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Summary HPI4009 Case 5: Solidarity in healthcare financing
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Complete summary of case 5 of HPI4009 Health Systems Governance
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Case 5 Solidarity in Healthcare Financing 09-12-2022Defining solidarity
There is no consensus on the definition of solidarity. Solidarity is a highly contested concept in the
political debate and its meaning seems to be strongly influenced by the political perspective taken.
There is more and more emphasis on the individual responsibility nowadays in Western-European
countries.
- Solidarity: an ambiguous and ethical concept in policymaking, connected to social justice.
- Solidarity: relations of personal commitment and recognition (Ter Meulen).
Schuyt (1998): “Solidarity, as a social phenomenon, means sharing of feelings, interests, risks and
responsibilities”. He thus adopts a slightly more specific approach, with feelings and responsibility
referring to the cultural or identity-based solidarity and risks encompassing the utility aspect.
Distinguish of solidarity between warm feeling vs. cold feeling
Buyx & Pransack (2012)
“Solidarity signifies shared practices reflecting a collective commitment to carry costs (financial,
social, emotional or otherwise) to assist others. It is important to note that we understand solidarity
as a practice and not merely as an inner sentiment or an abstract value. As such, it requires actions.
Motivations – feelings such as empathy – are not sufficient to satisfy this understanding of solidarity,
unless they manifest themselves in acts”
Although solidarity is to be understood primarily as a shared practice (or a cluster of such practices)
reflecting a collective commitment, simply claiming that such practices exist is unsatisfactory. Our
definition, therefore, consists of three tiers starting with a conceptualization of how individuals come
to engage in practicing solidarity. They stand in a hierarchy of institutionalization, with the first tier at
the interpersonal and most informal, and the third tier at the most formal – legal – level.
1. Tier 1: interpersonal level
a. The level of individuals.
b. Solidarity comprises manifestations of the willingness to carry costs to assist others
with whom a person recognizes sameness or similarity in at least one relevant
respect.
c. The recognition of similarity with one (or more) other people in a relevant respect
can entail the awareness of being associated by choice, by ‘fate’ or other
circumstances with others.
d. E.g.: Income and risk solidarity --> the most vulnerable people high healthcare risks
and low funds.
2. Tier 2: group practices
a. Manifestations of a collective commitment to carry costs to assist others (who are all
linked by means of a shared situation or cause).
3. Tier 3: contractual and legal manifestations
a. If solidarity practices solidify not only into group practices and social norms, but
manifest themselves in contractual or other legal norms, then we have an instance of
Tier 3 solidarity. Examples are the welfare state and social welfare arrangements.
While the lower tiers of solidarity can exist without the higher levels, higher levels typically do not
exist without having been preceded by the lower levels.
Solidarity and forms of solidarity
1. Solidarity: that which binds individuals into a relatively autonomous society, or negatively
stated, that which prevents the disintegration of a society.
2. Solidarity: the willingness to protect those human persons whose existence is threatened by
circumstances beyond their control, particularly natural fate or unfair social structures.
, 3. Solidarity suggests a sense of community and the willingness to bear the consequences of
community membership – it implies a certain bond.
The classic sociologists Durkheim and Weber saw solidarity as the social cohesion arising from a
sense of shared fate between individuals and groups.
The most important solidarity concepts in healthcare are income solidarity and subsidizing solidarity.
Policy trend in many countries
- Since 1980s, policy trend of decreasing solidarity and increasing individual responsibility;
- Financial protection becoming less universal, more selective and conditional.
- What drives this policy trend?
o Ageing, increasing costs --> sufficient explanation?
o Explanations based on sociological theories vs. theory of justice.
Current debates on solidarity:
- Obamacare
- Sustainability of arrangements in the Netherlands is questioned
- Behavioral factors and health
How do sociological theories on solidarity explain this concept, and what motives for
solidary behavior can be derived from these theories?
Motives for solidarity
Theories of sociologists who perceive solidarity as a characteristic of a social system, thus not as a
belief or a feeling held by individual people
From this can be concluded that: solidarity can be defined as an actual state of interrelations
between individuals, groups and the larger society, which enables the common good of groups and
society to be served.
