KEY POINTS:

• Governance is defined as the system of rules (governance rules) for the pro­duct­ion of public policy.

• A governance gap indicates a mismatch between the existing and required govern­ance structure and decreases the problem-solving capacity of health systems. 

• The effectiveness and legitimacy of governance concern the extent to which governance rules contribute to the effectiveness and legitimacy of policymaking respectively.

• Governance rules can be divided into authorization rules, participation rules, decisi­on rules, coordination rules, compliance rules, financing rules, trans­parency rules, accountability rules, integrity rules, and legal protection rules.

• Based upon the modus of decision-making and compliance, a distinction can be made between the anarchic model, the hierarchical model, the majority-voting model, the net­work model, and the market model of governance. Each governance model has its strengths and weaknesses concerning the effectiveness and legitimacy of health policymaking.

• Based upon the locus of decision-making, a distinction can be made between the state governance model, the self-governance model, the state-local model, the state-agency model, and the corporatist model. Each governance model has strengths and weaknesses concerning the effectiveness and legitimacy of health policymaking.

• Motives for centralization fall into two main categories: enhancement of the effectiveness and legitimacy of governance. The same motives are put for­ward to argue for the decentralization of governance.

• The restructuring of health governance is a priority in health system reforms.

• Global governance is an attempt to navigate between the impossibility of a world government and the failure of anarchy.

• The International Health Regulations and the WHO Framework Convention on Tobacco Control are examples of global governance. 

6.1 Introduction

The problems described in box 6.1 are governance problems. These problems concern the organization of the policymaking process rather than the content of policymaking. The lack of an adequate crisis structure to manage an enduring public health crisis, the absence of effective steering capacity, the crowded health policy arena, the prominent role of informal and parallel structures for consultation, decision-making and coordi­nation, and the absence of an appropriate legal basis for far-reaching policy measures are each a manifestation of a deficient organization of the policymaking process. In the absence of an adequate governance structure and information on the spread and infection rate of the virus, a great deal of policymaking rested upon improvisation. The formal crisis structure was not equipped for an enduring and deep crisis affecting society. Crisis contingency plans appeared no more than ‘phantasy documents’ (Boin et al., 2021).

This chapter offers an introduction to the governance dimension of health policymaking. The focus is not on the content of policymaking (formulation of policy goals, choice of policy instruments, and so on) but upon the organization of the policy­making process, the interaction between policy actors, and the written and unwritten rules that structure interaction. A related theme concerns the impact of governance on the problem-solving capacity (system performance) of health systems.

The chapter starts with a discussion of the concepts of governance, governance gap, and the impact of governance on the problem-solving capacity of health systems. Hereafter follows an overview of basic governance rules. The next two sections describe alternative governance models based upon the modus of decision-making and complian­ce and the locus of decision-making respectively. A discussion of multi-level governance models and the centralization and decentralization of health system governance follows this overview. The final part of the chapter discusses the problem of global govern­ance. 

6.2 What is governance?

The term ‘governance’ is nowadays frequently used in theoretical and practice-oriented discussions about the (lack of) steering of society (Kjaer, 2004). The broad interest in the concept mirrors an intellectual development that can be summarized as an attempt to move away from the traditional state-centric approach to the steering of society. Though the prominent role of the state in public health remains undisputed, health policy­making cannot be reduced to a state-centric activity only. Such a view ignores the pressure from the outside upon state health policymaking as well as the state’s dependence upon the market and civil society in achieving its objectives. Health policymaking does not work without the input and cooperation of non-state actors: it asks for collective action.

A second reason for the increased interest in governance (Greer et al., 2016; Kjaer, 2004; Bevir, 2013) is that governance influences the effectiveness and legitimacy of health policymaking. Many policy failures find their main cause in a deficient governance structure. Hence, it is no coincidence that a great deal of health system reforms is directed at the structure of governance. The purpose is to strengthen the problem-solving capacity of a country’s health system by redesigning its governance structure.

Sometimes, the interest in governance has a clear political background. For instance, the popularity of decentralization in Central European countries after the fall of the Berlin Wall was closely associated with the desire to move away from the state-directed type of governance characteristic of the old political system (Sitek, 2010). Intellectual modes in governance may also play a role. An example is the emergence of market governance in Belgium, the Czech Republic, Germany, the Netherlands, Slovakia and Switzerland (Van Ginneken, 2016). The interest in market solutions reflected the influence of the neo-liberal wave in public policymaking. In short, the structure of governance influences the problem-solving capacity of health systems (governance as the independent variable), but it is, for its part, influenced by political and intellectual developments (governance as the dependent variable). 

Alternative definitions of governance

The World Bank (2000) represents a traditional state-centric approach to governance. The Bank defines governance as ‘the institutional capacity of public organizations to provide the public and other goods demanded by a country’s citizens or their representatives in an effective, transparent, impartial, an accountable manner, subject to resource constraints’ (p. 48). The attention of the World Bank is particularly directed at measuring the quality of a country’s governance system. Its operationalization of governance captures three dimensions: (1) the process by which governments are selected, monitored and replaced; (2) the capacity of government to effectively formulate and implement policies; (3) respect of citizens and the state for institutions that govern economic and social relations (Kaufman, 1999).

The state-centric approach to governance is also manifest in the definition of Pierre and Peters (2000), who define governance as ‘the capacity of the government to make and implement policy, in other words, to steer society’ (p. 12). Bartolini (2011), on the other hand, represents the modern approach to governance. He loosely describes the concept as ‘a system of co-production of norms and goods where the co-producers are different kinds of actors’ (p.8). Following this ‘framework concept’ of governance, he identifies five dimensions of governance: the identity of the co-producers, the level of involvement in co-production, the ways of achieving co-production, the institutional context of co-production, and the modes of implementation. His conceptualization of governance mirrors the view of governance as collective action with the state as an important but not the only relevant actor.

