International Political Science Association
Research Committee 25:
Comparative
Health Policy
Activities
2006 20th IPSA World Congress, Fukuoka, Japan, July 9-13
2003 19th IPSA World Congress, Durban,
South Africa, 29 June-4 July
2002 Inter-Congress Meeting, Paris
France, 20-22 June
2000 18th IPSA World Congress, Quebec,
Canada, 1-6 August
Research
Committee 25 Comparative Health Policy
Will sponsor four panels at the 20th World Congress
Of The International Political Science Association
July 9-13, 2006 in Fukuoka, Japan
§ § § §
Globalization and Regulatory Governance: Health Care, Healthcare Products, and Diseases in a Global Context.
Dramatic political and economic transformations are taking place around the globe. Not only have these transformations blurred the boundaries between public administration and healthcare systems towards competition and privatization, thus generating a shift in the balance of power away from the stewardship of the state to free markets, but also the boundaries traditionally drawn around subfields in political science: international relations, comparative politics and public policy. The imperative of “think globally, act locally” became the conventional wisdom throughout the 1980s. Fifteen years later, the conventional wisdom is replaced by another imperative: “Think globally, act globally.” The implications of these shifts in discourse and public action for the international health policy community(ies) are not always clear nor are they problematized or examined. Yet globalizing forces are at work at every level of decision-making: global, regional, national and local, which warrant systematic analysis.
Diseases pose severe challenges to the international (health) community, healthcare budgets, and stakeholders. The United Nations, WHO, UNICEF, and the World Bank and others have responded with a policy shift away from the delivery of health services to a disease orientation. This novel approach to fighting diseases raises high expectations everywhere. Yet, realistically, all international commitments to funding cures and services for special diseases fully depend on local capacities and care infrastructures to yield any significant outcomes and impacts. And despite these newly emerging international commitments by IGOs and NGOs, meaningful public action primarily remains a national and local enterprise, and any progress toward the achievement of goals largely depends on local educational and care infrastructures. Governments in industrialized and developing countries alike continue to face severe challenges in both implementing established regulatory policies and laws and launching regulatory strategies with a focus on new diseases. If the international community wants to better understand whether a disease-orientation works better than other approaches tried before, we need systematic research that explores the factors that shape and/or inhibit the domestic implementation of regulatory policies while recognizing that international and global as well as regional (e.g. European Union) factors remain crucial in any conversion process of international, transnational or national goals into concrete strategies and programs.
In contrast to the discipline of political science as a whole, which has used a variety of approaches, in health policy research the politics of policy making approach has been a dominant paradigm for the last twenty years. RC 25 invites these and complementary analytical perspectives on the well-founded belief that no single approach or methodology can explain the effectiveness of a disease-oriented strategy, a regulatory strategy or a cost containment strategy. Health policy research could use, for example, international relations approaches to explain the how and why of globalization and international trade with pharmaceuticals and medical technologies and regional integration (e.g. EU, MERCUSOR, ASEAN etc.). In the field of comparative politics, the new institutionalism would be useful in explaining the functioning of institutions in charge of regulation or a disease-strategy and in highlighting the particular trajectory of such institutions and the way they shape decisions on new health strategies. A public policy approach could help explain how policies are made on a daily basis, who participates in policy processes, and who is in charge of domestic implementation.
A few key issues stand out: under what conditions and with what policy tools can the international, regional or local health community implement its goals and strategies? What are the new institutional forms (formal and informal) for managing the growing interdependence of health policy discourse and national, transnational and global policy actors (state and non-state)? Are nationally-oriented regulatory regimes, procurement, and other administrative practices being replaced and/or complemented by new global or regional regulatory regimes? What are the effects of globalization and regionalization of healthcare and healthcare product markets and industries on healthcare systems? How does a disease-oriented strategy fit into established practices?
A better fit between political discourse and pragmatic solutions is needed.
