Institutions are broadly accepted rules of the game giving direction to social action: social action comprises what actors take for granted or assume (belief system) and established patterns of social interaction.
A central proposition of the institutionalist model is that society cannot endure and prosper without institutions. Institutions are indispensable for social order.
The institutionalist model postulates that health policy changes unfold gradually rather than radically.
Health systems can be conceptualized as a complex pattern of institutions regulating medical practice, patient expectations, organizational behavior, and health policymaking.
Healthcare reform is a combination of institutional change and institutional continuity.
A reciprocal relationship exists between institutional structure and health policymaking. Institutional impact is the impact of the institutional context on health policymaking; institutional change is the impact of health policymaking upon the institutional context.
A distinction can be made between three types of institutionalist models of health policy analysis: the rational choice model, the sociological model, and the historical model.
Path dependency means that once taken policy choices tend to persist by feedback mechanisms limiting the margin of policy change.
Factors explaining institutional continuity are the force of habit, sunk costs, functionality, power relations, and legitimacy.
Factors explaining institutional change are external shocks and endogenous processes.
Successive incremental policy changes can fundamentally change the institutional structure and performance of health systems.
Differentiating between the process and results of change four types of institutional change can be distinguished: reproduction by adaptation, survival and return, replacement after breakdown, and gradual transformation.
There are several models of gradual transformation: displacement, layering, drift, conversion, and exhaustion.
Box 11.1 The enactment of the 2006 Health Insurance Act in Dutch health care
The Health Insurance Act (Zorgverzekeringswet) that came into effect by the 1st of January 2006 integrated the sickness fund scheme with all other, mainly private, schemes into a single mandated scheme covering the entire population and a broad package of health services, including general practitioner care, hospital care, pharmaceutical care, maternity care, and many other services. To induce competition between insurers, consumers were free to choose their insurer, type of health plan and switch to another insurer by the end of each year. The new legislation permitted insurers to set their premium rates but obligated them to apply community rating. Experience rating was explicitly forbidden. Furthermore, insurers had to accept each applicant without restrictions. Persons on a low income could apply for an income-related care allowance to uphold income solidarity.
The reform formally started in 1986 with the installment of the Dekker committee (a group of independent experts) which in its report ‘Willingness to Change’ (published in 1987) recommended the government to reform Dutch health care according to the principles of regulated competition. The reform marked a historical moment in Dutch health care because it put an end to the bifurcated health insurance landscape with sickness funds (covering about two-thirds of the population) and other, mainly private, insurers. It also included other system changes. Insurers were charged with the purchase of health services on behalf of their customers. Providers and insurers had to negotiate contracts on prices and quality. Selective contracting by insurers was permitted. The state defined its responsibility for health care as ‘system responsibility’, an ambiguous term that meant that the state’s primary responsibility was to promulgate market regulation and organize effective oversight of competition. Only if access to or quality of health care would be at risk, the state could directly intervene in the market.
At the same time, however, the reform reflected in many ways the old system. For instance, the Health Insurance Act would have been politically unfeasible without hard provisions for risk solidarity and income solidarity. Its benefits package largely coincided with the benefits package of the sickness fund scheme. The mandated structure of the new scheme was rooted in the tradition of the sickness fund scheme. Furthermore, the reform mirrored the traditional public-private mix in Dutch health care (public financing in combination with private provision) and the divide between basic and supplementary health insurance. In short, the market reform constituted a complex mix of institutional change and institutional continuation.
Source: Jeurissen & Maarse 2021.
The historical context and political circumstances always influence health policymaking. The political struggle on what has come to be known as the ‘market reform’ in Dutch health care demonstrates the impact of this context. An important reason why the Dekker Committee's recommendations to reform Dutch health care on the basis of the principles of regulated competition got bogged down in a long political struggle was that they clashed with deeply rooted beliefs on the organization of Dutch health care. Opponents argued that competition would hollow out solidarity in healthcare financing and undermine universal access to health care. Some critics warned of the risk of a two-tier healthcare system. Health care was, in their view, simply unfit for competition. Eventually, it took almost twenty years before the government managed to build a political majority for a major reform. This success would never have been politically feasible without hard conditions for a solidary system of healthcare financing. Hence, the new legislation included various provisions to preserve risk solidarity and income solidarity. The main challenge in the political struggle was to craft a proper balance between the principle of solidarity to guarantee universal access and the principle of competition to foster efficiency and innovation. The new Health Insurance Act can indeed be understood as a complex balancing act between efficiency and solidarity.
The market reform in Dutch health care demonstrates a mixed face. On the one hand, it was directed at system change. On the other hand, however, it involved much continuity. For this reason, the reform can be understood as a complex mix of change and continuity (Helderman et al., 2005). This observation highlights the central proposition of the institutionalist model: the institutional context heavily influences health policymaking. Reforms that radically differ from institutionalized beliefs and interests meet strong opposition if seen as an unacceptable infringement of established rights and intended. As a consequence, policy changes are gradual rather than radical. Changes that, for political reasons, are sold as ‘reforms’ most of the time appear as a complex mix of change and continuity. All health policymaking is rooted directly or indirectly in history which constrains the room for change. Policy changes involving a radical breach with the past have little chance of crossing the finish.
This chapter contains an introduction to the institutionalist model in health policy analysis. It starts with a discussion of the concept of institution, the concept of institutional pluralism, and the problem of institutional incompatibility. Hereafter follows an analysis of the reciprocal relationship between health policymaking and institutional context (or institutional structure). There are several versions of the institutionalist model. Three versions will be briefly discussed: the rational, sociological, and historical model. The final part of the chapter is devoted to two main themes in the institutionalist model: institutional continuity and institutional change. These themes are discussed in the final part of the chapter. The chapter ends with a brief exploration of the implications of the institutionalist model for health policy analysis.
There exists no single definition of the concept of institution. The literature offers a variety of models and definitions. Political scientists following the ‘old institutionalist’ model were particularly interested in the (comparative) analysis of the structure and dynamics of the central state organizations in a country, most notably the government, the Parliament, the state bureaucracy, and the judiciary. They called these organizations institutions. A basic assumption underpinning old-style institutionalist analysis was that a country’s institutional structure heavily influences the problem-solving capacity of the state and society and the strength of its democracy (Peters, 1999).