The definition of Greer and his colleagues (2016) has much in common with Bartolini’s definition. They describe governance as ‘the systematic, patterned way in which decisions are made and implemented. Governance shapes the capacity of health systems to cope with everyday challenges as well as new policies and problems’ (p.4).

Rhodes (1997) takes a somewhat different view on governance by stating that ‘governance refers to self-organizing, interorganizational networks characterized by interdependence, resource exchange, rules of the game, and significant autonomy from the state’ (p.15). In this definition, governance occurs in policy networks in which the state no longer plays a central role as in the state-centric approach.

Bartolini’s and Rhodes’ approach to governance highlights that government is not the same as governance and that governance does not necessarily involve government action (governance without government). The state-centric approach fails to comprehend health policymaking as collective action in a multi-actor and multi-level setting. 

Definition of governance 

This book draws upon the modern approach to governance. Governance is defined as the system of rules (governance rules) for the production of public policy. Governance rules regulate the relations and interactions between actors in the policymaking process. They regulate, for instance, the organization of the decision-making and policy implementation or access to the inner circle of policymaking. Other examples are the regulation of horizontal and vertical coordination in health policymaking or the regulation of the account­ability and transparency of health policymaking. Governance rules are a prerequisite for collective action. Our approach to governance leaves the role of the state in health policymaking open.

Governance has a structural and processual dimension. The structural dimension refers to the system of rules, and the processual dimension to the practicing of these rules. A distinction can be made between formal and informal rules. Codes of conduct are an example of informal rules. For instance, while formal rules allow for hierarchical decision-making, the code of conduct may ‘prescribe’ that policymakers should opt for consultation and negotiation. Policy conflicts should prefer­ably not be settled formally by top-down decrees but by means of a compromise that is acceptable to all policy actors. This practice constitutes the heart of the practice of ‘polderen’ (Visser & Hemerijck, 1999). Informal rules may also fill structural holes in the formal governance structure. The management of COVID-19 in the Netherlands is emblematic of this practice. In no time, new informal governance structures were set up to handle the scarcity of personal protection equipment and organize the spread of patients across hospitals. These examples demon­strate that the study of governance should not be confined to the formal governance structure but should include an analysis of the informal governance rules. In many situations, the practical structure of governance differs markedly from its formal structure. 

6.3 Governance gap

In its evaluation of how the Dutch government has managed the first stage of COVID-19, the Dutch Safety Board pointed to a mismatch between the existing governance structure and the complexity of a deep and enduring public health crisis surrounded by multiple uncertainties. The Board concluded that its fragmented structure had hindered a rapid and adequate response. A great deal of policymaking took place in informal and parallel structures. The government issued emergency ordinances as the legal basis for its interventions, but these ordinances had only been intended for emergencies of short duration. They provided no appropriate legal basis for radical policy measures such as lockdowns and curfews. In essence, the Board observed a gap or mismatch between the existing and required governance structure. This diagnosis was reason to recommend more space for central orchestration to be better prepared to manage an enduring public health crisis.

Sometimes, governance rules are largely or completely absent. One may speak of a governance gap. Hajer (2003) describes this situation as an ‘institutio­nal void’. For instance, providers seek coordination but miss an adequate governance structure for coordination. A compartment­alized governance structure appears to be a formidable obstacle in policymaking on transboundary issues. An effective and broadly accepted governance system for global action is largely illusory (see section 6.10). According to Weiss (2013), the only feasible route to resolve the governance gap in global governance is to negotiate a network governance model. However, negotiating governance rules costs a lot of time and agreement on effective sanction mechanisms to enforce compliance is challenging. 

The problem of collective action 

The protection and promotion of public health require collective action: actors must coordinate their actions to achieve a common goal. However, collective acti­on is difficult to achieve without a central authority that can impose binding rules and sanction the violation of these rules. In this situation, coordination is only possible if actors voluntarily agree on coordinating their actions. Several factors explain why voluntary coordination may fail (Olson, 1965).

The first factor is the absence of strong incentives to coordinate activities. Actors give priority to their private interests or play the role of free-rider by benefiting from coordination but not participating in it. Lack of information is a second factor. If actors are not informed about each other’s behavior or do not trust each other, they may prefer to abstain from collective action, even though they endorse the need for it. They do not want to be exploited by other actors. The third factor is political. Disputes about the distribution of the costs and benefits of collective action hinder collective action. Another problem is that collective action involves the transfer of some sovereignty. Loss of sovereignty for a common purpose is always a delicate political issue, even more so in a polarizing world with geopolitical rivalries (Cadman, 2013). The World Health Organization must operate cautiously to avoid a collision with powerful nation-states (chapter 5). As said earlier, populists distrust international coordination by the World Health Organization, the European Union and other international organizations arguing that they only serve the interests of the global elite and hollow out national sovereignty (Wilson et al., 2020).

The magnitude of the problem of collective action varies. Collective action is, ceteris paribus, easier to organize if the number of actors involved is small. A small number makes it easier to agree on a joint approach and more difficult for actors to adopt the role of free-rider. Free-riders run the risk of severe punishment if they shirk out of coordination. Costa-Font speculates that collective action at the global level is more likely in preventive care than in curative medicine. Given increased disease mobility, nations have a common interest in the eradication of communicable diseases, particularly if these diseases are life-threatening. In this situation, public health has the structure of a public good. Collective action to ensure people across the world access to curative medicine is much more difficult to organize because rich nations will be inclined to give priority to their own citizens (Costa-Font et al., 2022). This is a painful observation in the context of the growing incidence of non-communicable diseases such as cancer, cardiovascular diseases, and diabetes in low- and middle-income countries. 

6.4 Governance and problem-solving capacity

Governance rules have consequences for the problem-solving capacity of health systems. A simple example is the risk of policy paralysis inherent to the unanimity rule in decision-making. If each actor has veto power, policy deadlocks are imminent. The solution to this problem requires a revision of the decision-making rules, for instance, by the introduction of (qualified) majority voting. Lack of transparency, absence of a decision-making structure well-geared to the multidimensional or transboundary structure of public problems and lack of enforcement power are other factors undermining the problem-solving capacity of health systems.