RC
25-1 Globalization and Regulatory Governance
Chair: Dr. Christa Altenstetter, The City University of New York, Graduate
Center
E-mail: caltenstetter@gc.cuny.edu or caltenstetter@aol.com
Presenters
and Papers
1. Dr. Robin Gauld, Univeristy of Otago, New Zealand
E-mail: rgauld@otago.ac.nz
Comparative Social Health Insurance in Advanced Asian States
Mandatory social health insurance is the predominant funding method for health care in advanced East-Asian countries, with several variations in existence. There is widespread international interest in the Asian experience and approaches, particularly in the US where individual savings accounts – the Singaporean model – have arrived on the landscape. This paper compares the social health insurance schemes in Japan, Taiwan, South Korea and Singapore. In particular, it looks at the politics surrounding the administration and regulation of the schemes, which are under continual pressure from a range of interests and issues. The paper reviews pharmaceutical coverage, rationing, price setting and cost control, service claim and payment mechanisms, and the process of establishing benefits. The paper also looks at the impact of the schemes on the overall health system, including the capacity to integrate care, be cost-effective, equitable, and deliver quality accessible services.
2.
Dr. Jean Crête, Université Laval, Québec, Canada
E-mail: Jean.Crête@pol.ulaval.ca or http://www.CAPP.ulaval.ca/
Politics and Public Health in Canada: Forty Years
of Public Discourse
In Canada, the responsibility for the delivery of public health services rests with the Federated states. Over the last forty-five years those federated states, coordinated by the federal government, have built a public health system. In this paper we ask ourselves: when do governments pay attention to health issues? Is it when problems arise? When they know that a solution is available? Or is it when the political party in power has already taken a stand on these issues? To answer these questions we analyse the public discourse of the governments of the Canadian provinces over a period of 45 years using a mixed methodology – a quantitative content analysis complemented by a qualitative analysis.
3.
Dr. Christa Altenstetter (CUNY) and Dr. Govin Permanand (co-author), London
School of Economics and Political Science
E-mail Dr. Altenstetter: caltenstetter@gc.cuny.edu or caltenstetter@aol.com
E-mail Dr. Permanand: G.Permanand@lse.ac.uk
The Regulation of Pharmaceuticals and Medical Devices in Comparative
Perspective
The use of prescription drugs and medical devices are at the heart of the delivery of health care during all stages of life. Patients are recipients of drugs, medical devices, and transplanted tissues. While revolutionary medical advances have increased diagnostic and therapeutic capabilities, they also have increased the risks to patients and users. The US, the EU and Japan have the largest share of global trade, control the largest markets, and are the most important importers and exporters of prescription drugs and medical devices. Hence understanding their regulatory approaches is important for an understanding of regulatory developments elsewhere. This paper is limited to the European Union. It compares similarities and differences in stringency of regulating pharmaceuticals and medical devices and explores the balance that has been struck between competing regulatory objectives.
4.
Dr. Cynthia Massie Mara, Penn State University
E-mail: czm10@psu.edu
Assisted Living Regulations in the US: A Model for the World to Embrace
or to Avoid?
The history of long-term care regulations in the U.S. is problematic.
Although nursing homes are highly regulated, consistent quality of care
has not resulted. Assisted living is a newer, less expensive alternative
for less impaired individuals. Assisted living apartments are regarded
as the person’s home and therefore are less regulated. States that have
regulations often define assisted living differently, resulting in a mishmash
of state regulations. In this study, assisted living regulations from
selected states will be analyzed in terms of effectiveness in facilitating
quality care delivery. Recommendations will be developed regarding those
aspects of the regulations that may be useful in other countries.
5.