This book follows a different model. An institution is conceptualized as a system of broadly accepted rules of the game giving direction to social action whereby action comprises both the belief system (assumptive world) of actors and established patterns of social interaction. This alternative approach to institutions draws, among others, upon the work of Scott (1995), who emphasizes that ‘institutions provide stability and meaning to social behavior’ (p. 33). They ‘discipline’ social interaction by a common frame of reference (‘frame’ or ‘script’) for interpretation and interaction. Scott argues that social life would inevitably end in chaos without effective institutions. Institutions ‘normalize’ social interaction. He makes a distinction between normative, cognitive, and regulative institutions. Whereas normative institutions are beliefs (or mind set) about ‘good’ and ‘bad’, ‘appropriate and ‘inappropriate’ or ‘right or wrong’, cognitive institutions are widely accepted ideas about ‘what is’, ‘how to explain’, ‘what works’ and ‘what does not work’. Regulative institutions consist of rules of the game for how people should interact with each other.
Institutions either have a formal or informal status. A formal institution of the constitutional state is that state intervention requires a proper legal basis, that any discrimination based on religion, philosophy of life, political conviction, race, sexual disposition, or any other basis is forbidden, that legislative proposals must be approved by a (qualified) majority in the Parliament, that people have the right to demonstrate, and so on. A central theme in the institutionalist model is that many rules regulating social action are informal rules that have developed over a more extended period. Examples are widely shared values and norms, habits, traditions, social conventions, convictions, mutual trust, and public confidence in the state and in science. Sanctions to reward rule compliance and punish rule violations can also be informal. Examples of informal sanctions are trust and promotion (positive sanctions) and loss of reputation, exclusion, and ‘naming and shaming’ (negative sanctions). Informal rules can be converted into formal rules. A considerable part of the constitution of nations builds upon practices that have developed in the past (codification).
As said, the institutionalist model postulates that society cannot endure and prosper without broadly agreed and appropriate rules regulating social interaction between people and organizations (Leftwich, 2005). In other words, institutions are understood as a precondition for social order. The linkage between social order and institutions is recognizable in the definition of Streeck and Thelen (2005), who describe institutions as ‘building blocks of social order: they represent socially sanctioned, that is collectively enforced expectations with respect to the behavior of specific categories of actors or to the performance of certain activities. Typically they involve mutually related rights and obligations for actors, distinguishing between appropriate and inappropriate, ‘right’ and wrong’, ‘possible’ and ‘impossible’ actions and thereby organizing behavior into predictable and reliable patterns’ (p. 9).
Nobel-prize winner North (1991) conceptualizes institutions as an established practice. He defines institutions as ‘humanly devised constraints that structure political, economic and social interaction’ (p. 97). With many others, North underscores the role of institutions in creating social order and reducing uncertainty in social interaction. The focus of his empirical work is on the historical development of formal and informal institutions that have stimulated economic growth and the flourishment of trade. North concludes that institutions are indispensable for prosperity because they reduce transaction costs (the costs of negotiating, monitoring, overseeing, and so on). For instance, nothing reduces transaction costs more than mutual trust, and nothing is as costly as mutual distrust. He stipulates that institutions ‘evolve incrementally, connecting the present with the past and the future: history in consequence is largely a story of institutional evolution in which the historical performance of economies can only be understood as a part of a sequential story.’ (p.1).
Institutions are also central in how March and Olsen (1976) conceptualize organizations. They distance themselves from the idea of an organization as a purposeful system regulating the behavior of its members by rationally-designed formal rules. Organizational behavior is largely regulated by informal rules (organizational culture). Not the ‘logic of the consequences’ prevails in organizational behavior but the ‘logic of appropriateness’. Organizational behavior following the logic of the consequences is based upon systematic analysis and assessment of the consequences of alternative options, whereas organizational behavior following the logic of appropriateness is regulated by social norms. The logic of appropriateness refers to the impact of organizational culture on the functioning and performance of organizations.
If we abstract from the mainly subtle differences between these definitions, it is clear that they have much in common. Each definition emphasizes that institutions, whether formal or informal, constrain action and make action predictable to a certain degree. However, some institutions are more compelling than others. The same applies to sanctions. By its emphasis on the institutional context of human action, the institutionalist model of policymaking contrasts with what is known as methodological individualism in social and political analysis. This analytical model of human behavior postulates that individual subjective motivation explains social phenomena. These phenomena are viewed as the result of individual decisions. Consequently, the adherents of methodological individualism demonstrate less interest in the impact of institutions on individual decision-making (ref). The rational choice model in neo-classic economy takes the preferences of actors even as given (exogenous) and assumes that individual behavior is driven by self-interest. In doing so, methodological individualism abstracts from the impact of institutions upon individual decision-making. Scharpf (1997) takes a middle position in the debate on methodological individualism. Institutions, he argues, only constrain action; they reduce action variance but have no determinative effect on it. Actors always interpret institutions and can give these a twist of their own. Sometimes, they may even ignore or violate the rules of the game. Hence, a study of institutional structures only cannot explain policymaking well. Policy analysts must also investigate how actors deal with the rules of the game in decision-making. On the other hand, actor decisions cannot be reduced to purely individual choices. Hence, policy analysts must study the impact of the institutional context in which they make decisions. This is the core of Scharpf’s model of actor-centered institutionalism.
A distinction can be made between problem-oriented and process-oriented institutions. Problem-oriented institutions give direction to the formulation of policy problems and policy goals as well as the choice of policy instruments. An example is the principle of solidarity that had to be respected in the market reform of Dutch health care. The reform would have been politically infeasible had the new health insurance legislation not contained regulations to protect this ‘public value’ in a market-based healthcare system. Likewise, the call for a shift from a predominant medical perspective to a comprehensive perspective of public health (Chapter 1) can be understood as an attempt to rewrite the health policy agenda by institutionalizing new leading principles for health policymaking.