The problem-solving capacity of governance has two dimensions: effectiveness and legitimacy. Effectiveness refers to the extent to which governance rules contribute to effective policymaking and legitimacy to the extent to which these rules contribute to policymaking that is accepted as legitimate. Sometimes, effectiveness and legitimacy are at odds which each other. This situation occurred in the Dutch response to COVID-19. The effectiveness of state intervention urged a quick and radical response for which, in the view of legal experts, no appropriate legal basis existed. Following this reasoning, the legitimacy of the policy interventions taken was questioned. The enactment of new legislation (the Temporary Act on COVID-19) had to solve this problem. Another example to illustrate the tension between effectiveness and legitimacy is transparency. Trans­­parency contributes to the legitimacy of health policymaking but may undermine its effectiveness. Negotiating a delicate compromise in all openness does not work. 

6.5 Classification of governance rules

Health policymaking is, as pointed out in the preceding chapters, a collective activity of state and non-state policy actors. Policymaking requires broadly accepted rules for interaction in the health policy arena. Governance rules influence the problem-solving capacity of health systems. Good governance can be conceptualized as governance that contributes to the effectiveness and legitimacy of policymaking.

A distinction is made between the following types of rules: authorization rules, participation rules, decision rules, compliance rules, coordination rules, financing rules, transparency rules, accountability rules, integrity rules, and legal protection rules. This list of rules is an extended version of the TAPIC framework which stands for Transparency, Accountability, Participation, Integrity and Policy Capacity (Greer et al., 2016).

Authorization rules

Authorization rules regulate whether a policy actor has formal (or informal) com­petence to take binding decisions. The rule of law holds that the state (or another policy actor) must be authorized to take action. Lack of or unclear authorization rules puts the problem-solving capacity of health systems in two ways at risk. First, necessary policy decisions cannot be taken or are contested because they miss a proper legal basis. Second, lack of or ambiguous authorization rules hollow out the legitimacy of policymaking. Authorization rules are essential to good governance and protect citizens against state arbitrariness.

Participation rules

Participation rules regulate access to the health policy arena. Inclusive participation rules allow for broad participation, free speech, and free media, while exclusive rules restrict access. Participation rules also regulate the kind of participation ranging from the right to be heard to more active forms like participation in decision-making processes or policy implementation.

Decision rules 

Decision rules regulate the organization of the decision-making process. Examples are hierarchical decision-making, delegated decision-making, and decision-making by (qualified) majority voting. Decision-making in policy networks predominantly rests upon informal rules for consultation, persuasion, or negotiations. The absence of decision rules and unclear decision rules are a risk to the effectiveness and legitimacy of policy­making. The unanimity rule can paralyze policymaking, and decision rules that restrict democratic control undermine the legitimacy of policymaking. 

Compliance rules

Compliance rules regulate the binding of policy decisions. These rules determine, in combination with authorization and decision rules, the enforcement power of policymakers. Compliance rules are a critical element of each governance system.

Coordination rules

Health policymaking requires horizontal and vertical coordination of decision-making in a multi-actor and multi-level setting. The purpose of coordination rules is to achieve that activities are properly geared to each other. Inconsistent or overlapping coordination rules are a risk for good governance. 

Financing rules

Financing rules regulate the taxing capability of actors. Lack of fiscal space makes regional or local governments dependent on financial grants from the national (federal) government and restricts their decision space. 

Accountability rules

Good governance requires policy actors to know for which part of policymaking they carry accountability. Accountability rules are essential for understanding what has gone wrong and which policy lessons should be learned. They must prevent that responsible policymakers shirk out of their accountability. A frequent problem with accountability rules is confusion on who is accountable for what to whom, and how. If everybody is accountable, nobody is accountable.

Transparency rules

Good governance involves a transparent policymaking process. Democratic control of health policymaking is impossible without rules guaranteeing openness and access to information. Transparency rules regulate, among others, the right to public information, freedom of information, and independent research institutions. They are indispensable for investigating behind-the-scene decision-making, malfeasance, and other dubious practices. 

Integrity rules

Integrity rules regulate ethical conduct in policymaking. Good governance means that policy actors respect each other, act trustfully in social interaction, and abstain from misleading action, corruption, or any other form of unethical behavior. 

Legal protection rules

This category of rules constitutes a central element of the state of law. Citizens and organizations must be able to protect themselves against policy decisions they consider for whatever reason wrong. An independent agency must be in charge of judging the legal basis of policy decisions. 

6.6 Governance models: modus of decision-making and compliance

Most governance systems have a complex structure. The devil is always in the detail. Besides, the practice of governance often markedly differs from its formal structure. Governance systems also change over time. They are not cast in concrete. How do policy analysts escape the risk to get lost in the labyrinth of detailed regulations? An effective strategy is to use a typology of governance models to unravel their complexity. Each model describes the basic characteristics of a specific governance system and abstracts from its details. No model exists in pure form. All governance systems have a hybrid structure.

This section and the following section present two typologies of governance systems. The first typology rests on the modus of decision-making and compliance. The second typology takes the locus of decision-making as point of departure. This section discusses governance systems from the perspective of the modus of decision-making and compliance. The second typology will be presented in section 6.7.

A central characteristic of each governance system is the organization of collective action. How is decision-making organized, and which instruments are in place to effectuate compliance with the decisions made? In response to these questions, the following typology can be constructed (table 6.1).

Table 6.1 Typology of governance models according to modus of decision-making and compliance

Anarchic governance model

At first sight, it seems strange to conceive anarchy as a governance model, because the term anarchy suggests a ‘non-structure’. There is no governance center and the actions of actors are driven by self-interest, opportunism, and their estimation of the balance of power. The model does not exclude the possibility that actors agree on common rules of the game to create minimum order (collective interest). However, these rules are easily broken if they no longer serve an actor’s self-interest.

