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Literature Summary Comparative Health Policy ()
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Comparative Health PolicyInhoudsopgave
Comparative Health Policy............................................................................................................................. 1
Week 1.......................................................................................................................................................... 2
Beckfield - HC systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and
Five Missed Turns – Beckfield, Olafsdottir, Sosnaud.............................................................................................2
D. della Porta : Comparative analysis: case-oriented versus variable-oriented research.....................................7
Week 2:......................................................................................................................................................... 9
Hall and Peter - Political Science and the Three New Institutionalisms................................................................9
Mahoney and Thelen 2009: A Theory of Gradual Institutional Change .............................................................17
Van de Bovenkamp, Institutional layering in governing healthcare quality.......................................................21
WEEK 3........................................................................................................................................................ 26
Lawrence, Suddaby & Leca (2011) - Institutional Work: Refocusing Institutional Studies of Organization.......26
Institutional Work in Changing Public Service Organizations: The Interplay Between Professionalization
Strategies of Non-Elite Actors (Bochove, & Oldenhof, 2018)..............................................................................31
WEEK 4........................................................................................................................................................ 37
Policy learning from abroad: why it is more difficult than it seems (Ettelt, Mays, & Nolte, 2012).....................37
Nielson & Jensen – Travelling frictions: Global Disease Self-Management, Local Comparisons and Emergent
Patients................................................................................................................................................................41
Bennett (1991) - Review Article: What is Policy Convergence and What Causes It?..........................................46
1
,Week 1
Beckfield - HC systems in Comparative Perspective: Classification,
Convergence, Institutions, Inequalities, and Five Missed Turns –
Beckfield, Olafsdottir, Sosnaud.
Introduction:
4 research themes: classification, convergence, institutions (specifically, institutional boundaries), and
inequality.
Why should we compare HC systems:
- Three concerns motivate most work:
o Accurate description: the descriptive impulse is strongest when one attempts to develop
clusters or types of HC systems on the basis of selected measures such as expenditure,
performance, and organization.
o Performance assessment: performance impulse is strongest in the tradition of health
economists to look at the health production function, in ranking HC systems and in
applied policy research on the results of specific policy innovation.
o Policy diffusion: diffusion impulse strongest in work that identifies lessons from HC
systems for other HC systems and in research on globalisation of HC.
The authors see need for more work that is motivated by general institutionalist theory; comparative HC
systems research is especially well positioned to investigate how institutions have distributional
implications and generate winners and losers 🡪 HC systems shape inequalities within and between
societies.
- HC systems vary greatly, so there are 2 central questions for comparative HC systems research:
o What explains this institutional variation
o How does this institutional variation matter for the distribution of population health.
Classifying HC systems
HC system = organisation that both delivers care and medical services, and that arrange for the financing
of care.
- What to base HC system categorisation on? Researchers often come back to 2 key dimensions:
funding and ownership
o Bismarck, Semashko, Beveridge.
- More recently: Moran (1990) proposed the “HC state” concept = incorporates consumption,
provision and production of HC. 4 families of HC states:
o Entrenched command-and-control state, supply state, corporatist state, insecure
command-and-control state.
▪ In command-and-control states: state control all three governing areas (UK)
▪ In corporate HC states: mix of public law and doctor’s associations control the
HC field (Germany)
2
, ▪ Supply states: provider interests dominate (US)
▪ Insecure command-and-control sates: different from other NHS because their
nationalised hospital sector coexists with large private sector (Greece)
o Requires more specification to meaningfully compare countries 🡪 developed classification
of 27 distinct types of HC systems based on the potential range of variation of financing,
service provision, and regulation.
▪ Focusing more on access regulation than on the balance of state market:
▪ Identify 3 ideal types: state HC system, societal HC system and private HC system
▪ Identify 6 mixed types systems under each ideal
o In one of the first attempts to empirically test these HC system clusters: find 3 distinctive
HC types
▪ Health service provision oriented (GE)
● Put high importance on service provision, especially in outpatient sector
● High number of providers and free choice of medical doctors
● Patients pay only modest OOP
● Contrast to US: autonomy of patients and equal access greatly valued
and matter more than autonomy of the medical profession
▪ Universal coverage-controlled access (UK)
● All citizens are covered through universal plans, but access to care is
strictly regulated by state
▪ Low budget-restricted access (SP)
● Low spenders that restrict use through high co-payments and that
require patients to use the same doctor for a long period
Convergence: new and old
Strong pressures for convergence of HC systems 🡪 increasing similarity between HC systems, often studied
in richer countries.