Process-oriented institutions regulate the process of health policymaking and health system governance. The prominent role of self-regulation in the medical sector exemplifies a deep-seated normative principle in Western industrialized countries (Tuohy, 2003; Freidson, 2001) which sharply contrasts with the institutionalized subordinate role of the medical profession in many Central European countries before the fall of the Berlin Wall in 1989 (Sitek, 2010). The so-called ‘implicit concordat’ between the state and the medical profession in the National Health Service is another example of an institutionalized rule of the game in UK health policymaking. The concordat means that the state accepts the autonomy of the medical profession in decisions about the use of resources in return for the medical profession’s acceptance of the right of the state to set budgetary constraints (Klein, 2012). The decentralized governance structure in public health in many countries (Chapter 7) reflects the influence of historical notions on the most appropriate structure of state governance. Polarization can be conceptualized as the institutionalization of a new political culture: politicians make much of ideologically-driven differences of opinion, seek confrontation instead of collaboration, and love personal attacks.
Viewed from an institutionalist perspective, politics is a struggle over the rules for policymaking. Institutions shape the power structure in society and the policy arena. For instance, institutions regulate the role of accountability and transparency in policymaking or which actors have access to the inner circle of the policymaking arena. Acemoglu and Robinson (2012) conclude from their research that inclusive economic and political institutions foster social welfare and prosperity (system performance). In contrast, extractive economic and political institutions are an important cause of poverty. They define extractive economic institutions as institutions that do not allow private property. Contrary to inclusive economic institutions, extractive institutions are designed to extract incomes and wealth from one subset of society to benefit a different subset. Inclusive political institutions, on the other hand, correspond with a pluralistic type of society. Power is not concentrated in the hands of a narrow elite. According to Acemoglu and Robinson, politics is about choosing economic and political institutions.
Health systems can be conceptualized as a set of established rules of the game regulating, among others, medical practice, patient expectations, organizational behavior, health policymaking, and political decision-making. According to Payer, medical practice resembles in several respects a culture (Box 11.2).
Box 11.2 Medicine and culture
In her comparative study of varieties in medical treatment in France, Germany, the United Kingdom and the United States, Payer (an American medical journalist with a background in biochemistry) found remarkable institutionalized differences in the doctor’s attitude to patients, prescriptions, testing, and diagnostics. Her initial assumption that medicine is science-based and hence an international activity proved incorrect. In her view, medicine is a matter of culture. ‘Why, for example, did the French talk about their livers all the time? Why did the Germans blame their hearts for their fatigue where there didn’t seem to be anything seriously wrong with them? Why did the British operate so much less than the Americans? And why did my French friends become upset when I said I had a virus? (p.15). Payer concludes that ’the choice of diagnosis and treatment is not a science. While scientifically conducted studies can show us that a certain cause of action or treatment can result in certain benefits and risks, the weighing of those benefits and risks will always be made on a cultural scale’ (p. 154).
Source: Payer, 1988.
Institutions guide how health policy actors make sense of problems and settle conflicts. They regulate the interaction between actors in the health policy arena. Policy implementation offers many examples of established practices that influence health system performance.
Institutional change and continuity are also manifest in health systems. Examples are the gradualist transition from a hierarchical (paternalistic) relationship between doctor and patient to a more horizontal kind of relationship, the shift from trust-based accountability to contract-based accountability in health governance, and the advance of digitalization and datafication of public health. Each of these changes has major repercussions for the structure and performance of health systems. Institutional change, however, usually takes a long period. A dramatic example of the tenacity of an established practice in the history of medicine is the slow uptake of a ground-breaking finding by the Hungarian doctor Ignaz Semmelweis. Resistance to change is an important cause of institutional continuity (Box 11.3).
The publicization of public health or the process of growing state involvement in public health also indicates a process of gradualist institutional change. New rules of the game hold the state responsible for the health of its population. Citizens expect protection from health hazards. Other manifestations are the progressive jurifidication and bureaucratization in health policymaking and the present-day emphasis on transparency, accountability, and integrity. None of these manifestations are unique to health policymaking; they are visible in all public policymaking. Likewise, one can interpret the call for a ‘new public health’ by moving away from the prevalent bio-medical approach and individualistic orientation towards a comprehensive approach as a call for institutional change. It asks for a reorientation of the causes of health and disease and a new health policy agenda (Cribb, 2005; Wiley, 2016).
Box 11.3 Semmelweis’ tragedy
Semmelweis discovered that the high mortality maternity death rate – on average 25 percent of the women died in childbirth in the Vienna hospital where he worked – was caused by a lack of hygiene. Doctors and nurses were not accustomed to washing their hands in medical practice. Semmelweis demonstrated that maternity death could radically drop by appropriate hygienic measures. However, his call for these nowadays self-evident measures remained contested in the medical community, which was also caused by the fact that Semmelweis’ political-liberal ideas were controversial in Vienna at that time. Although he had published his ground-breaking findings already in 1861, it took some twenty years before his ideas became widely accepted.
In society, multiple institutions co-exist. While some institutions pervade all spheres of social life (for example, politeness norms), other institutions are sector-specific. Distinct institutions regulate social action in the market sector, the judicial sector, the not-for-profit sector, the political sector, the administrative sector, and so on. Professional training is directed at the institutionalization of sector-specific rules of the game. For instance, legal experts will reason more in terms of legal principles than in terms of efficiency and profit-making than students trained in business administration. Likewise, the rules of the game for scientific research differ from the rules of the game for policymakers: the exploration of what is true or false asks for other rules of the game than trying to get something done, preferably as soon as possible.
Institutional pluralism raises the issue of institutional compatibility. Alternative institutions can peacefully coexist in a pluralistic society but also cause institutional friction or incompatibility. Compatibility is an important theme in institutional analysis. For instance, how do market principles in health care relate to ethical principles in the provision of health care? The medical profession has repeatedly said that competition conflicts with the ethical code of rendering patients the best possible medical care (Berenson & Cassel, 2009; Pellegrino, 1999). Advocates of competition on their side argue that the rules of the game of competition will ultimately make health care more efficient and patient-driven (Herzlinger, 1997). The risk of value erosion can be prevented by strict regulations (Enthoven, 1993).