It speaks for itself that the anarchic governance model scores low on problem-solving capacity. Problems requiring collective action remain unaddressed and negotiated agreements on collective action are easily broken. Effective sanction rules are absent. On the other hand, the model can enhance the effectiveness and legitimacy of governance if problem-solving requires creativity and innovation. Central direction and bureau­cratization run the risk of destroying creativity and innovative power. The principle of ‘the wisdom of the crowd’ rests upon this idea (Suro­wiecki, 2004).

From an empirical viewpoint, the anarchic governance model seems to have little relevance for health policymaking. Actors complain more about an oversupply than a shortage of governance rules. Anarchy-like situations, however, are not uncommon. Reports on lack of direction, non-cooperation, self-interest, or unresolved disputes about problem ownership, accountability, and authorization, to mention a few examples, may be interpreted as signals of anarchy. What in theory looks like a well-crafted governance system functions in practice as a chaotic and unworkable system.

Hierarchical governance model

Decision-making in the hierarchical governance model has a top-down structure with a center that is authorized to make decisions. The model is associated with decisiveness, effectiveness, and leadership. It allows, at least in theory, for rapid and binding decision-making. Hierar­chical governance reduces the transaction costs of decision-making because the policy center has the formal power to cut the knot and give binding instructions. The hierarchical governance model is also referred to as the command-and-control model.

The practical meaning of the model is limited. State bureaucracies function in practice much less top-down than the formal governance structure suggests. In many situations, hierarchical decisions are pre-digested at lower hierarchical levels and may be little more than negotiated agreements with powerful interest organizations. Health policymaking is mostly not a matter of unilateral top-down action but a matter of co-production in the context of mutual dependency. From this perspective, it is hardly surprising that top-level policymakers often complain about the lack of enforcement power and argue for more hierarchy. The sigh of the Dutch prime minister about the government’s lack of decision and enforcement power during COVID-19 is emblematic of this complaint (Box 6.1).

There are also other reasons for not overstating the problem-solving capacity of hierarchical governance. Persuasion and soft speak may work better than command and control. Information problems restrict the effectiveness of policymaking because policymakers at the apex of the hierarchy are unable to collect and process all necessary information. Besides, there is always a risk of being misinformed. In short, the picture that the state can dictate health policymaking is usually a caricature of what really happens in practice.

The legitimacy of hierarchical governance is not without problems too. The model contrasts with a culture of participation, consultation, and shared responsibility. Hierarchical governance can even be unfeasible because of constitutional restrictions or deeply rooted political objections against transferring decision power (sovereignty) to a hierarchical center. This problem is not only manifest in countries with a federal governance structure (e.g. Germany and the United States) but also a formidable obstacle in policymaking on global problems such as global warming or pandemics. A ‘world government’ does not exist and will (probably) never exist. 

Majority-voting governance model

The majority-voting governance model is an essential element of democratic governance. Decisions are taken by the members of a community or their representatives in a decision-making body (e.g. parliament). Decision-making is binding. Decision rules require a simple or qualified majority and can entail specific requirements to avert premature decision-making, for instance, concerning decision-making on constitutional issues.

Governance by majority voting can increase both the effectiveness and legitimacy of policymaking. Majority voting is an instrument to reduce transaction costs by ending policy deadlocks (the majority decides). It also contributes to the legitimacy of policymaking by giving the members of a community or their representatives a voice in the decision-making process.

The problem-solving capacity of the model has some limits. Building a majority can be time-consuming and result in policy incrementalism if a majority for radical policy decisions is beyond political reach. The need for political compromises may degenerate into muddling through and policy inertia. This problem worsens in a polarized political context where opponents seize every opportunity to delay or thwart legislation. The problem-solving capacity can also be limited if decision rules require a majority in two distinct democratic bodies with different political majorities. The legitimacy of majority voting is at risk if the majority can push through decisions without seriously taking the preferences of the minority into account or if the representativeness of the decision-making body is under attack. The latter critique is, as spelled out earlier, popular among populists who argue that the needs of ordinary people in society are not given priority and are made subordinate to the priorities of what they call the ‘ruling elite’ (Muller, 2016). 

Network governance model

In this model, collective action is organized in policy networks. Decision-making takes place through consultation and negotiation in a multi-actor setting. Hierarchical decision-making and decision-making by majority voting do not (well) fit in network governance. Compliance usually rests on agreements and moral commitment rather than on formal obligations.

The network governance model is viewed as the best option for resolving complex policy problems (Mayntz, 2016). Hierarchical governance and governance by majority voting are unfit for this task. Network governance enables policymakers to bridge the gap between the formal governance structure and the complexity of multidimensional and transboundary public problems. Policy networks create a platform for policymakers, interest organizations, and experts to discuss policy issues, settle conflicts, connect policy sectors, and work out (technical) solutions for policy problems. They are a vehicle for collective decision-making, shared responsibility, and the organization of public-private partnerships (Provan & Kenis, 2007). Network governance is considered the only realistic model for resolving global problems. Given the impossibility of a ‘world state’ on the one hand and the pressing need for global action on the other hand, network governance serves as a ‘half-way house between anarchy and hierarchical direction’ (Weiss, 2013).

However, network governance is not without weaknesses. Agreement on common rules for policymaking may require time-consuming negotiations. There is always a risk that these negotiations get stuck in disputes on authority, decision procedures, distribution of power, sanctions, or other sensitive issues. Though network members realize the need for collective action, they may nevertheless find it difficult to give up some of their independence and authority. Opportunism and distrust may flourish. Another weakness concerns the coordination of policymaking between networks. Network governance involves the risk of adhocracy. Decision-making may be biased toward the interests of powerful network participants. Besides, network governance can hinder democratic control. A potential risk of public-private partnerships in network governance is that commercial interests constrain the room for public action.

