Case 2 Governance in healthcare policymaking: actors
and institutions
Definitions of governance:
Hoppe, 2010: any activity or process of deliberately using power in order to coordinate
sizeable groups of people’s performances to bring about desirable aggregate results and
avoidance of risk and undesirable outcomes
Greer et al, 2016: the process and institutions through which decisions are made and
authority in a country is exercised.
How things are done rather than what should be done
Smith et al, 2012: rules of the game in public policymaking
Governance is not a static thing but a process.
Difference government and governance:
- They used to be a synonym in a sense that the government was responsible for governance
and was governing.
- Governance: is the process through which you coordinate or steer/arrange the health
system. How do you arrange functions in the model (e.g. financing, service delivery etc).
- One way to do that: is to have everything centralized and have the government in charge of
pretty much everything (top-down)
- Also other ways to do this: market based/coproduction where government has different role
and is more equal to other sectors (is part of governance but not the only one involved).
- So government is just one actor in the governance process.
How do we make sure that the system does what we want it do to?
-There are several actors, processes and interactions related to this
Governance types: in the literature often is characterized by values or descriptive (structural) terms
preceding governance definitions:
Values
1. Democratic (governance)
2. Good
3. Good enough
4. Smart
Descriptions
5. Horizontal (shared)
6. Networked
7. Hierarchical
8. Market-based
Different forms or ideas about governance (too broad or generic). We want a specific type or form of
governance.
Governance is process of making decisions and achieving certain outcomes in your health system
Interaction between different actors, institutions which make up governance process.
All elements interact together
1
,Institutions: what are they, why are they important and what is their relevance to policy?
Institutions definition (Van Oijen et al, 2020): systems of prevalent, established rules that structure
social interactions which have an important regulatory function in society
Example of core societal institutions: the state, market, religion and education
System of prevalent, established rules that structure social interactions:
Importance in formal (e.g. laws) and informal rules (e.g. social norms, appropriate behaviour
and what is the legitimacy)
Have an important regulatory function in society
There are legal sanctions (e.g. prison), reputational sanctions (e.g. seen as less legitimate) or
social sanctions (e.g. network of collaborations that you have)
So institutions are not organizations in the context of this course.
They are the rules of the game of our social life (things we sanction or not etc). Institutions
will determine what we see as good governance.
Organizations are the players of the game
Institutions can change over time and differ between countries due to cultures.
In US: behaviour of profit seeking behaviour and relationship between pharmaceutical
companies and hospitals. This differs between US and Netherlands.
Certain behaviour is not sanctioned for instance in the US where it would be in NL
Norms, values and beliefs are important
Important actors in higher education for example:
Universities
Students
Government
Funders
Professionals
Competitors
Regulatory bodies (e.g. quality of education/accreditation)
Local communities
Institutions: relevance to policy
-Institutionalized expectations of healthcare systems ultimately constrain the scope of action
(formally and informally) and perspective on solutions to healthcare problems
Solidarity vs individualism (in society)
Who is responsible for paying? For outcomes? (self-responsibility or group)
Scope of practice/malpractice/profit seeking (rules)
-Ideologies and dominant norms shape what we see as problems (are culturally specific)
How do we define health (broad or narrow definition)?
Medicalization of social problems
Involvement of patients in care processes
Importance of actors in relation with governance and institutions
2
, Institutions influence actors:
- Institutions are the most important influences on actors and interactions
- Actors depend upon socially constructed rules to orient their actions in otherwise chaotic
social environment
- Have explanatory value because sanctioned rules will reduce the range of potential behavior
by specifying required, prohibited or permitted actions
One direction: Actors and institutions are constitutive of one another (institutions provide
prohibiting actions and provides room for actors to act, do not only constrain)
Other direction: actors can leverage resources to change institutions and shift norms.
Social movements
Actors can work to protect or fight against status quo (‘’as things are’’)
1.Who are the main actors in health systems and how would you explain their governance
relationships?
Key actors in healthcare governance:
Political parties
Professional associations
Media
Interest groups/lobbies
Patients
Shareholders
Regulators (e.g. inspectors)
Professionals and organizations (e.g. hospitals)
Role of actors:
1. Issue framing
2. Highlight (or hide) prominent issues for attention
3. Leverage resources (e.g. time and voting)
4. Regulatory power
5. Interdependence (e.g. actors rely on each other and gives actors leverage as well)
6. Commercial interest
Three categories of actors can be distinguished (Brinkerhoff, 2014):
1. State actors: includes politicians, policymakers and other government officials
2. Health service providers: includes mixes of public, private and voluntary sectors providers
depending on a given health system country.
This mix can include: hospitals, clinics, laboratories and educational institutions
3. Clients/citizens: service users, the general public and organized civil society
Can be categorized into different ways by:
-Income (poor vs not poor)
-Location (rural vs not rural)
-Service (maternal and child health)
-Disease (HIV or TB)
3
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