation and quantification of scientific research results, as they provide a comprehensive view of the impact and evolution of a field of knowledge over a given period (Arango, Espinal et al., 2021; Rodríguez Orejuela et al., 2021).

The methodological process was developed in stages, namely:

Source of information: The information was extracted from the Scopus database, due to its prestige, wide coverage, and statistical analysis capabilities (Echchakoui, 2020; Pranckutė, 2021).

Search strategy: the following search equation was used (TITLE-ABS-KEY (“health systems”) OR TITLE-ABS-KEY (“national health systems”) OR TITLE-ABS-KEY (“healthcare models”) AND TITLE-ABS-KEY (“theory of economic regulation”) OR TITLE-ABS-KEY (“Health Care Coordination and Monitoring”) OR TITLE-ABS-KEY (“Government Regulation”)) AND (LIMIT-TO (DOCTYPE, “ar”)) AND (LIMIT-TO (OA, “all”)).

The keywords were selected from the DeCS/MeSH terms in the BVSalud database of Bireme and the UNESCO Thesauri (Espíndola et al., 2020; Carrillo-Vera et al., 2024; Olarte & Muñoz, 2025).

Eligibility criteria: completed research was included; article type; open access; the article was related to the topic of the review; no language restrictions; and no publication date restrictions. Duplicate articles in the database were excluded, as were articles whose main topic did not correspond to the topic of the review, working papers, newsletters, technical reports, recommendations and technical standards, books, abstracts, academic courses, conference notes, conference proceedings, editorials, and letters to the editor (Fajardo et al., 2024).

Extraction process: Once the final sample of documents was obtained, it was downloaded in CSV format, including all the fields provided by Scopus (Osorio et al., 2025). Microsoft Excel was used to consolidate and systematize the information collected (Burguet & Burguet, 2020; Ramírez et al., 2025).

Information processing: Data analysis was carried out in two stages, based on the methodology of Donthu et al. (2021). In the first stage, performance was evaluated by analyzing individual contributions to research using bibliometric indicators. In the second stage, a visual representation or network map was created to examine the interconnections between the elements studied and define trends in the field; for this purpose, VOSviewer software was used (Bukar et al., 2023; Gómez Velasco et al., 2021; Reina-Guaña, 2024; Silva et al., 2021).

Ethical component: the review was conducted following the ethical principles of the Declaration of Helsinki (World Medical Association, 2025) and the provisions of Resolution 8430 of 1993, which classifies this type of study as risk-free, given that it employs retrospective documentary research techniques and methods (Acosta-Sarasty & Zambrano-Acosta, 2022).

Figure 1 shows the eligibility criteria according to the order established in the methodology, through the development of each phase of the PRISMA flow chart. A total of 536 articles were retrieved in the search, and 335 were excluded for not meeting the inclusion criteria. Finally, 201 were included for descriptive analysis and eight for cluster analysis (Forero-Peña et al., 2020; Olarte & Muñoz, 2025; Orellana et al., 2024; Caballero & Mojica, 2021).

Figure 1
PRISMA flow chart

Note. Adapted from Haddaway et al. (2022).

Performance evaluation

Chronological indicator

According to data extracted from the Scopus database, research on economic regulation and health systems dates back to 2006. The first document, published by Dietrich (2006) that year, concludes that pharmaceutical faculties should impart knowledge not only of chemistry, but also of the health system, social skills, cost structures, clinical benefits, and the cost-benefit ratio of medicines. Figure 2 shows an initial growth in publications, peaking in 2020 and 2021 with 28 publications total.

Figure 2
Scientific output over time

Country indicator

Figure 3 shows the worldwide scientific output. Notably, the United States accounts for over a quarter of the published documents, with 49 publications. This indicator also demonstrates the contributions of other countries to the field of study, including the United Kingdom with 31 publications, Brazil with 28, Australia with 22, and Canada with 19.

Figure 3
Scientific output by country

Magazine indicator

Table 1 shows the ranking of the five leading journals with the most publications related to the review topic. According to the SJR index, these journals stand out for their high international academic impact. In the Colombian context, they are classified as TOP by Publindex.

Table 1
Scientific output by journal

Indicator of most influential authors

Table 2 lists the five most influential authors and the number of research studies they have conducted. Brazil stands out with three publications. The h-index assesses a researcher’s work quality and influence (Koltun & Hafner, 2021). Busse has the highest score, followed by Bernal.

