the social context of health politics health politics
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The social context of health politics Health Politics. Ana Rico, Associate Professor Department of Health Management and Health Economics [email protected]. O. Introduction The political system and the social systems I. Research question - PowerPoint PPT PresentationTRANSCRIPT
2005
The social context of health politics
Health PoliticsAna Rico, Associate Professor
Department of Health Management and Health Economics
2005
OUTLINE: Theories of the social contextOUTLINE: Theories of the social context
O. Introduction The political system and the social systems
I. Research question Is the social context the main cause of policy? Does politics matter?
II. Main concepts - definitions Context, social structure, power, politics, representation, national culture,
convergence
III. Thesis and arguments The social context directly determines policy We can treat politics as a black box
IV. Aplications – Theories and evidence Structural theory: class and race National culture: Liberal (pro-market), non-Liberal (pro-state) Convergence theory: Pressures and policies
2005
WHAT IS THE SOCIAL CONTEXT?WHAT IS THE SOCIAL CONTEXT?
Context (= pressures external to the health care system)
A subjective concept: variables in the background, which are assumed to be exogenous = independent from politics
NOTE: There is wide agreement nowadays that most causal relationships in political science are endogenous
Depending on the authors, the social context includes:
A. Conjunctural factors: wars, crisis, etc.. B. International pressures: agreements, loans, competitors, multinationals C. Socioeconomic factors: income and social class, technology, demography,
epidemiology D. Cultural factors: values, ideology, expectations
Mechanic, 1996. Comparative health systems
2005
CAUSES OF POLICY CHANGE: Operationalization in WS/HC research
Adapted from Walt and Wilson 1994
Distrib. of formal pol. power: electoral law, constitution, federalism, corporatism Contracts and org. structures Norms of behaviour Sanctions/incentives
CONTEXT
INSTITUTIONS
POLITICS: InteractionsProcess
Individual and collective
• Socioeconomic structure:• Ownership, income• Education, knowledge• Social capital (status, support)
• Sociopolitical structure:• Cleavages and political identities
• Values: Culture and subcultures
-
Access & participation Policy strategies Coalition-building Competition and cooperat. Changing resources Learning
POLICY Entitlements & rights Regulation by law (of power, ownership, financing, behaviour, contracts) Redistribution: Financing & RA Production of goods & services
Conjunctural factors: ec crisis, wars
Interest groups Profesional assocs. Poilitical parties State authorities Citizens: PO/SM Mass media
POLITICAL ACTORSPreferences
ResourcesFormal and informal
2005
a. Demands and supportsb. Access to the political systemc. Decision-making
d. Institutional changee. Social impact of policyf. Distribution of costs and benefits
THE POLITICAL & SOCIAL SYSTEMS
Sociopolitical actors
Institutions
Dynamic interactions
Political actors
Policy change
POLICYPOLITICSPOLITYINPUTS
Outcomes
THE POLITICAL SYSTEM
SOCIALCONTEXT
a
c
de
b
OUTPUTS
Outputs
f
HC services
Implemen-tation
ECONOMY
SOCIETY
CULTURE
2005
OUTLINE (1): Structural theoriesOUTLINE (1): Structural theories
I. Research question Does the relative power of social groups determine policy?
II. Main concepts - definitions Structure, cleavages, social groups, identities and ideological subcultures
III. Thesis and arguments The distribution of ownership (+ other resources) across social groups determines their relative
power to approve policies which favour them When priviledged groups have most resources, pro-rich policies prevail, and inequalities widen
Underpriviledged groups will revolt (if they develop a political identity under capable leadership), in order to impose pro-poor policies
When less ec. inequality + democracy, policy depends on the changing balance of power The distance between the middle class, and the rich/the poor, will determine who they support
politically, and thus which policies will prevail
V. Criticisms (antithesys and sinthesis) Social groups only influence policy via representatives (sociopolitical & political actors) + Powerful social groups can have weak representative organizations
VI. Policy implications Redistribution of resources to less powerful social groups (or their representatives) is required to
avoid conflict and for democracy to work
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POWER RESOURCES:POWER RESOURCES:INFORMAL (social) & FORMAL INFORMAL (social) & FORMAL
(institutional)(institutional)
Adapted from Hughes-Tuohy 2003 and Hicks & Mishra 1993
Institutional resources
Collective action resources
Financial resources
Knowledge-based resources
• Internal cohesion
• Coalition capacity
• External support
• Formal political power
• Formal organizational power• Ownership
• ”Sponsorship”
• Informal, experience-based
• Formal, evidence-based
2005
$
The social context
The political game
HC SYSTEM
Sociopol. context = Policy sub-system
PolicyMACRO: Political actors
MESO: Sociopol. actors
MICRO:Social actors
Citizens’ Associations
Political parties’ members IGs
- Bussiness - Insurance
Profes. + providers’ Assoc.
Patients’ Assoc. Patients’
Advisors and managers
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WHAT IS THE SOCIAL STRUCTURE?WHAT IS THE SOCIAL STRUCTURE?