The issue of institutional compatibility was also a central theme in the market reform of Dutch health care. Opponents of the reform argued that competition and entrepreneurialism conflicted with deep-rooted principles of solidarity in healthcare financing and universal access to health care and might ultimately lead to the emergence of a two-tier healthcare system nobody wanted. Mol (2006) put it this way: the ‘logic of health care’ is antithetical to the ‘logic of the market’. In his analysis of the prospect of economic development in Third-World countries, Leftwich pointed to the risk of institutional incompatibility between democracy and development (Box 11.4).
Institutional (in)compatibility is also a central theme in Sitek’s comparative analysis of healthcare reform in Poland, the Czech Republic, and Hungary. After the fall of the Berlin Wall in 1989, these four countries embarked on a reform to overhaul their state-dominated healthcare system with ‘Back to Bismarck’ as the leading motto. Doctors naively believed that the introduction of social health insurance would end their subordinate position in the public arena. Policymakers, on their part, naively assumed that the reform would increase efficiency and innovation and make health care provision more patient-driven. The reality turned out to be quite different. While the reform proved relatively successful in the Czech Republic and Hungary because of the concentration of authority and longevity of governments, it was much less successful in Poland because of political instability, frequent changes of government coalitions, and the weak position of the minister of Health within the ranks of the government. The absence of strong political leadership and political instability were major stumbling blocks in the reform process. The political structure was not conducive to the intended reform of the nation’s system of health insurance (Sitek, 2010).
Box 11.4 Democracy and development: is there institutional incompatibility?
Leftwich starts his analysis of development with the observation that, contrary to a few decades ago, economic and social development cannot be achieved without a strong role of the state. Development is not the same as economic growth. Development in relatively low-income countries or highly unequal economies involves radical and rapid changes in these countries’ social, economic, and political structures. What crucially distinguishes development from growth is the issue of the distribution of the benefits of growth. Development requires a more equal distribution of the benefits which in turn requires a radically different political structure and distribution of power.
How likely is it that such a transformational process will be successful? An effective state capable of maintaining the institutions of a competitive democracy does not exist in most countries, as a consequence of which the risk of quick corruption is imminent. Leftwich also holds it questionable that the informal institutions of democracy will be respected: will the losers of power accept defeat, and will the winners agree to exercise restraint? A winner-takes-all culture will only exacerbate the political conflict and make development even harder to achieve.
Source: Leftwich, 2005.
The central message in the previous sections was that institutions matter. They make social action predictable. Without institutions, social chaos would follow. This message also applies to health policymaking: institution sets constraints to health policymaking. Policymakers cannot ignore the institutional structure they are acting in. Their policy decisions are, to a great extent, a ‘product’ of this structure. On the other hand, however, health policymaking influences the institutional structure of health systems. The goal of healthcare reforms is to alter the institutional structure of these systems to improve their performance. The relationship between institutional structure and health policymaking is thus reciprocal (Figure 11.1).
The impact of the institutional structure on health policymaking is called institutional impact. The concept of institutional change refers to the impact of health policymaking upon the institutional structure of health policymaking.
Institutions influence health policymaking in many ways (Clemens & Cook, 1999). The rules of the game influence who has access to the health policy arena, who belongs to the inner circle of health policymaking, how decision-making is organized, which policy options are acceptable or unacceptable, lawful or unlawful, and so on. Established power relations also form part of a country’s institutional structure. However, as spelled out earlier, institutions have no determinative impact on social action. A one-to-one relationship between the institutional structure and health policymaking does not exist. Discussing the role of values (a normative institution!) in policymaking, Marmor and Klein (2012) conclude that the impact of values on the organization of health care is mediated by a complex combination of factors, including the countries’ political structure, the accommodation of clashing interests in the past, power relations, and what Tuohy has called ‘accidental logics’ by which she meant ‘that key features are ‘accidental’ in the sense that ideas and agendas shaped them in place at the time a window of opportunity was opened by factors in the broader political system’ (Tuohy, 1999).
Institutions shape policy preferences and expectations (Clemens & Cook, 1999). Policy preferences are endogenous instead of exogenous as assumed in methodological individualism. They are context-bound. Consequently, the institutionalist model focuses on the impact of structural and cultural influences on social action rather than on individual behavior. Individual decisions are much less individual than adherents of methodological individualism assume.
An example of an informal rule in health policymaking is the institutionalized practice of consultation and mutual adjustment in Dutch health policymaking. Though the atmosphere may polarize now and then, government and national organizations of doctors, hospitals, health insurers, and other stakeholders do their best to settle conflicts by negotiated agreements (compromises). This practice is known as ‘polderen’ (Visser & Hemerijck, 1997). The predominant practice of self-regulation in health policymaking in Germany and other Western-European countries is another example of an institutionalized practice.
A concept underscoring the impact of institutional structures on policymaking is policy style. Richardson and his colleagues (2018) describe this concept as a ‘system of decision-making’ that structures policy choices (including choices in policy implementation) in predictable ways. The study of policy style does not focus on the content of the decisions taken but on the values, norms, and standard operating procedures that ‘regulate’ the decision-making process (Howlett & Tosun, 2018). Policy styles can widely diverge, for instance, regarding the role of research and evidence in policymaking, the extent to which policymakers are driven by ideological or pragmatic considerations or the way policymakers deal with risk and uncertainty. Polarization is a new policy style. Godt’s international-comparative study of healthcare reform and strategies to deal with organized interests demonstrates differences in dominant policy style (Box 11.5).
Box 11.5 Three alternative policy styles: confrontation, consent, and corporatism
In his comparative analysis of state strategies in France, Germany, and Great Britain in the 1960s and 1970s to control healthcare expenditures and meet resistance of the medical profession Godt concludes that these countries followed, generally speaking, different strategies (his synonym for policy style) to resolve conflicts between the interests of the medical profession and public interests. The British government pursued a strategy of consent or diplomacy of mutual adjustment to win the support of the medical profession for its cost control policy. The government understood that its policy could never succeed without the doctors' commitment. The federal government of Germany followed a different strategy. Building upon the German tradition of corporatism, the federal government delegated much of the responsibility for health policymaking to the representative organizations of doctors and insurers at the state level. Health policymaking was seen as a matter of shared responsibility (Konzentierte Aktion). In response to the confrontational policy style of the doctors over payment issues, the French government resorted to a counter-confrontational strategy ‘using pluralist politics to manipulate various actors and pit them against one another’ (p. 474). Godt emphasizes that each of these styles (strategies) mirrors the impact of the institutionalized political-administrative context of each country.