Table 2
Scientific output by authors

Indicator for seminal texts

The five most cited articles, according to the Scopus database (see Table 3), cover a variety of topics including the COVID-19 pandemic (Aquino et al., 2020), the consolidation of the hospital market (Cutler & Scott-Morton, 2013), the use of big data in healthcare (Auffray et al., 2016), traditional medicine (Fokunang et al., 2011), and perceptions of the pandemic (Hager et al., 2021). This diversity reflects how research on economic regulation and health systems interrelates with global social, political, and technological issues (Loschiavo & Fucci, 2024).

Table 3
Most cited articles

Visual representation analysis

Bibliographic coupling network

Articles are considered linked when they share one or more references in their bibliographies, which suggests that they may cover related topics (Boeris, 2010). This analysis is based on the strength of coupling, determined by the total number of citations or references in common (Mas-Tur et al., 2021; Phan Tan, 2022). Figure 4 shows the bibliographic coupling network (Van Eck & Waltman, 2014).

Figure 4
Coupling network

The bibliographic coupling network helps us identify the main trends or dominant themes in a field of study. In this case, three clusters were identified and represented by different colors. Cluster 1 consists of the studies by Camacho et al. (2017), Vasconcellos and Morel (2012), and Walls et al. (2020); cluster 2 involves the studies by Campbell et al. (2019), George and Iyer (2013), and Sheikh et al. 2015; and cluster 3, the studies by Azzopardi-Muscat et al. (2017) and Ow Yong and Koe (2021).

The notable growth in 2020 and 2021 coincides with the COVID-19 pandemic, an event that intensified scientific production on topics related to economic regulation in health, access to services, financing, and government response (Hale et al., 2021; Kickbusch & Holzscheiter, 2021). The pandemic tested the regulatory capacity of health systems, sparking debates about state intervention, drug price regulation, and striking the right balance between efficiency and equitable access to services (Arellano, 2022; Forero-Peña et al., 2020).

The United States is known for its substantial investment in research and development (R&D), which has strengthened its position as a leader in health-related scientific publications (Gyawali et al., 2020; Woloshin et al., 2020). Additionally, the U.S. healthcare model is characterized by a high degree of privatization and fragmented regulation. This has generated sustained interest in studying regulatory policies, costs, and healthcare reforms that enable access to medical care (Cutler et al., 2019; Himmelstein et al., 2020).

In Latin America, healthcare systems such as Brazil’s prioritize universal and free care, which requires a type of economic regulation focused on public financing and cost control to ensure access to care (Juárez et al., 2024; Quispe & Avega, 2024). On the other hand, in countries such as Mexico and Colombia, the privatization of some services and the coexistence of private and public insurance result in more complex regulatory approaches that seek to balance market competitiveness with universal coverage (García & Esquer, 2024; López-Mallama, 2023; Restrepo-Zea & Zapata-Cortés, 2022; López-Mallama et al., 2024).

In Europe, economic regulation takes different forms. Countries such as the United Kingdom, with its National Health Service, opt for state-planned economic regulation (Zalakain, 2022). Germany, on the other hand, implements a mixed model in which private insurance plays an important role in health coverage (Fernández-Sánchez et al., 2021). This difference in regulatory models has direct implications for the efficiency of the system and equity in access to health services, as Reyes-Morales et al. (2024) argue.

In regions such as Asia and Africa, regulatory variations are influenced by levels of economic development and available resources. Many African health systems face significant challenges in terms of infrastructure and resources. This has led to innovations in care, such as the integration of traditional medicine with regulatory policies and the implementation of pharmaceutical price regulations to limit the impact of poverty on access (Atwoli et al., 2022). Meanwhile, Asian countries such as China have made progress in economically regulating health services by integrating emerging technologies, such as telehealth, which marks a departure from traditional approaches that focus on physical infrastructure (Rodríguez-Pérez, 2024).

Journals that lead scientific production in this field, such as BMC Health Services Research and Health Research Policy and Systems, are recognized for their prestige and high impact factor. According to the SJR (Scimago Journal Rank) index, these publications are in the Q1 quartile, reflecting their influence within the global scientific community (Duque & Duque, 2022). Previous studies, such as that by Ávila-Toscano et al. (2022), have shown that journals in the Q1 quartile tend to address the most relevant topics and disseminate knowledge to the greatest extent. These findings suggest that research on economic regulation and health systems is emerging as a key area within global health policy, indicating that it is becoming a priority topic in these journals (Gómez-Hurtado, 2021).