Social structure, social groups and social power resources
Social structure = Distribution of social power resources (ownership & income, knowledge & information, status & social support) across social groups
Social groups are sets of individuals with shared characteristics (class, etnia, religion, community, gender) around which shared identities and subcultures are formed
Some social groups develop conflicting ideological/political subcultures which tend to form opposition poles (cleavages or axis), usually associated to power resources imbalances
Individuals
Organizations
Social groups
Social structures, political institutions,social policies
Political actors
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CONCEPTSCONCEPTS
Politics: Process through which political actors make, take and enforce collective
decisions which committ all members of a society Power: 2 types
Power for: As capacity to advance goals through intended action = capacity to decide among alternative courses of action
Power over: As control upon. Capacity to obtain obedience (of conditioning others’ actions) even when it goes against self-interest
Democratic representation: Relationship between political actors (representatives) and social groups
(represented/constituency) by which group members delegate their decision rights in exchange for representatives’ committment to defend their interests and
values in the political process
with or without mandate: delegates versus representatives
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CONCEPTSCONCEPTS
NOTE: Democratic politics requires representation
Decision costs
Risk of despotism
Number of decision-makers100
Sartori, 1987
2005
OUTLINE (2): Cultural theoriesOUTLINE (2): Cultural theories
I. Research question Do national culture determine policy?
II. Main concepts - definitions Culture, liberalism/statism
III. Thesis and arguments Policies are only feasible if compatible with historical national cultures National cultures pre-date democracies, and do not change
IV. Aplications – evidence Social expenditure in Anglosaxon countries vs. the rest
V. Criticisms (antithesys and sinthesis) National culture is divided in ideological, conflicting subcultures National culture is the same as public opinion, and is directly influenced by politics (e.g.
Persuasion, manipulation by political and social actors) National culture changes as a result of market/state performance (policy feedbacks)
VI. Policy implications In Anglosaxon countries, only liberal welfare states can exist, in which state intervention is small,
and relies on the market for provision of services
NOTE: Initially, Esping-Andersen theory was a combination of structuralism and culturalism
2005
Neo-liberalism
Conservatism
Socialdemocracy
ITA
AUS
FRA
GER BEL
IREFIN
NOR
SWEDNK
NETH NZ
UKCAN
AUZ
SWI
USA
JAP
1. & 2.: THE WS, Measurement & Types
Based on Hicks & Kenworthy 2003
2005
OUTLINE (3): Convergence theoryOUTLINE (3): Convergence theory
I. Research question Do countries converge towards same policies?
II. Main concepts - definitions Context, globalization, convergence
III. Thesis and arguments As pressures globalize, policies converge
IV. Aplications – evidence Pressures and policies
V. Criticisms (antithesys and sinthesis) Same pressures explain convergence, but not divergence
Health care politics can account for both
VI. Policy implications Convergence theory: An open economy, in the presence of international
competition, guarantees adoption of best practice policies Political theory: Best practice will only be adopted if acceptable to political
actors; compatible with previous institutions; and led by capable governments
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CONVERGENCE THEORY: RQs & CONCEPTSCONVERGENCE THEORY: RQs & CONCEPTS
Convergence Defined as “the tendency of societies to grow more alike”, or as “The movement over time towards some identified common point” Note that:
The essential theoretical emphasys is temporal, not spacial A “process of becoming”, not “a condition of being”
Analytical dimensions of convergence: 1. Convergent pressures/social context 2. Convergent politics (=actors, institutions and process) 3. Convergent policies:
Convergent policy goals Convergent policy content & instruments
4. Convergent outcomes
Industrialization < modernization < globalization
Bennett, 1992. What is policy convergence and what causes it?
2005
CONVERGENCE THEORY: THESIS & ARGUMENTSCONVERGENCE THEORY: THESIS & ARGUMENTS
Convergence led by industrialization & globalization:
Industrialism: “As societies progressively adopt a progressively more industrial infrastructure, certain [automatic] processes are set in motion which tend overtime to shape social structures, political processes and public policies in the same mould”
Globalized context pressures globalized economy convergent social structures, politics, policies and outcomes
Bennett, 1992. What is policy convergence and what causes it?
2005
CONVERGENCE THEORY: THESIS & ARGUMENTSCONVERGENCE THEORY: THESIS & ARGUMENTS
Competition among countries and social darwinism Like in markets, most efficient innovations (best practice) spread
automatically, without direct interaction Competition provides powerful incentives to converge in
expenditure/imitate best practice Degree of adoption across countries depends on level openess of
the economy to the international market
The political system as a black box National politics do not have an impact in policy (as countries adopt
the same policies independently of different national political and health care systems)
Mechanic, 1996. Comparative health systems
2005
(1) PRESSURES A. Financial and macroeconomic pressures
Slowly growing (or rapidly decreasing) GDP + Fiscal pressures to decrease taxes in order to boost exports and attract foreign investors
B. Demographic and epidemiologic transition: Aging, through its effects on morbidity, (costs?) and financing Growing and changing inequalities
C. Technology developments Solid evidence (OECD 2003) main cause of expansion in costs Important differences across countries on rate of investment
D. Increased citizen expectations E. A widening and deepening EU
NOTE: In political science, D & E are treated as endogenous to the political system, rather than exogenous/external factors.