Source: Godt, 1987.
Health policymaking is not only influenced by the institutional structure it is embedded in. It also affects this structure. Seen through an institutionalist lens, healthcare reform is an orchestrated attempt to overhaul an established institutional structure based on a new model or paradigm for the provision, financing, regulation, and payment of health services (‘policy reframing’). The new model entails new rules of the game for policymaking and the relationship between the state, market, and civil society. In short, new rules for action in the health system to improve its performance. Tuohy’s analysis of the transition from a trust-based to a contract-based model of accountability offers an insightful analysis of institutional change and the counter-reaction it has provoked (Box 11.6).
Box 11.6 From trust-based to contract-based accountability in health governance
Accountability has always been a central issue in health governance: how to hold doctors accountable for their provision of medical care to patients? Accountability is a multidimensional concept involving the identification of accountability or who should be held accountable for what, the provision of information, and the availability of sanctions. Accountability represents a complex problem in health care because of three specific characteristics of health care: information asymmetry, the difficulty of evaluating the product, and the high costs of error (Arrow 1963).
Using a principal-agent model, Tuohy analyzes a fundamental shift in mechanisms to hold doctors accountable for the provision of medical care. In the old situation, accountability was based on trust. The state in its role of principal had to trust doctors (agents) because of the specific characteristics of health care mentioned above. Accordingly, the state relied on self-regulation by the medical profession to achieve that health care met professional standards. Accountability rested upon trust, collegiality, and self-correcting mechanisms in the professional community. Self-regulation was complemented by some formal mechanisms to punish unprofessional health care.
Tuohy argues that the trust-based model of accountability has to a great extent been replaced with a contract-based model of accountability. This development started with the interference of the state in healthcare finance and healthcare quality. Even more important was the rapid advance and diffusion of information technology that made it possible to collect large amounts of information on healthcare needs, the costs of health care and healthcare quality, and, last but not least, the experiments with managed care and regulated competition. These developments had major consequences for the relationship between the state, doctors, payers, and patients. Nowadays, complex contracts between payers and providers with numerous specific regulations of costs, quality, and many other issues regulate accountability.
Source: Tuohy, 2003.
There are several versions of the institutionalist model. This section briefly discusses three alternative models: the rational choice model, sociological institutionalism, and historical institutionalism (Peters, 2001).
The rational choice model investigates the impact of institutions on actor behavior under the assumption of rationality. A classic example is the Prisoner’s Dilemma in which two actors, A and B, have two strategic choices: cooperation and non-cooperation. The actors achieve their best collective result if they cooperate, but if one chooses cooperation and the other non-cooperation, the cooperator will end up with the worst individual outcome and the non-cooperator with the best individual outcome (and vice versa). If both actors choose for non-cooperation hoping that the other actor will choose for the strategy of cooperation or expecting that the other actor will choose for the strategy of non-cooperation, both will end up with the second-worst outcome. Because none of them wants to run the risk of being exploited by the other, non-cooperation is the dominant strategy. The main lesson of the Prisoner’s dilemma is that individually rational behavior can produce irrational collective outcomes! None of them can individually escape from this trap because of the risk of exploitation unless they decide to collective action by common rules of the game, including effective sanction mechanisms to punish non-cooperation.
A practical application of the Prisoner’s dilemma is the Tragedy of the Commons (Hardin, 1968). This model describes a situation where individual users acting in their self-interest have open access to a common pool of resources. Without effective formal or informal rules regulating access and use, the common pool will soon be depleted to the detriment of all users. The lesson is again that uncoordinated action inevitably ends in tragedy. Overfishing, global warming, air population, or escalating healthcare expenditures eroding the financial sustainability of health care are illustrations of the Tragedy of the Commons. These problems can only be effectively remedied by collective agreements and regulations supported by effective sanctions.
The rational choice model takes an outer position in the institutionalist model of health policymaking. In contrast to its alternatives, the model premises methodological individualism by taking players’ policy preferences as given (exogenous) and assuming that they are driven by self-interest. Institution formation is a central theme in the rational choice model. The challenge is to develop formal rules of the game to resolve the problem of collective action (see Chapter 6). The actor-centered model developed by Scharpf (1997) is a variation of the rational choice model. Postulating that institutions only structure but do not determine interactions, the way actors use their choice options influences the outcome of interaction (or policymaking). For instance, if the government is formally authorized to take regulatory measures to address a pressing problem, it can nevertheless opt for soft measures (e.g. persuasion) or even non-intervention to reach the same result. Policy analysts using an actor-centered model do not confine themselves to investigating the impact of institutional structures on policymaking. They also examine how policy actors choose their policy goals and ‘play’ with institutions to achieve them.
Scott (1995) is a representative of the model of sociological institutionalism. The leading thought is that the behavior of people and organizations follows certain patterns or routines. Institutions offer a script or framework for how to think and act. Institutions are considered necessary for social order. A central claim of the model is that institutionalized interaction patterns tend to be resistant to change. Tradition and habits work as formidable barriers to changing behavior. Research on the de-implementation of institutionalized practices of low-value care demonstrates the tenacity of tradition and habits in providing health services (Nilson et al., 2020).
Institutional change is conceived as the outcome of more or less non-orchestrated processes spanning a more extended period. Institution formation is not a matter of design as in rational choice models but the outcome of gradual transformation. For instance, the advance of medical knowledge and the introduction of new technologies have gradually radically changed the understanding of health and disease. Likewise, the emancipation process in Western industrialized societies has affected the relationship between patient and doctor. The patient-doctor interaction pattern has become more ‘horizontal’ than it used to be only a few decades ago when it still had a relatively ‘vertical’ or paternalistic structure. The ‘spontaneous’ emergence of new practices have also resulted in new legislation establishing and reinforcing patients’ rights (e.g. the right to consent, the right to complain, and the right to participate in decision-making).