Dr. Monika Steffen CNRS, Institute of Political Studies, Grenoble/France
E-mail: Monika Steffen E @upmf-grenoble.fr
The regulatory governance of health in the European Union
The paper assumes that, despite the prevailing national competency over the health sector, “Europe” may constitute a policy-determining factor. The aim is to explore how EU-driven objectives and policies affect the health policy sector and vice-versa. The first part will discuss theories and conceptual tools. Both “Europeanization” and “health policy” are stretchable concepts. The paper will then distinguish three main policy areas: First, the area of “public health” for which the EU holds a direct and legal mandate, and where Europeanization progresses via institution building and the creation of expertise systems (such as comparable epidemiological data systems). Second, the area of “health care” provision and financing, where the EU has no official competency. This area, however, forms a core part of the European social security systems, which have become subject to co-ordination between member states. Third, the multiple and complex facets of European integration, which includes market integration for medical goods and services, the free movement for UE-citizen with access to medical care in other member states under unified conditions, and also the legal protection of compulsory health insurance regimes from the European competition law. European health policy integration thus results from an indirect impact, deriving from other Community provisions and policies, rather than from a direct Treaty-based impact. It is a move away from purely medical issues and problem framing, which dominate in national policy arenas, towards consumer and trade interests and conflicts. Three distinct sources of pressure for Europeanization are identified: public health “crisis” and urgency; policy discourse diffusion and co-ordination; and compliance with the requirement of market and social integration. Health governance in Europe should be understood as an intersection between health policy and other policy fields and as an incremental process in issue-specific policy areas.
Discussants:
Dr. Angela Burger, University of Wisconsin Colleges. Note: for additional
information see RC25-4 (currently all information is in 186)
Dr. Paul Godt, The American University of Paris
§ § § §
RC 25-2 Health governance at international level
Chair: Dr. Monika Steffen, Institute of Political Science, Grenoble, Fr.
E-mail: Monika Steffen@upmf-grenoble.fr
Presenters
and Papers
(*All papers will be in English at a later date)
1. Dr.Fred Eboko, Institut de Recherce pour le Dévelopment, France
E-mail: Fred.eboko@bondy.ird.fr
Les États Africains, le Sida et les relations internationales:
la double peine?*
L’Afrique subsaharienne est la région du monde qui paie le plus lourd tribut à la pandémie du sida. Le Programme commun des Nations Unies sur le VIH/sida (UNAIDS) estimait que 40 millions de personnes vivent avec le VIH/sida sur la planète et que l’Afrique Subsaharienne en compte à elle seule 70 %. La contribution analysera les réponses différenciées des Etats africains, depuis le milieu des années 1980. Elle mettra en lumière la diversité de leurs trajectoires politiques et sanitaires et de leur adaptation plurielle aux modèles diffusés au niveau international. Plusieurs pays (Cameroun, Côte d’Ivoire, Burkina Faso) ne se sont adaptés que verbalement et passivement aux normes des institutions internationales, d’autres (Ouganda, Sénégal) y participent activement, alors que l’Afrique du Sud du président Thabo Mbeki est entrée en “ dissidence ”. Les pays du Nord ont, eux aussi, réagi de manière différenciée : du Fonds mondial inauguré par Kofi Annan en 2001, au PEPFAR lancé en 2003 par le président G. W. Bush. L’arrivée des médicaments antirétroviraux et la concurrence imposée par les médicaments génériques constituent une date dans les relations internationales : les Etats africains se meuvent dans ces nouveaux espaces ouverts au niveau international, entre “ morale ” et politique, droit et économie, marché et santé. La contribution dessinera une configuration internationale plus large que celle d’ “une” Afrique face à un “Nord”.
2.
Dr Marc Dixneuf, Université de Droit et de la Santé and
Conseil National du Sida
E-mail: Marc DIXNEUF@sante.gouv.fr
International governance of research against AIDS, Two opposite models
within community-based organizations (Europe and USA)
In 2004 and 2005, the governance of research against Aids set European community-based organization (CBO) of people living with Aids against the equivalent North American organizations. Two different therapeutic strategies were discussed and subject to controversy: TDF as pre-exposure prophylactics on the one hand, and the development of anti-CCR5, a new promising drug, on the other hand. European CBOs, lead by the French, seem to be involved in transnational networks where their perspective and interests are influenced by their counterparts from developing countries (in particular Cambodian sex workers, as an example). This alliance is mainly preoccupied by “ethics”. On the opposite side, North American CBOs are closer to pharmaceutical firms and to transnational ONGs. They are more aware of their self-interest and of the long-term perspectives for their own policy: the fast development of clinical progress and new treatment. The analysis of the international controversy among CBOs and the links with others public and private actors identifies two distinct models of research governance in the HIV/Aids field (first part of the paper). The second part will show how these two models interact with each other, and how this produces new patterns of international policies and politics.