Provan and Kenis (2007) mention four critical factors for effective network governance. First, network participants must trust each other and be willing to engage in collaborative relationships. Second, the effectiveness of networks is affected by the number of participants. A large number of participants is in principle a risk for effective governance. Third, there must be a sufficient degree of goal consensus within the network. Participants must agree on the urgency and goals of collective action. The fourth condition is that the necessary competencies for effective coordination are present in the network. 

Market governance model

The market governance model is closely associated with the neo-liberal wave in public policymaking. The model finds its intellectual basis in neo-classical economic theory which postulates that market transactions yield maximum welfare. Collective action should be organized by voluntary contracts that are binding. Collective action is achieved by ‘the invisible hand of the market’. There are several versions of market governance: privatization of public organizations, outsourcing public tasks, contracting, pricing externalities, public tenders, and regulated competition. Its advocates promote the model as the alternative to hierarchical (state-directed) governance which they associate with inefficiency, bureaucracy, lack of innovation, and lack of freedom of choice. Market governance encourages entrepreneurialism and fosters efficiency and innovative power. Citizens are viewed as active consumers who should have freedom of choice to enforce providers, insurers, and other purchasing agents to optimal performance in terms of quality and costs. Clarke and Newman (1997) describe the switch from hierarchical governance to market governance as the transition from the ‘bureaucratic state’ model to the ‘managerial state’ model.

The advocates of market governance recognize that the problem-solving capacity model only works under certain preconditions, including freedom of choice, complete information, consumer protection, many suppliers and demanders, free entry and exit, and the absence of external effects. These preconditions assume a decision-making center (the managerial state!) capable of issuing strict regulations. In other words, the market governance model is, strictly speaking, a hybrid model. A political issue is the scope of regulation: should regulation be kept to a minimum or include regulations to protect public values like universal access to health care, quality of care, and fiscal sustainability (Enthoven, 1993)?

The effectiveness and legitimacy of market governance are much disputed. Critics put forward that the model only works in some areas of public health and will eventually hollow out public health values. Public health and health care, they argue, are no market commodity.

6.7 Governance models: locus of decision-making

An alternative approach to constructing a typology takes the locus of decision-making as the analytical point of departure. Where does decision-making take place? This section gives a concise description of the state-governance and self-governance model. Multi-level models are discussed in the next section.

State-governance model

The state-governance model accords the state a central role in health policymaking. The central role of the state rests upon two main grounds. First, state governance is considered a precondition for effectiveness because of its power to enact and enforce legislation and mobilize the necessary resources. State governance also contributes to the economies of scale and scope. Second, state governance is a precon­dition for legitimacy. Moral principles such as universal access, respect for the integrity of the body, autonomy, and equal treatment require legislation subjected to democratic control. In sum, state governance is a precondition for good governance.

However, the model has some weaknesses. Two reasons for not overstating its problem-solving capacity are that the state’s decision and enforcement power is often less strong than formal decision and enforcement rules suggest and that the concentration of power into the hands of the state as single policy actor can put the effectiveness and legitimacy of policymaking at risk. Accommodation of policymaking to local circumstances by decentralization of decision power enables local communities to accommodate national policies to local conditions and exercise democratic control upon policy decisions that affect their everyday life. 

Self-governance model

The self-governance model, also called the self-regulation model, is the opposite of the state-governance model. Its basic characteristic is not top-down but bottom-up policymaking without (much) state involvement. The model has a long tradition in health care. The prominent role of mutual aid organizations in the nineteenth century and the first half of the twentieth century in providing and financing health care rested upon the principle of self-governance. These organizations claimed a sovereign position in the financing and provision of social and health services for their constituency. Self-regulation is also common in the professional medical community. Most medical guidelines and quality standards result from self-governance (Freidson, 2001). Aside, self-regulation is defended on communitarian grounds. The community is better suited to resolve public health problems than the state. The state should only intervene if the community cannot take care of its members.

There are several motives for self-governance. The first motive is ideological and arises from the principle of subsidiarity. The organization of society should be the result of ‘internal’ action instead of ‘external’ state action. This was the principal argument of the civil society sector to protect its independent position in the provision and financing of health care. The second motive pertains to expertise. Regulation should be left to professional organizations because of their acknowledged expertise. The third motive is defensive. Interest organizations frequently opt for self-governance to avert state regulation.

Soft regulation and compliance are known as the Achilles heel of self-governance. Compliance may only rest upon moral commitment. Formal sanctions to punish non-compliance are lacking or ineffective. This does not mean, however, that there are no informal instru­ments to foster compliance. Examples are loss of reputation, public exclusion, monitoring, and naming and shaming.

6.8 Multi-level governance models 

Multi-level governance models assume that good governance requires the division of decision power over several decision levels. The concentration of all decision power at a single level is rejected for two main reasons. The first reason is effectiveness. Policy problems should be addressed at the most immediate level that is consistent with their resolution. This line of reasoning is known as the principle of subsidiarity. The upper division level in governance should be concerned with problems requiring central direction, while the lower decision level should take the lead in resolving problems that can best be addressed at that level. Subsidiarity is obviously an abstract principle that is open to multiple interpretations and different choices regarding the division of decision power. Unsurprisingly, it is also an object of political dispute. The second reason for multi-level governance is legitimacy. The concentration of decision power at the national or federal level is a risk for democracy. Multi-level governance enables people and organizations at lower levels to set their own priorities in policymaking.

Multi-level governance is a common model in public health. In many countries, power and responsibility are distributed among state actors at the central, regional, and local level. Box 6.2 presents some international examples. 

State-local government model

This model accords a distinct role to local (or regional) government alongside the state in health governance. Local government is assumed to be better informed about the local situation and better equipped to accommodate national policies to local circumstances. Moreover, local government can best develop and implement an intersectoral approach at the local level given its policy tasks in housing, public transport, schools, welfare, physical infrastructure, public security, and so on. The involvement of local government also draws upon the assumption of strengthening democracy (Box 6.3). A risk inherent to the state-local model is the failure of vertical coordination. 