The third version is historical institutionalism. At its core, this model postulates that history always matters in policymaking. The simple idea is that policy decisions taken in the past create an institutional context that influences later policymaking. Past decisions are assumed to have an enduring influence on policymaking at later stages: they induce a self-reinforcing policy trajectory (policy path). Policymakers operate as ‘agents of history’ who must respect ‘the legacy of the past’.
A central concept in the historical institutionalist model is path dependency. Policy changes are path-dependent. The best predictor of a policy at point (t) is the policy at point (t-1) or even (t-10). Initial policy choices tend to persist by feedback effects; they set the course for policymaking over a long period (Krasner, 1984). In other words, historical institutionalism postulates that policy change is inevitably locked in. Historical institutionalism does not exclude institutional change. However, the model emphasizes that institutional change is not a ‘one-shot operation’ (a radical reform) but the cumulative result of gradual or incremental changes over a longer period (North, 1979). The concept of path dependency explains why most health policymaking follows an evolutionary rather than a radical path. Even fundamental policy reforms appear less radical than policymakers had in mind or hoped for. Policymakers cannot ignore the past and must respect established rights created in the past. The 2015 reform of long-term care policy in the Netherlands is an instructive example of path dependence. The initial policy decision of a distinct statutory scheme for long-term care set out the course for policymaking in later years (Box 11.7).
Box 11.7 Path dependency in Dutch long-term care policy
1968 was a crucial year in the history of Dutch long-term care. The introduction of the Exceptional Medical Expenses Act in that year terminated four decades of political discussion fueled by conflicting ideological convictions about how to organize and finance long-term care. The act would function as the regulatory flagship of long-term care for almost 50 years. The essence of the established regime was that the state assumed political responsibility for long-term care by introducing a distinct statutory insurance scheme financed by social contributions. The act conferred each citizen meeting the eligibility criteria the formal right to publicly-funded services of long-term care. The provision of these services remained in the hands of private, not-for-profit providers, as had been the case in the past. Initially, the new act covered only residential care for vulnerable older persons in nursing homes and handicapped persons. Over time, however, service coverage of the regime extended at a large scale. As a result, long-term care gradually transformed into a labyrinth of specific regulations for ever more specific target groups.
A remarkable aspect of the history of the Exceptional Medical Expenses Act is that the extension of coverage continued despite warnings of the then state-secretary of Health in the early 1980s that the financing of long-term care would become unsustainable and for this reason required fundamental restructuring. However, his cry for reform remained unanswered. It took until 2015 before an overhaul of the organization of long-term care came into force.
The 2015 Long-term Care Act as the successor of the Exceptional Medical Expenses Act respected the fundamental principles of the old legislation. As its predecessor, the new legislation is shaped as a statutory health insurance scheme financed by social contributions; clients meeting the eligibility criteria retain their right to long-term care services, as in the old situation, provided by private providers. The reform involves some restrictions on the right to long-term care, gives clients more freedom of choice, restructures the organization of long-term care organization, and includes last but not least, a sizeable package of expenditure cuts that was largely undone soon after. All in this together, the reform did not bring about a major revision of Dutch long-term care: it was, in many respects, a path-dependent reform.
Source: Maarse & Jeurissen 2016; Companje 2013.
As spelled out in the introductory section of this chapter, the central proposition of the institutional model of public policymaking is that policy changes are incremental rather than radical. Institutional continuity defined as the continuation of established rules directing social interaction prevails. Radical change only occurs under exceptional conditions (see next section). Policy change is conceptualized as an evolutionary process of continuous accommodations to altering circumstances. This is also true for healthcare reform. Most reform rhetoric suggests more change than actually takes place.
How to explain institutional continuity or the persistence of institutions? Institutional continuity is often ascribed to the force of habit, lack of knowledge, and disbelief. For instance it took many years before the Semmelweis’ insights about the role of hygiene in maternity care were accepted by the medical community. Resistance to change can also be motivated by material interests.
Mahoney (2000) mentions four alternative models for explaining institutional continuity. His first model links institutional continuity to sunk costs. Radical changes (e.g. reforms) are costly making them unattractive. Furthermore, radical changes divert attention from other urgent issues. Hence, it is prudent to follow the route of successive accommodations to enhance system performance.
The second model relates institutional continuity to functionality. If a certain rule or practice has a central function in the overall system, there are strong forces against institutional change because of its spill-over effects. For instance a new payment system for doctors may have big administrative consequences for healthcare management.
The other models connect institutional continuity with power and legitimacy (see also Kuipers, 2004). As spelled out in section 11.4, institutions ‘define’ a power structure that powerful agents will not easily give up. Loss of power motivates them to thwart institutional change. Consequently, the room for institutional change is contingent upon the power balance in the health policy arena. One of the conclusions of an evaluation of the ‘political death’ of the market reform in Dutch health care in the early 1990s was that the government had been unable to break through the clay layer of vested interests and that it took till the end of the 1990s that the reform process was resumed. (Willemsen Committee, 1994).
Finally, broadly accepted values and established rights restrict the room for institutional change. Reformers must respect these values and rights. The incumbent political elite can refer to these values and rights to discredit reform plans. The same is true for the beneficiaries of state programs who are eager to preserve their established rights.
A frequently mentioned weakness of the institutionalist model in health policy analysis is the tendency to underestimate the role of institutional change. The model misses powerful analytical concepts to explain institutional change and capture variations of institutional change and its consequences for social systems. The proposition that most institutional changes involve minor adaptive adjustments to altered circumstances causes what Streeck and Thelen (2005) call the ‘conservative bias’ in institutionalist analysis. The challenge is giving institutional change a firm place in the institutionalist model. How to explain institutional change, and which types of institutional change can be discerned?