3.
Drs. Bijoyini Mohanty and Indramani Jena, Utkal University, Orissa, India
E-mail: bijoyinimothaty@yahoo.com
The cheap therapeutic revolution. The role of the Indian pharmaceutical
industry in the control of the AIDS epidemic.
In 2004 and 2005, the governance of research against Aids set European community-based organization (CBO) of people living with Aids against the equivalent North American organizations. Two different therapeutic strategies were discussed and subject to controversy: TDF as pre-exposure prophylactics on the one hand, and the development of anti-CCR5, a new promising drug, on the other hand. European CBOs, lead by the French, seem to be involved in transnational networks where their perspective and interests are influenced by their counterparts from developing countries (in particular Cambodian sex workers, as an example). This alliance is mainly preoccupied by “ethics”. On the opposite side, North American CBOs are closer to pharmaceutical firms and to transnational ONGs. They are more aware of their self-interest and of the long-term perspectives for their own policy: the fast development of clinical progress and new treatment. The analysis of the international controversy among CBOs and the links with others public and private actors identifies two distinct models of research governance in the HIV/Aids field (first part of the paper). The second part will show how these two models interact with each other, and how this produces new patterns of international policies and politics.
4.
Dr. Frédéric Bourdier, Institut de Recherch pour le développement
(IRD), Unité Intervention publique, espace société
E-mail: Frederic.bourdier@tiscali.fr
Les institutions et acteurs de lutte contre le Sida au Cambodge. Une
anthropologie politique.*
Cet article propose une anthropologie politique des institutions et acteurs engagés dans la restructuration des systèmes de santé engagée sous l’impact d’une épidémie. L’analyse portera principalement sur le cas du Cambodge, avec un regard comparatif sur le Vietnam et le Laos. Elle visera les effets du Fonds Global de financement au niveau des politiques nationales et de leur mise en œuvre. C’est l’extension effective de l’accès aux traitements antiviraux qui se trouve au cœur des problèmes politiques et économiques se posant aux responsables publics et privés. L’analyse s’appliquera aux décideurs, gestionnaires et développeurs - internationaux aussi bien que locaux - chargés de cette tâche dans cette région asiatique, pour mettre en évidence les processus pouvant expliquer pourquoi et comment la région est arrivée dans la situation actuelle, marquée par risque épidémiologique majeur et un besoin urgent de restructuration des services médicaux. Des puissances régionales, notamment le Japon, interviennent de plus en plus, notamment au Cambodge, non seulement dans le domaine de l’aide au développement en général, mais aussi et en particulier dans celui de l’organisation sanitaire et de la lutte contre le Sida. La contribution vise à éclairer les stratégies et motivations de ces institutions et acteurs : internationaux, nationaux et locaux, engagés dans l’enjeu sanitaire de la région.
5.
Dr. Olivier Nay, Institut d’Études Politiques de Paris and HIVIAIDS,
UNESCO
E-mail: O.nay@liep.unesco.org
The rôle de l’UNESCO dans l’action publique internationale en
direction des pays en voie de développement. Le cas de la lutte
contre le Sida.*
Le sida a tardivement été reconnu comme une priorité de l'action publique internationale en direction des pays en développement. Ce n'est qu'au début des années 2000 que la lutte contre l'épidémie est devenue un enjeu majeur de l'aide publique internationale, avec les “ Objectifs du millénaire pour le développement ” (2000) et la déclaration d'engagement de l'Assemblée générale des Nations Unies (2001). Dès lors, le sida n'est plus seulement perçu comme un problème dramatique de santé publique affectant des populations, voire des pays entiers, mais aussi comme un enjeu du “ développement ”, dans la mesure où l'épidémie affecte l'ensemble des secteurs les plus stratégiques pour l'avenir des sociétés les plus pauvres (la santé, l'éducation, l'économie), affaiblit les chances de renforcer la protection des Droits de l'Homme et de lutter contre la corruption, et enfin multiplie les risques de conflit et d'instabilité politique, notamment sur le continent africain
Depuis 2002-2003,
les agences des Nations Unies ont considérablement renforcé
leur programme de lutte contre le sida, de même que les bailleurs
de fonds et les organisations de la société civile. Néanmoins,
les réponses nationales (prévention, accès aux soins
et aux traitements, lutte contre l'impact du sida sur les secteurs les
plus vitaux pour le développement) restent très inégales
et l'aide financière accordée par les nations les plus riches
n'aboutit pas toujours à la réalisation de programmes nationaux
justes et efficaces. Un grand nombre de barrières (manque de coordination
entre les principaux acteurs, faiblesse des capacités techniques,
fuite des savoirs, déclin économique, déni des gouvernements...)
