Case uitwerking
HPI4009 Health Systems Governance Case 2
Summary HPI4009 Health Systems Governance Case 2
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Voorbeeld 2 van de 11 pagina's
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Voorbeeld van de inhoud
Health system governance (HPI 4009)Tutorial group 2 08-11-2019
Case 2: Governance in healthcare policymaking; actors and institutions
Bartolini (2011)
Co-production
Governance as a field: the space for norm production which is intermediate between the legal rules
according to constitutional procedures, and private dealings, traditional norms and social routines on
the other.
Governance: a system of co-production of norms (decisions, rules, policies) and public goods where
the co-producers are different kinds of actors (while the type of actors involved, the extent of
involvement of public authorities and of partners, the outcome and the production, the decision
procedures, the institutional context and the type and role of sanctions all vary).
In this course: What should be done, how it should be done, who should do it?
So: co-production is a specific mode of governance
o Classic national government model: Demands from citizens are transferred and aggregated by
the political system and then generate a policy response which is implemented by the public
administration.
o Classic community government: Initiatives are coming from the commission, mediated and
modified by the inter-governmental process and applied by national administrations.
Example: in negotiations between hospital and insurance companies are co-dependent on each other
because they both have the goal to create quality of care. But the hospital depends on the payment by
insurance and the insurance depends on the hospital to produce good quality of care.
The point of improving governance is to improve policy performance, meaning better formulated and
implemented policies. While better governance is always desirable, the key issue is that governance
must be ‘good enough’: good enough to permit a country to advance, and good enough to manage the
policies it must implement.
Eight dimensions by which forms of governance as co-production can be characterized
1
, 1. Identity of the co-producers
o Private actors: the producers of mutual contractual obligations within their sphere of autonomy
o Governmental actors: the producers of general validity and binding obligations.
Governance is based on the cooperation of different kinds of actors that results neither in merely
private agreement nor in public decisions. The actors can be private and/or governmental, and from
different levels (local, regional, international, etc)
2. Level of involvement of public authorities
Governance modes are always set up and carried out in the shadow of hierarchy, with public
authorities being somehow involved, at least in the minimal sense of allowing private actors to
regulate what could be left unregulated or could be regulated differently. National and international
public authorities are always in the position to regain control of forms of co-production governance,
when and if the circumstances so require. E.g. monitor, legislation, recapture control.
3. Level of involvement of partners
Level of involvement can range from providing information to direct and consistent involvement.
Participation in governance arrangements is always voluntary: you can always drop out (but bear the
costs.
4. What is actually produced
Binding decisions on the partners, to general norms, simple goal definition, softer texts with
recommendations, agreed-upon standards, guidelines, benchmarks, best practices, indicators,
monitoring arrangements and timetables.
5. Ways of achieving co-production
Cannot be ‘government’ or solely private competition; both ‘coercion’ and ‘competition’ are not
viable. The means to achieve co-production must by highly cooperative; decisions must be reached by
negotiations, deliberation, exchanges and consensus.
6. Nature and role of sanctions
Ranging from enforceability (toepasbaarheid) with precise and ex-ante (terugwerkende kracht)defined
sanctions to enforceability that largely rests on voluntary adhesion and perhaps only reputational or
‘blaming’ costs. exclusion. If they don't get a deal, a hospital can find another insurance. They can
lose reputation.
7. Institutional context
This is highly formal. A lot of institutions are involved
8. Mode of implementation
Hospitals need a clear plan and they need to report back on the quality that gets provided. Next year
negotiation again.
Brinkerhoff (2014)
Governance: state-society problem solving
in public arenas.
Health governance framework:
Different actors:
1. State actors: politicians, policymakers
and other government officials. Also
other public sectors than usually
associated with health system (e.g.
ministry of finance, judicial system)
2. Health service providers/institutions:
public, private and voluntary sector
providers: hospitals, clinics, laboratories
and educational institutions). Also
includes organizations that support service provision (insurance agencies, health maintenance
organizations, pharmaceutical industry and equipment manufacturers and suppliers).
3. Clients/citizens: service users, the general public and organized civil society.
These actors are linked through the governance relationships illustrated in the figure.
Their principal-agent relationships are both instrumental (related to how governance helps to achieve
health system goals) and normative (reflecting commonly accepted principles of good governance).
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