The social context of health politics Health Politics

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The social context of health politicsHealth
Politics

• Ana Rico, Associate Professor
• Department of Health Management and Health
  Economics
• ana.rico_at_medisin.uio.no

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OUTLINE 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

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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
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CAUSES OF POLICY CHANGE Operationalization in
WS/HC research

• Access participation
• Policy strategies
• Coalition-building
• Competition and cooperat.
• Changing resources
• Learning

• Conjunctural factors ec crisis, wars

• Socioeconomic structure
• Ownership, income
• Education, knowledge
• Social capital (status, support)

CONTEXT

• Sociopolitical structure
• Cleavages and political identities

• Values Culture and subcultures

• Interest groups
• Profesional assocs.
• Poilitical parties
• State authorities
• Citizens PO/SM
• Mass media

• Distrib. of formal pol. power electoral law,
  constitution, federalism, corporatism
• Contracts and org. structures
• Norms of behaviour
• Sanctions/incentives

POLITICS InteractionsProcess
Preferences Resources
INSTITUTIONS
POLITICAL ACTORS
Individual and collective
-
Formal and informal

• Entitlements rights
• Regulation by law (of power, ownership,
  financing, behaviour, contracts)
• Redistribution Financing RA
• Production of goods services

POLICY
Adapted from Walt and Wilson 1994
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THE POLITICAL SOCIAL SYSTEMS
SOCIAL CONTEXT

THE POLITICAL SYSTEM
a
Dynamic interactions
Sociopolitical actors
ECONOMY
SOCIETY
c
Implemen- tation
Policy change
CULTURE
b
HC services
Institutions
Political actors
Outputs
d
e
f
Outcomes
POLICY
POLITICS
POLITY
INPUTS
OUTPUTS

• Demands and supports
• Access to the political system
• Decision-making

d. Institutional change e. Social impact of
policy f. Distribution of costs and benefits
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OUTLINE (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 RESOURCESINFORMAL (social) FORMAL
(institutional)
Collective action resources
Knowledge-based resources

• Internal cohesion
• Coalition capacity
• External support

• Informal, experience-based
• Formal, evidence-based

Financial resources
Institutional resources

• Formal political power
• Formal organizational power

• Ownership
• Sponsorship

Adapted from Hughes-Tuohy 2003 and Hicks Mishra
1993
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Policy
MACRO Political actors
The political game
MESO Sociopol. actors

HC SYSTEM
Advisors and managers
Political parties members
Citizens Associations
IGs - Bussiness - Insurance
Profes. providers Assoc.
Patients Assoc.
Patients
Sociopol. context Policy sub-system
MICROSocial actors
The social context
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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
  

Social groups
Social structures, political institutions, social
policies
Political actors
Individuals
Organizations
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CONCEPTS

• 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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CONCEPTS

• NOTE Democratic politics requires representation

Decision costs
Risk of despotism
Number of decision-makers
100
Sartori, 1987
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OUTLINE (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

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1. 2. THE WS, Measurement Types
Conservatism
ITA
AUS
GER
BEL
FRA
FIN
IRE
JAP
NZ
NOR
NETH
UK
CAN
USA
SWE
DNK
AUZ
SWI
Neo-liberalism
Socialdemocracy
Based on Hicks Kenworthy 2003
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OUTLINE (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 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 lt modernization lt globalization

Bennett, 1992. What is policy convergence and
what causes it?
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CONVERGENCE 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?
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CONVERGENCE 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
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CONVERGENCE THEORY APLICATIONS

• (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.

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Trends in total health expenditure as of GDP,
1970 - 1999
12
Germany
10
France
Sweden
8
Spain
Percentage
United Kingdom
6
4
2
0
1970
1975
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Year
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TRENDS IN POPULATION AGED gt65 BY EUROPEAN
SUBREGIONS, 1970 - 1999
Source WHO Health For All Database 2000
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DIFFERENCE IN SMOKING PREVALENCE AMONG HIGH AND
LOW STATUS GROUPS, 1995 ( poor smoke more -
rich more)
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Source Moïse, 2003b (OECD).
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Source McKee, 2003
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Source Sadana et al, 2003 (OECD).
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CONVERGENCE THEORY APLICATIONS

• (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

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Source Schoen, 2003 (OECD).
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CONVERGENCE THEORY APLICATIONS

• 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)

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Source Bouget, 2003 (OECD).
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CONVERGENCE THEORY V. CRITICISMS

• 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)

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CONVERGENCE THEORY SINTHESYS

• 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

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CONVERGENCE 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)