State-agency model

In the state-agency or agentification model, regulation and oversight are put in the hands of (public) agencies at arm’s length of the state. These agencies are referred to as (quasi-) independent regulatory agencies. Examples are the Dutch Health­care Authority, the Care Quality Institute (CQI) and the National Institute for Health and Care Excellence (NICE) in the United Kingdom Box 6.4), and the Food and Drug Administration (FDA) in the United States. Agencies carry out their policy tasks within a regulatory framework set out by the state. The relationship between agency and state varies. Board members are either appointed as independent members or as representatives of a specific category of stakeholders (a combination is also possible). 

The leading motive for governance by regulatory agencies is depoliticization and effectiveness. Regulation and oversight must be based on expertise and objectivity and be insulated from political influence as much as possible (Majone, 1999). A drawback of the model is the risk of a democratic deficit because regulation and oversight are only indirectly subject to political control. Two other risks are the reduction of the government’s decision power and a rising distance between state policymaking and policy implementation. Problems may also arise if a regulatory agency is dependent upon the financial contributions of organizations they control. For instance, The Food and Drug Administration in the United States is authorized to collect user fees from pharmaceutical companies to assess the effectiveness and safety of their medicines. According to critics, this funding model may compromise the assessment procedure. In their view, the FDA must be entirely funded by taxpayers-as-consumers: ‘The FDA should entirely be clear about whom it serves’ (Light et al., 2003: p. 9). 

Neo-corporatist governance model 

In the neo-corporatist model (alternative names are association model or private governance model), the state accords a privileged place in health policymaking to leading non-state organizations representing the interests of major stakeholders (associations). These organizations share ‘in the state’s authority to make and enforce binding decisions’ on policy (Streeck & Schmitter, 1985: p. 131). The model explicitly rests upon the concept of shared responsibility for health policymaking.

A minimum version of the neo-corporatist model is regular consultation of privileged interest organizations (e.g. the interest organization of health professionals, hospitals, and health insurers) in the policy development and formation stage. The purpose of consultation is to collect information, allow interest organizations to express their policy preferences, and build support for policy initiatives. Participation rules can formally prescribe the consultation of interest organizations.

Neo-corporatist governance can go beyond consultation and involve collective bargaining with privileged interest organizations. This version explicitly draws upon the notion of shared responsibility. To achieve its policy goals, the state must seek cooperation with these interest organizations. The corporatist governance model offers them the opportunity to influence health policymaking. On its part, the government prefers a common approach to hierarchical decision-making for effectiveness and legitimacy.

In the more radical version of neo-corporatist governance, the state delegates a sizeable responsibility for health policymaking to privileged interest organizations. Health policy­making is organized as a two-stage and multi-level process. In the first stage, the national (federal) government sets out a general framework for policymaking. In the second stage, privileged organizations work out this framework in concrete regulations and are charged with policy implementation. A great deal of health policymaking in Germany rests upon this version of neo-corporatist governance (Box 6.5).

The strength of the neo-corporatist governance model lies in the principle of shared responsibility. The model builds upon consensus and cooperation rather than antagonism. However, the model has some weaknesses. A serious risk is that shared responsibility results in policy incrementalism and, consequently, undermines the effectiveness of policymaking. The privileged position of stakeholders also involves the risk of private interest government and the risk of undermining democratic control. 

6.9 Centralization and decentralization

So far, governance has been discussed as a set of procedural rules for policymaking. Our leading questions were: how do these rules look, and how do they affect the problem-solving capacity of health systems? An alternative way is to study governance as a target of reform. How should the governance of health systems be organized to enhance their problem-solving capacity? Redesigning the governance structure is a priority in many health system reforms.

Two approaches to governance reform are centralization and decentralization. Centralization involves an upward transfer of decision and enforcement power. Decentralization is a downward transfer of decision and enforcement power (Saltman & Bankauskaite, 2006). A distinction can be made between geographical and functional (de)centralization. Geographical (de)­centralization involves the transfer of decision power from the national to local (or regional) authorities, and functional (de)centra­lization the transfer of decision power to specialized bodies.

The scope of decentralization varies from restricted to broad. In the restricted version, the decision space of local or regional actors is restricted to mainly administrative tasks. The legislative framework leaves these actors little discretionary space. The alternative model is to offer local or regional policymakers considerable leeway in policymaking. In this model, the national government confines its role to setting out a general policy framework for decentralized policymaking. A critical aspect of decentralization is the coupling of policy responsibility and financing. A mismatch between policy responsibility and fiscal space is an important source of problems: either local or regional policymakers do not receive the financial resources necessary to carry out their policy tasks properly or their taxing capacity is restricted as a consequence of which they cannot properly carry out the decentralized policy tasks.

Motives for centralization and decentralization 

Table 6.2 summarizes the main motives for centralization and decentralization. These motives relate to the efficiency and legitimacy of health policymaking. 

Reinforcing the efficiency of governance through concentrating decision power at the central level is a common argument for centralization. The dispersion of decision power across various governance levels is viewed as an important cause of policy fragmentation and lack of political direction. Particularly in times of a deep and enduring crisis such as COVID-19, the need for centralized policymaking is strongly felt. The central government wants to take over the lead in crisis management for reasons of effectiveness, efficiency, and communication. An enduring crisis asks for strong and visible leadership and consistent communication. Framing a public health problem as a crisis is less innocent than it might seem at first view because it can be a deliberate prelude to centralization. A second motive for centralization from the viewpoint of effectiveness and efficiency is the reinforcement of negotiating power. This motive has motivated the member states of the European Union to transfer the negotiations with the pharmaceutical industry on purchasing a vaccine to terminate COVID-19 to the European Union. Furthermore, centralization is used as argument to achieve economies of scale and scope, resolve the problem of vertical coordination and reduce transaction costs in policymaking.