- The essence of and basis for such relations is that people have or experience a common fate,
either because they share identity as members of the same collectivity and therefore feel a
mutual sense of belonging and responsibility, or because they share utility: they need each
other to realise their life opportunities. \
This implies that the strength and range of a system's solidarity is a function of the nearness and
dependence among the social actors it embraces, which in turn leads us to argue that people can
have four different motives to support an actual state or relation of solidarity:
1. Mutual affection and identification (Mayhew’s view, shared identity) --> The degree to which
people feel attracted to one another and are loyal at the micro level, and the degree to
which they perceive a collective identity and we-feeling at the meso and macro level are
decisive for the solidarity between them.
a. macro and micro level
2. Moral convictions (Durkheim and Parsons view) --> Culturally-based convictions, which imply
that the individual feels a moral obligation to serve the collective interest and to accept
existing relations of solidarity.
3. Perceived self-interest (Hechter’s view, and Durkheim’s, shared utility) --> Rational choice
based approach. People learn that they benefit from contributing to the collective interest (if
not immediately then in the long run).
a. macro and micro level
4. Accepted coercion (dwang) (External view, if nothing works in solidarity principles, then this
motive). Contributing to the collective interest is an act of solidarity only if it results from
, institutional role obligations. Purely voluntary contributions do not bind, they lack true
commitment. Hechters ending: fair of sanctions. Example: if a child is not solidary to brother,
a mother says child should share eventually solidarity (if there are no moral convictions or
moral obligations)
Support for solidarity relations will generally be stronger to the degree that:
1. such relations link up with existing patterns of mutual affections and identification;
2. they correspond with relevant moral convictions and perceived duties being in force;
3. they correspond to the (long term) self-interest of individuals and groups involved, and;
4. to the degree that they are backed by a more legitimate authority body.
Solidary relations and arrangements that are legitimate on the grounds of all four motives,
however, are likely to be the strongest.
Non-solidarity: you pay a premium according to your risk. So, people with a higher risk profile pay
more. It would be unjust to force a group or person to pay for the needs/burdens of others. It is
unfair, because it reduces access to life opportunities and increases suffering for those disadvantaged
by risk, pain, and illness.
Sociological theories
Durkheim - macro-level - characteristic of a social system
Emile Durkheim perceived solidarity, positively stated, as that which binds individuals into a relatively
autonomous society, or negatively stated, that which prevents the disintegration of a society. Two
main sources for social solidarity: `...the likeness of consciences and the division of social labour'
- Mechanic solidarity – shared identity – macro level
o `Likeness of consciences’ refers to a situation in which individuals share the same
fundamental cultural elements
o The individual identifies strongly with the group. The strong sense of `we' leaves little
space for individuality. This type of culturally-based mutual bon implies that group
interests can prevail over the interests of the individuals involved .
o Broader societies and collectivizes: Individuals share the same fundamental cultural
elements, which they use as a basis for recognizing and accepting each other as
members of the same collectively
o The cultural bond as the heart of the mechanic solidarity (dominant in homogeneous
pre-modern societies)
- Organic solidarity - shared utility – macro level:
o ‘The division of labour’: causes people to become mutually dependent on each other
for their life opportunities: Division of labour thus gives rise to structural bonds,
people are connected
o Organic solidarity presupposes explicitly that individuals allow collective interests to
prevail over their own: can be internalized during the socialization process and
thereby seen an experienced as an intrinsic moral duty (and not a externally forces
behavior)
o Organic solidarity: structural interdependence as the heart of this, present in modern
societies with a high DoL → functional necessity for survival and existence of the
system
Weber - micro-level - solidarity characterizes & social relations between individuals
Social relations, Weber argues, are solidary if they are directed at interests that transcend those of
the individuals involved and as such establish a bond between them. Referring to Tinnies' well known
dichotomy of Gemeinschaft and Gesellschaft, Weber identifies two types of solidary relations.
- Communal relationships – shared identity - vergemeinschaffung:
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