- Most analysis of diffusion examines national-level policy innovations (evidence-based policy
making).
- Schmmid find evidence of convergence across HC systems, in so far as policies borrowed from
other systems are leading to hybrid systems (e.g. US, GE and UK have all adopted DRGs)
- The “common pressures” argument: because the rich democracies face similar challenges, they
will tend to adopt similar responses.
- Grignon: if there has been convergence, it has been slow. Why?
o Path dependency, veto points, public opinion, and stakeholder mobilisation.
Institutional boundaries
Where, analytically, is the HC system? One of the underlying issues in the convergence debate is that
although HC systems are national, they are also international and arguably becoming more international
over time as global health gains attention and funding as patients engage in medical tourism.
- Difficult to distinguish HC systems from the welfare state. (Expenditures on health care
constitute, in many rich democracies, one of the largest shares of government outlays across
policy domains)
- Medical care which is usually implicitly seen as the core of the HC system, is not the only part of
the system and ‘nonmedical health policies’ integrate the HC system with other parts of the
welfare states.
- “Health in all policies” (Health care is delivered at the local level, such that field analyses can
capture the multiplicity of actors involved in health care, and caregivers (most often women) face
severe constraints when health care is delivered in the home or in schools. To put it bluntly: We
are arguing that the boundedness and coherence of any healthcare system should not be taken
for granted. Rather, its social ontology should be investigated as a research question)
- The variable boundaries of what researchers call healthcare systems are apparent in cases in
which the organization of the polity structures healthcare systems.
3
, - Migration is one significant trend that blurs the institutional boundaries of healthcare systems.
(Research on migrants is usually focused on documenting disparities, but research on migrants
that seeks to explain the evolution of healthcare systems highlights how international migrants
experience very different national institutional environments over the life course)
- Managed-care organizations in the United States in the 1990s were under pressure to
demonstrate a wider “community benefit”: example of how policy can blur the boundary
between healthcare organizations and the community in which it is embedded. Such blurring has
generated a debate over the role of public versus private actors in healthcare systems.
Disparities, inequalities, inequities
Although most research on social inequality in health care appears under the rubric of healthcare
disparities research, there is a robust debate over conceptualization.
- Efforts toward reducing healthcare disparities, and advocates and researchers are interested in
incorporating health inequalities research into policy.
▪ This is despite the rule of thumb that the healthcare system contributes no more than
10% to overall healthcare disparities.
- Nevertheless, there is growing interest in the relationship between healthcare disparities and
health disparities, particularly in countries that have passed the demographic transition and
exhibit higher rates of chronic disease.
- There is also increased need for comparisons of how healthcare systems moderate or exacerbate
different kinds of healthcare disparities.
- One pressing question is how the healthcare system relates to other broad social conditions that
matter for health and disease.
- An alternative, and perhaps currently predominant, approach to measuring healthcare system
performance is to quantify healthy life expectancy—or the average amount of time the average
person at a given age can expect to live in good health.
▪ The aim of such research is to establish a single number as a policy maker–friendly
measure of the performance of healthcare systems. This underestimates the capacity of
both the policy maker and the healthcare system.
▪ Policymakers attend to distributional issues, so they would probably attend to measures
that included information about the distribution of health across socially meaningful
groups. Such an aggregated, summary estimate of a central tendency also potentially
underestimates healthcare systems because such systems represent institutions that
create winners and losers.
▪ Monitoring quality and inequality is a forefront area for data collection because current
data collection often fails to match the political.
- A new controversy surrounding healthcare system effects is the relationship between population
health measures such as healthy life expectancy and measures of inequalities in health.
▪ On one side of the debate are those who argue that social inequality in health is in part a
function of improvements in population health. That is, the very things that improve
population health (e.g., basic sanitation, medical technology, and healthy behaviors) are
likely to increase health inequalities because those with greater socioeconomic
resources will be better positioned to adopt such technologies.
▪ Conversely, others argue that advances in mortality and life expectancy will instead be
associated with declining inequalities in health because such population health
improvements are propelled by enhanced health prospects among previously
disadvantaged groups.
▪ Moreover, some evidence suggests that the relationship between health improvements
and health inequalities may differ across nations and social contexts raises the
possibility that healthcare systems play a role in determining the extent to which
improvements in population health are accompanied by widening or declining
inequalities.
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