Table 6.2 Motives for centralization and decentralization

Centralization is also advocated from the viewpoint of legitimacy. It has been propagated as an instrument to resolve the problem of unequal access to health services. If local policymakers are left free to make their own choices, one should not be surprised to find great variation in the provision of health services. A senior Swedish planning official phrased the concern on unequal access once as follows: ‘We are one country, and we should have a single health policy’ (Saltman & Bankauskaite, 2006: p. 132). Additionally, centralization is used as a motive for resolving a democratic deficit. Fragmentation of decision power hinders political control. Outsourcing regulatory tasks to regulatory agencies at arm’s length of the government is a risk to democratic control upon regulation. Reassertion of the role of the state should resolve this control problem.

Paradoxically, effectiveness and legitimacy are also mentioned as motives for decentralization. Decentralization is in this line of thought a governance arrangement to enhance the problem-solving capacity of health systems. It enables local or regional policymakers to accommodate policymaking to their local situation. A one-size-fits-all approach does not work or is at best suboptimal. Local or regional policymakers are best informed about the local situation. Besides, their involvement in other policy areas makes it possible to develop an intersectoral approach and exercise political control at the local or regional level. Concentrating all decision and enforcement power in the hands of the state is a risk to democracy and may end in the abuse of power. Division of power is good in itself.

Sometimes, the central government opportunistically uses the effectiveness argument to justify expenditure cuts. If local government is in the best position to accommodate health policy programs to the local situation, it is also in the best position to increase the efficiency of these programs. Because greater efficiency means fewer public resources are required to attain the programs’ policy objectives, expenditure cuts are assumed to have no repercussions for goal attainment. The decentralization of a great deal of health-related social services to local government in the Netherlands as part of the 2015 reform of long-term care rested upon this policy belief (Maarse & Jeurissen, 2016).

Swinging pendulum

The history of health policymaking can be analyzed as a swinging pendulum or a history of successive processes of decentralization and centralization (Saltman et al., 2007). Decentralization was a leading policy concept in countries with a traditionally state-centric governance model. After the fall of the Berlin Wall in 1989, countries in Central and Eastern Europe opted for decentralization as the main strategy to resolve the gross inefficiencies in their Semashko-type of health care system (Marrée & Groenewegen, 1997). Important characteristics of this system were a high degree of centralization and solid political control on the governance of health care. The purpose of the reforms was to enhance the effectiveness and legitimacy of their health system by moving away from the hierarchical and state-directed governance model toward a model with more freedom of choice for payers and provider organizations (Sitek, 2010).

Decentralization was also a leading concept in the reform of the Norwegian healthcare system in the 1970s. The central argument for transferring decision power from the central to the regional level was to bring health policymaking ‘closer to the people’. However, the state retained its broad strategic and regulatory authority and maintained control over hospital financing. Because the formal separation between decision-making and financing did not work well, the government partly reversed the decentralization in 2002. A similar development took place in Denmark where the government, with some exceptions, centralized back fiscal and political responsibilities to the national government in its major reform of health governance in 2006 (Saltman., 2008).

Health governance in the Netherlands is another example of a swinging pendulum between centralization and decentralization. In the nineteenth century, the gravity point in the health governance system was still with local government. Municipalities were held politically responsible for public health. Furthermore, civil society (mutual aid) organizations claimed sovereignty in providing and financing health care. Gradually, however, the structure of governance has fundamentally altered. The publicization of health care has gone hand in hand with a considerable centra­lization of decision power. The structure of governance has become increasingly state-centric. The market reform in Dutch health care in 2006 and the reform of long-term care in 2015 signified a new direction in health governance. The market reform had to increase the decision power of health insurers and hospitals and the reform of long-term care the decision power of municipalities in providing health-related social services. At the same time, however, insurers, hospitals, and municipalities had to bear the financial consequences of their decisions (Jeurissen & Maarse, 2021; Maarse & Jeurissen, 2016). The 2008 Public Health Act confirmed the role of municipalities in public health by charging them with the elaboration of the state’s public health spearheads into local public health plans (box 6.3). How governance will unfold in the future remains uncertain, but dissatisfaction with the restricted role of the state in the market governance model and the limited problem-solving capacity of the health system to manage an enduring public health crisis may induce a new swing in governance toward a reassertion of the role of the state. 

6.10 Global governance and its limits

Health policy is traditionally a nation-bound activity. The basic principle is that each country operates its health system to serve its population. The principle of sovereignty explains the diversity in national health systems and policies. At the same time, however, there is mounting evidence of the need for international coordination in health care. For instance, in border regions, healthcare quality can benefit from prac­tical agreements on cross-border blood transfusion or the transport and hospitalization of patients in emergencies. Agreements on the transfer of patients in emergencies are another example of international coordination. Coordination is the outcome of negotiated agreements between the participants in regional cross-border policy networks.

The need for international coordination is clearly manifest at the global level. The outbreak of COVID-19 in 2020 reminded public authorities of the simple fact that viruses do not respect national borders. The number of studies reporting on the alarming consequences of climate change for public health is rapidly increasing (Balakrishnan, 2018; KNAW, 2023). Countries with a poorly developed health system are unable to cope with trans­boundary health threats their population is exposed to. The unequal distribution of health and disease on a global scale – in the view of many observers potentially a threat to international security (Stoeva, 2016; Cadman, 2013) – cries out for global collective action at the global level.

However, the organization of collective action to protect people from health risks and improve public health is challenging. There is no ‘world government’ that is capable to take effective and binding policy measures. Hierarchical governance is simply an illusion. Given that neither anarchy nor the market can provide effective solutions, the only workable alternative is to organize collective action in international or global policy networks. Weiss (2013) describes global governance in global policy networks as a ‘half-way house between the international anarchy (……) and a world state’ (p. 25). The main problem of global governance is ‘that the evolution of intergovernmental institutions, and the form of collaboration they engage in, lags well behind the emergence of collective problems with trans-border, especially, global dimensions’ (p.2).