CONVERGENCE THEORY: APLICATIONSCONVERGENCE THEORY: APLICATIONS
2005
Trends in total health expenditure as % of GDP, 1970 - 1999Trends in total health expenditure as % of GDP, 1970 - 1999
0
2
4
6
8
10
12
1970 1975 1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
Per
cen
tage
France
Germany
SpainSweden
United Kingdom
2005
TRENDS IN POPULATION AGED >65 TRENDS IN POPULATION AGED >65 BY EUROPEAN SUBREGIONS, 1970 - 1999BY EUROPEAN SUBREGIONS, 1970 - 1999
Source: WHO Health For All Database 2000
Italy Sweden
EU average
NIS average
7
8
9
10
11
12
13
14
15
16
17
18
1970 1975 1980 1985 1990 1995 2000
% o
f p
opu
lati
on a
ged
65+
Year
CEE average
2005
2005
DIFFERENCE IN SMOKING PREVALENCE AMONG HIGH AND DIFFERENCE IN SMOKING PREVALENCE AMONG HIGH AND LOW STATUS GROUPS, 1995 (+ poor smoke more; - rich more)LOW STATUS GROUPS, 1995 (+ poor smoke more; - rich more)
2005
Source: Moïse, 2003b (OECD).
2005
2005
2005
Source: McKee, 2003
2005
Source: Sadana et al, 2003 (OECD).
2005
(2) POLICIES 1. Cost-containment policies 2. From hierararchy to competition to cooperation
3. Transfer of autonomy to providers (power + risk) 4. Private management instruments 5. Regulated competition and cooperation
6. Expanding the role of patients 7. Transfer of financing responsibility - copayments 8. New rights and powers (eg choice)
9. Integrated care = coordination across levels of care 10. Strengthening of primary and community care 11. Promotion of new public health
12. Evaluation of performance
CONVERGENCE THEORY: APLICATIONSCONVERGENCE THEORY: APLICATIONS
2005
Source: Schoen, 2003 (OECD).
2005
EVIDENCE ON THE CONVERGENCE THESIS Not enough research + evidence in health care (only on expenditure):
Nixon (1999) and Hitris and Nixon on EU concludes YES suggests club convergence.
General conclusion of a 1992 review (covering several policy sectors): “Although there is considerable evidence of policy convergence, which should
convince us that it remains a significant topic for political sciencists, it is by no means a general finding. The literature provides plenty of evidence on divergent responses” (Bennett, 1992)
Conclusions of a 2003 review on social expenditure and welfare policies: “The short term and middle term analysis show an spiralling link between the
trend of social expenditure and economic development, and the existence of cycles... The cycle of social expenditure shows that a part of convergence is not due to any convergence in social policies...[but] The long-term convergent trend of social expenditure and its cycles have not blurred the distinction between the systems during the previous decades” (Bouget, 2003)
CONVERGENCE THEORY: APLICATIONSCONVERGENCE THEORY: APLICATIONS
2005
Source: Bouget, 2003 (OECD).
2005
General criticisms from political science: “This [covergence] logic can easily collapse into an argument for
economic or technological determinism” (Bennett, 1992) “Dominant groups in control of policy-making are able to impose an
interpretation of context... which is not politically neutral”
Pressures interact differently with diverse national institutions E.g. Aging (pressure) has very different impact on expenditure in a
country with developed community care and health promotion; and with less investment in technology (eg Scandinavia vs. The US)
The same policy ideas are applied through very different policy instruments
E.g. Role of patients in financing US, Norway & Denmark (Mossialos et al, 2003)
CONVERGENCE THEORY: V. CRITICISMS CONVERGENCE THEORY: V. CRITICISMS
2005
IN SUM: There are nationally specific interactions between (shared)
pressures and particular actor and institutional configurations There are some signs of converge but more of divergence Politics matters and can explain both convergence and divergence
CONVERGENCE THEORY: SINTHESYSCONVERGENCE THEORY: SINTHESYS
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CONVERGENCE THEORY: VI. POLICY IMPLICATIONSCONVERGENCE THEORY: VI. POLICY IMPLICATIONS
Three positions on the dynamics of policy adoption across countries...
Two of them represent extremes: All countries converge to a single model of best practice (ECONOMICS) Each country develops its own policy models based on a trial and error
process and on historical experiences, as policy problems differ across countries, and feasible policy solutions depend on nationally specific context, actors and institutions (INSTITUTIONALISM)
And the third, an intermediate position...: Club convergence: there is a limited trend to convergence across
nations with similar actor and institutional configurations which face similar context pressures (COMPARATIVE POLITICS)