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This studies conceptualizes health systems as networks of delegation relationships. In these delegation relationships, actors may act opportunistically, and thereby lower the performance of the health system. The typical example is the supply-induced demand, the increase of the quantity of medical services provided by the providers for the reason to increase personal income. Counter measures consist of controlling these relationships. How can this be done? Internally, by installing appropriate incentives in the relationship (e.g. competition, provider remunerations which are independent from the quantity of services). Externally, by the state, i.e. the government. This may either directly intervene in the operation of the health system, for instance by setting the overall budget. Or the government may reform or threaten to reform the health system, in order to hold actors at bay. When is the government able to exercise external control? When it is not internally blocked, which it may be in the case of many direct veto players but also in the case of many indirect, societal veto players. The basic hypothesis is that the better organized the control, the higher the performance of the health system. The empirical implementation consisted in operationalizing and testing the hypothesis. The independent variables were operationalized by measuring delegation, internal, built-in control (in particular incentives), and measuring external control (governmental control and the capacity for reforms). The dependent variable performance was operationalized firstly by the level of health status, citizen’s satisfaction, but also the share of the health output, which is actually attributable to the health system. Secondly, it was operationalized by the efficiency by which these outputs were reached, i.e. whether doing so consumed many or few resources, but also the level and dynamics of expenditure. As for the results, the findings indicate no systematic effect of internal and external control on health system performance.

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