Global governance occurs in international policy networks in which states and national and/or international non-state organizations set up structures for international collective action to address global public health problems. Coordination rests upon negotiated agreements between the participants in the network (section 6.3). Reaching an agreement is challenging because ideological considerations, national interests, political pressure, and power relations influence the negotiating process. Geo-political rivalries also frustrate global governance. The only option is to negotiate a compromise (McGinnis et al., 2020). Compliance is also problematic. Commitments are frequently not met. The absence of effective sanctions worsens the problem of non-compliance.

The remaining part of this section describes two initiatives of the World Health Organization to organize global collective action for public health: the International Health Regulations and the WHO Framework Convention on Tobacco Control.

International Health Regulations

The International Health Regulations (IHR) are an international legal instrument under the auspices of the World Health Organization that is formally binding on 196 State Parties across the globe, including all the Member States of WHO. However, the regulations explicitly respect national sovereignty in health matters. To resolve the tension between sovereignty and binding regulations, the regulations rest upon the principle of ‘shared responsibility’. They involve a complex balancing act between sovereignty and formal binding. An effective sanction mechanism is absent (Sridhar, 2022).

The purpose and scope of the IHR are 'to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.' If a State Party has evidence of an unexpected or unusual public health event within its territory, irrespective of its origin or source, which may constitute a public health emergency of international concern (PHEIC), the Party shall hand over to the World Health Organization all relevant information. The Director-General determines, after the advice of an independent Emergency Committee and based on all information available, whether the reported event constitutes a PHEIC following the criteria and the procedure set out in the Regulations. The IHR consist of recommendations, general obligations, and public health measures (www.who. int/ihr).

A contentious aspect of PHEIC is its binary structure: a situation is an emergency or isn’t. There is nothing in between. This complicates the declaration of a PHEIC. While a timely PHEIC is of vital importance for effective risk communication, its declaration may confront countries involved with huge financial damage because of loss of trade and tourism. Another problem is limited information. As a consequence, the decision to declare a PHEIC comprises a complex balancing act between the benefits of a rapid response and political and economic costs in a context of uncertainty.

A second problem is compliance. This problem became manifest in handling the Ebola Crisis in West Africa (Guinea, Liberia, and Sierra Leona) in 2013-2014. A panel of international experts reported serious shortcomings in compliance with the regulations. There had been little signs of shared sovereignty. For instance, some member states had failed to develop certain core public health capacities under the regulations. The panel also found that there had been strong disincentives for countries to report outbreaks quickly and transparently for fear of travel and trade restrictions of other countries. Furthermore, the panel criticized the delay in declaring the outbreak of Ebola a PHEIC. The World Health Organization, the panel concluded, had no culture of rapid decision-making and tended to adopt a reactive rather than a proactive approach to emergencies. Its health emergency response capacity had clearly been substandard during the Ebola crisis (Report of the Ebola Interim Assessment Panel, 2015).

WHO Framework Convention on Tobacco Control

The WHO Framework Convention on Tobacco Control (FCTC) is the first treaty negotiated under the auspices of the World Health Organization. The FCTC is an evidence-based treaty that reaffirms all people's right to the highest health standard. The FCTC represents a paradigm shift in developing a regulatory strategy to address addictive substances. In contrast to previous drug control treaties, the Convention asserts the importance of demand reduction strategies and supply issues. It includes price and tax measures and non-price measures to reduce the demand for tobacco products. By signing the Convention, member states indicate that they will strive in good faith to ratify, accept, or approve it, and show political commitment not to undermine the objectives set out in it (www.who.int/fctc/text).

Once again, compliance is not without problems. There are notable international differences in the scope and pace of policy measures restricting the demand for smoking products. Eastern European countries appear to be poor performers. The Netherlands, too, was in some respects reluctant to carry out the Convention properly. The government held the opinion that the Netherlands strictly complied with the regulations, which was untrue. Clean Air Netherlands (an interest organization) filed a lawsuit against the government for its decision to exempt small cafes from the smoking ban. The Supreme Court ruled that this exemption conflicted with the regulations in the Convention. Contrary to the regulations, the government also failed to exclude the industry from tobacco policymaking, reasoning that the sale of tobacco was a legal activity and that the government needed to stay in contact with the tobacco industry to carry out its policy measures. Although the government won a lawsuit on this violation of the Tobacco Framework Convention filed by the Youth Smoking Prevention Foundation, it nevertheless published a protocol to clarify its implementation of the Con­vention. The protocol stated that government officials had to restrain their contacts with the tobacco industry ‘to prevent the industry from having influence on policy’. Contacts had to be restricted to ‘matters of technical execution’ (Willemsen, 2018: 156-158). 

6.11 Conclusion and suggestions for health policy analysis

The problem-solving capacity of health systems is not only a matter of policymaking but also a matter of governance. Health governance is defined as the system of rules (governance rules) for the production of public policymaking. It forms an essential dimension of their problem-solving capacity. The structure of health governance is often the target of reform to strengthen the problem-solving capacity of health systems.

A central aspect of public health governance is the need for collective action. Actors must coordinate their activities to protect and promote public health. However, there are various reasons why collective action fails. The study of health governance cannot be confined to an investigation of the formal governance rules only. An in-depth understanding of governance requires knowledge of informal governance rules and how formal and informal governance rules are implemented. The practice of governance may differ markedly from its formal structure. A fascinating aspect of governance systems is structural variety. There exists no single system. The structure of a country’s health governance system reflects the structure of its overall governance system and the impact of political influences.

The governance of health policymaking is an important topic of research in health policy analysis. Understanding health policymaking requires knowledge of the formal and informal rules of the game for policymaking and the governance structure in health policymaking. The study of governance gives insight into the problem of collective action in health policymaking and the presence of governance gap(s) influencing the effectiveness and legitimacy of health policymaking. The classification of governance rules and typology of governance models according to modus and locus of decision-making can be used as analytical models for studying governance of health systems and the impact of governance upon their problem-solving capacity. A specific topic of research concerns the structural weaknesses of global governance and the instruments used to overcome these weaknesses.

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