2005

The social context of health politics

Health PoliticsAna Rico, Associate Professor

Department of Health Management and Health Economics

ana.rico@medisin.uio.no

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

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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

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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

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$

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

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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

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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

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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?

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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

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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

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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).

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(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

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Source: Schoen, 2003 (OECD).

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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

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Source: Bouget, 2003 (OECD).

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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

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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)