The dominant model in the institutionalist model of policymaking is to assume a causal link between the occurrence of external shocks or major threats and institutional change. Examples of such ‘critical junctures’ are natural disasters, wars, political revolutions, and financial meltdowns. These events disrupt an existing institutional system and demand radical institutional adaptation. This model of institutional change is known as the punctuated equilibrium model: extreme external conditions disturb a state of equilibrium.
The outbreak of COVID-19 in 2020 caused by an infinitesimal particle (Christakis, 2020) is a textbook example of a major shock that compelled governments to take unprecedented policy measures to protect vulnerable people in society and avert a ‘meltdown’ of their healthcare system. The pandemic brought serious weaknesses in health systems to light. Despite earlier warnings from public health experts, most systems were not well-prepared for the pandemic outbreak. The policy lessons of a few earlier outbreaks (SARS in 2003/4; H1N1 (‘Swine Flu) in 2009; MERS in 2012) had not been learned well. Will COVID-19 bring about fundamental institutional changes in health systems (Box 11.8)?
Box 11.8 Three potential post-COVID scripts in health policymaking
In their investigation of the potential impact of COVID-19 on health policymaking, Boin and ‘t Hart stress the importance of crisis framing. Crises elicit what they call a ‘meaning-making battle’ (or sense-making battle). They refer to Spector, who has written that ‘facts (of the events) never speak for themselves [and] always await the assignment of meaning’. An archetypical storyline emphasizes the impact of exogenous forces (geography, war, weather, international markets, and so on). Crises are, at least to a great extent, unforeseeable and highlight the policymakers’ limit of control. An alternative storyline gives endogenous factors a central place in explaining crises. The outbreak of a crisis is the outcome of policy failure. The incumbent policy elite has failed to take appropriate measures to prevent the crisis or to be well-prepared if a crisis occurs.
Boin and ‘t Hart distinguish between three potential post-COVID scripts. In the crisis learning adaptation script, policy failures trigger a need for policy learning that results in policy adaptations to do better in the future (e.g. making a budget available to improve ‘pandemic preparedness’). Policy learning is mainly left to experts. The reaction to the crisis must be non-political and evidence-based.
An alternative script is the crisis >> exploitation >> reform script which conceptualizes a crisis as an opportunity to call for fundamental reform, including the need for centralization of power to enable responsible officeholders to take firm measures. Whether or not the explanation of the crisis is sought in exogenous or endogenous factors does not matter. What matters is that policymaking has failed and that policy changes are required. Policy lessons and policy changes are more radical in the crisis >> exploitation >> reform script than in the crisis >> learning >> adaptation script.
The crisis >> blame contest script follows a different line of reasoning. Political adversaries exploit the crisis as an excellent opportunity to blame the incumbent policy elite for its innocence and incompetence. They frame the crisis as the outcome of endogenous factors. This script particularly flourishes in a polarizing context.
Source: Boin and ‘t Hart, 2022.
Though critical junctures may trigger institutional change, the conceptualization of institutional change as the consequence of exogenous shocks only fails for two reasons. It ignores the influence of endogenous changes and misunderstands the cumulative effect of successive incremental changes on health systems. Most institutional changes develop gradually (Streeck & Thelen, 2005). For instance, consecutive advances in medical technology have been an important driver of institutional change. Consequently, modern healthcare provision radically differs from what it used to be only a few decades ago. The increased knowledge of the impact of environmental factors and health behavior on health and disease has stimulated a paradigm shift in health policymaking. Likewise, the process of emancipation has changed the patient-doctor relationship. Each of these institutional changes took place gradually.
Another explanation of institutional change is the absence of a one-to-one relation between institution and behavior. This is unsurprising, given that most institutions are ambiguous and leave room for interpretation and policy discretion. Streeck and Thelen argue that ‘the practical enactment of an institution is as much part of its reality as its formal structure (p. 18)’ and that ‘the enactment of a social rule is never perfect’ (p. 14). Most of the time, there is no single way of putting a rule into practice. For instance, policymakers or implementing agencies can decide for a strict or less strict rule application. The room for ‘rule mutation’ depends on the specificity of the rule. Specific rules leave, in theory, little room for mutation though practice shows that even strict rules may appear indeterminate in individual cases. In contrast, ambiguous rules (e.g. values and open norms) lead to differing practices (Clemens & Cook, 1999). Other endogenous factors triggering institutional change are conflicts on rule implementation and efforts of agents to reinterpret regulations, seek loopholes in the regulations, circumvent regulations, and likewise strategies.
Policy reform can be conceptualized, as spelled out earlier, as a pre-designed attempt to bring about institutional change. Proponents of reform argue that the old policy paradigm fails and call for a new model to enhance system performance. The existing institutional structure must be redirected. However, the practice of health policy reform demonstrates that policy reframing (Rein & Schön, 1994) is difficult and may take much time. Opponents to reform will hold on to the entrenched belief system for reasons described in the previous section. Reforms also fail because of political chaos, polarization, weak democratic institutions, or disrespect for the unwritten rules of democracy. Successful healthcare reforms may require concomitant reforms in the political-institutional structure which are not self-evident (Leftwich, 2005; Sitek, 2010). Disputes on the rules of the game for policymaking are also a well-known phenomenon. ‘Political institutions are not only periodically contested; they are the object of ongoing skirmishing as policy actors try to achieve an advantage by interpreting or redirecting institutions in pursuit of their goals, or by subverting or circumventing rules that run counter to their interests’ (Streeck & Thelen, 1995: 19). The likely result of these skirmishes is a gradual change in the structure of governance.
Streeck and Thelen introduce an interesting typology of institutional change. They distinguish between two dimensions of change: the pace of change which varies between incremental and abrupt and the result of change which varies between continuity and discontinuity.
Figure 11.2 Types of institutional change: processes and results
Result of change
Process of change
Reproduction by adaptation
Survival and return
Source: Streeck & Thelen, p. 9
Reproduction by adaptation means that minor adaptive adjustments to altering circumstances (incremental policy changes) leave the health system largely unaffected. Survival and return happen when political and social forces to resume old practices are so strong that an abrupt change eventually leaves a system largely unaltered. Survival and return can also result from the ‘normalcy bias’ or the human tendency to believe that the old situation will return or has returned despite warnings of the contrary (Drabek, 2012). Another possible result is that the system breaks down and is replaced with an alternative structure. Gradual transformation occurs if institutional change results from successive incremental changes with transformative effects over a certain period. Streeck & Thelen consider gradual transformation the most common type of institutional change. Evidently, the typology only gives a stylized overview of institutional change. Various gradations of change can be discerned. A combination of the four models is also possible.