In their recent publications, the most influential authors have had the following objective: to analyze the contexts of influence and textual production of the Emergency Care Network Policy (RUE) in Brazil using the policy cycle approach (Nogueira et al., 2024); conduct a genealogical analysis of deafness, that is, an analysis of the practices of knowledge and power in Brazilian health policy (Garcia et al., 2022); describe the elements present in medical practice that contribute to understanding its recognized low adherence to the guidelines of the Brazilian Primary Health Care (PHC) Policy (Reis et al., 2018); review working hour regulations for residents in different countries, with an emphasis on night shifts (Maoz et al., 2023); and identify predictors for patients who report unfavorable outcomes but high satisfaction and vice versa, following total knee arthroplasty (Schöner et al., 2025).

Analysis of the most cited articles provides a clear picture of the topics that have had a significant influence on academic literature and global health policy. Aquino et al. (2020) summarize the available evidence on the impact of social distancing measures on the epidemic and analyze the implementation of these measures in Brazil. Cutler and Scott-Morton (2013) discuss how hospital market consolidation affects competition, prices, and quality of care; Auffray et al. (2016) emphasize the growing importance of big data in health research and health policy formulation. Fokunang et al. (2011) present how research on traditional medicine can influence policy-making and health regulation. Finally, Hager et al. (2021) emphasize the importance of public perceptions and attitudes in the implementation of public health policies.

The identification of research trends revealed three tendencies: the first focused on the efficiency of the healthcare system and its influence on public policy (cluster 1). Studies by Camacho et al. (2017), Vasconcellos and Morel (2012), and Walls et al. (2020) investigate how economic regulation influences the performance of health systems in terms of costs, coverage, and access to health services. The second focuses on market regulation and competition in healthcare (cluster 2). The studies by Campbell et al. (2019), George and Iyer (2013), and Sheikh et al. (2015) focus on regulatory aspects related to competition, the market, and healthcare system governance. The third cluster was regional and global perspectives on health system regulation (cluster 3). The studies by Azzopardi-Muscat et al. (2017) and Ow Yong and Koe (2021) address health regulation based on the political, economic, and social characteristics of different societies.

The increase in academic research on economic regulation and healthcare systems reflects the scientific community’s growing interest in addressing these issues and responds to global factors, including the ongoing pandemic, regulatory reforms, and the need for financial sustainability in healthcare systems. The goal is to achieve equitable access to healthcare for the population.

The United States and other developed countries’ leadership in scientific production on economic regulation and health systems reflects the importance of the issue in contexts with diverse, highly regulated health systems. However, the lower participation of developing countries and emerging economies underscores the importance of promoting research in these regions to improve our understanding of regulatory dynamics while considering resource limitations and structural inequalities.

The presence of high-impact journals, particularly in the Q1 and Q2 quartiles, affirms the importance of economic regulation in health as a primary area of research. These publications provide decision-makers with information to address the challenges of economic regulation in health systems while considering the specific characteristics of each territory.

The most cited articles on economic regulation and health systems encompass a wide range of interconnected topics, including responses to health emergencies, hospital market consolidation, the use of data for health decision-making, and the integration of traditional treatments. The relevance of these studies for understanding health systems and economic regulation allows us to address issues related to equity, efficiency, and sustainability in health services.

The identified clusters illustrate the main areas of research: the efficiency and accessibility of health systems; market competition and governance; and regional variations in regulatory approaches. Addressing these issues is essential for formulating public policies that improve the economic performance of health systems and ensure equitable access to quality care for all patients.

The bibliometric review has limitations, given that it used a single database (Scopus), which could have excluded relevant studies indexed in other sources. Furthermore, the selection of articles focused on open-access publications; while this facilitated the availability of information, it could also have generated bias by leaving out studies with restricted access.

The authors declare that they have no conflicts of interest of a personal, political, financial, intellectual, racist, religious, or other nature.

The authors declare that they did not engage in any unethical practices or omit any legal aspects when conducting the research.

The authors declare that they have not received any financial support for this work.

Review article: Research conducted as part of project PS-0225 by the Semillero de Investigación en Economía de la Salud – SELMA, affiliated with the GISAP group at the Institución Universitaria Antonio José Camacho, Santiago de Cali, Valle del Cauca, Colombia.

Contribution: Natalia Carolina Cañar-Muñoz: analysis and interpretation of results, writing the introduction, methodology, discussion, conclusions, and writing the original draft. Oscar Marino López-Mallama: analysis and interpretation of results, writing of the introduction, methodology, discussion, conclusions, and final draft: review and editing. All authors participated in preparing the manuscript, reading it, and approving it.

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