How does gradual transformation take place? Which types of gradual transformation exist? In response to these questions, Streeck and Thelen distinguish five types of gradual transformation that may occur simultaneously. The boundaries between the types are fluid.
Drift is the process of gradual erosion of an institutional structure. On the surface, institutional structures appear stable but gradually erode in reality. An example is Hacker’s analysis of ‘the hidden politics of US welfare state retrenchment’. The declination of conservative politicians to adapt existing policy programs to changing economic circumstances and new social risks has led to emerging gaps in coverage and, consequently, the privatization of social risks. Institutional change by drift is not the result of a single major policy intervention or a master plan but rather the cumulative effect of successive incremental changes or non-decisions (Hacker, 2005). Drift can also result from minor but successive changes in the implementation of healthcare regulations that go unobserved yet have significant consequences for system performance. Without active maintenance, values and norms run the risk of gradual erosion. In this respect, opponents to the market reform in Dutch health care have always warned of the creeping erosion of public values of health care. Critics of managed care and regulated competition fear that a contract-based relationship will eventually hollow out the trust-based relationship between doctor and patient (Tuohy, 2003). Likewise, critics of the penetration of tech giants into health systems and the concomitant digitalization and datafication warn of unnoticed ‘surveillance creep’ (Sharon, 2021).
Institutional change by layering results from adding new elements to an existing institutional structure. Persistent and intractable problems, policy disputes, or the need for new coordinative structures are resolved by creating additional structures or layers. An example is the organization of quality control in Dutch health care. The call for outcome measurement and transparency at the turn of the century elicited various initiatives for quality measurement. These initiatives did not replace the pre-existent quality control system but introduced an extra layer in quality control. Lack of coordination resulted in a disjointed structure of quality control. The creation of the National Health Care Institute in 2014 was an attempt to streamline and coordinate quality measurement and improvement. The institute has formal enforcement power to resolve deadlocks (Van den Bovenkamp et al., 2013).
Institutional change by conversion means the redirection of existing institutions to new goals, functions, or purposes. For instance, policymakers respond to new environmental challenges by reorganizing established institutional structures. Healthcare reform is an orchestrated attempt to substitute new structures for old ones. Conversion may also result from changes in the power balance: new powerholders seek to convert the power balance to serve their political agenda. Streeck and Thelen emphasize that conflicting interests, political contestation, and the need for political compromise restrict the scope of conversion.
Displacement occurs when previously taken-for-granted practices disappear because of the diffusion of new models. Just as the old typewriter has disappeared, established medical practices are continuously displaced by new practices.
Institutional change by exhaustion occurs when an institutional system sets a process in motion that ultimately leads to its destruction or breakdown. An example is a generous but costly and unsustainable system of benefits. The difference between exhaustion and replacement is that the collapse is gradual rather than abrupt.
This chapter discussed the institutionalist model in health policy analysis. Institutions are broadly agreed rules of the game that give direction to social action. Health systems can be conceptualized as a set of established rules ‘regulating’ medical practice, patient expectations, organizational behavior, health policymaking, and the state-society relationship. Two central propositions of the institutional model are that society cannot endure and prosper without institutions and that institutional changes are gradual rather than radical. Initially, the emphasis in the institutionalist model was primarily on institutional continuity. Presently, institutional change and its underlying mechanism are given a more solid place. Successive gradual changes can fundamentally alter the institutional structure of health systems (gradual transformation). Healthcare reform can be conceptualized as a combination of institutional change and institutional continuity. Institutions set constraints on the pace and scope of reforms. Institutional change can take various forms: drift, layering, conversion, displacement, and exhaustion.
The institutionalist model provides an interesting starting point for studying health policymaking. The model sheds specific light on the basic concepts discussed in the previous chapters. The fundamental idea is that health policymaking cannot be well understood without insight into the institutional structure in which it is embedded. For this reason, health policy analysts should study the impact of this structure on policymaking. Insight into this institutional impact also helps explain the content and outcomes of healthcare reforms. Below is a list of research suggestions in health policy analysis from an institutionalist perspective:
Which institutions influence the problem frame, formulation of the policy goals, and the choice of policy instruments in health policymaking? What is the dominant policy paradigm influencing these policy elements? Which institutional change are reform plans directed at?
Which institutions influence the structure and course of the policymaking process? What is the dominant policy style in each stage of the policymaking process? Do science and research have an ‘institutional place’ in each stage of the policymaking process? What is the institutional impact on the success and failure of policy implementation? Which institutional incompatibilities can be observed, and what is their impact on health policymaking?
Which institutions influence the structure of the health policy arena? Which institutional changes can be observed, for instance, concerning the structure of policy networks and interest representation, the role of the media, and the impact of the judiciary on policymaking? Another research theme concerns the institutionalization of international (global) structures for health policymaking.
What are the formal and informal rules of the game in health system governance? Which institutional changes can be observed? How does a country’s health governance system fit into its overall governance system? Which institutional factors hinder collective action in health policymaking? Does an institutional gap exist between governance structure and system performance?
What is the institutional impact on health system performance? Has health policy reform brought institutional change?
What is the impact of path dependency on health policymaking and health system governance? Does history matter in health policymaking?
Which factors (barriers) explain institutional continuity? Which indications of institutional continuity can be observed?
Which factors explain institutional change? Which indications of institutional change and type(s) of institutional change can be observed?
The institutional model has implications for health policy analysts in their advisory role to policymakers. Their task is to inform policymakers on the impact of institutional factors on policymaking and policy outcomes. Another task is to inform them on the processes of institutional continuity and change in policymaking and the mechanisms explaining these processes. What are the consequences of institutional continuity and change for policymaking, and how can these processes be broken or promoted?
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