réduisent la portée des mécanismes financiers.
Les années 2005-2006 représentent un défi important.
Les gouvernements des pays donateurs ont en effet formulé des recommandations
claires invitant à une réforme radicale des modes d'intervention
et de coopération des acteurs internationaux, en particulier au
niveau des pays. Les agences des Nations Unies ont été invitées
à revoir en profondeur leurs dispositifs d'action afin que ces
derniers soient plus transparents, réellement harmonisés,
inscrits dans une “ démarche globale de développement ”
et plus inclusifs (associant les autorités nationales et les acteurs
de la société civile). Après la mobilisation du début
du millénaire, le temps est aujourd'hui à la restructuration
des mécanismes de l’aide international. L’enjeu est l’avenir de
populations entières.
Discussants:
Dr. James W. Bjorkman, Social Science Institute, Hague
§ § § §
RC 25-3 Comparative Health Care Reform
Chair: Dr. Yolande Cohen, University of Quebec - Montreal;
Historie: Université du Québec
E-mail : Cohen, yolande@uqam.ca
Presenters
and Papers
1. Dr. Howard A. Palley, University of Maryland and Institute for Human
Services Public Policy
E-mail: hpallye@ssw.umaryland.edu; and
Dr. Pierre-Gerlier Forest, Laval University, Quebec City, Quebec; and
Dr. C.D.W. Cameron, Chair, Health Canada
E-mail: pierre-gerlier_forest@he-se.ge.ca
Fiscal Federalism, Regionalization and Privatization: Problems and
Prospects for Canada’s Provincial Health Delivery Systems.
This study focuses on the ability of the Canadian provinces to shape in different ways the development of various provincial health care delivery systems within the constraint of the mandates of the federal Canada Health Act of 1984 and the fiscal revenues the provinces receive if they comply with these mandates. In so doing, it will examine the operation of Canadian federalism with respect to the health care delivery system.
This study
posits a comparative analysis framework in order to facilitate an understanding
of the dimensionality of policy development in provincial health care
delivery systems. Four sets of relationships will be “dealt with” in examining
two
areas of provincial health care system development. These areas are: the
case of provincial regionalization of health care delivery and the development
of private/public sector relationships in the delivery of health care
services in various provinces.
(While trends towards regionalization and increased involvement of the
private sector in the health care delivery system are global trends, the
manner in which they occur within nations are “embedded” in the history
and culture of national and local contexts.) The four sets of relationships
examined are: first, the various levels of government and the nature of
their involvement in public policy concerning the provincial health care
delivery systems; and secondly, the nature and characteristics of public
and private sector activities developed within provincial health care
delivery systems. The third area dealt with is understanding factors influencing
provincial governments’ political dispositions to act in various directions
and the fourth is to take into consideration the factors influencing the
“timing” of particular decisions (Heisler and Peters, 1977; also see Brown,
1998; Marse & Paulus, 2003; Wessen, 1999; Woodsworth, 1977). In applying
this framework, conclusions will be drawn as to how democracy works in
provincial decision-making affecting policy development in the Canadian
provinces’ health care delivery systems.
2.
Dr. Yue-Chune Lee, Associate Professor, Institute of Health and Welfare
Policy National Yang-ming University
E-mail: vclee@ym.edu.tw
Taiwan payment system reform: the process of getting providers to
change
Taiwan had introduced a mandatory single-payer National Health Insurance (NHI) program in 1995. To control costs under the fee-for-service (FFS) payment system and to enhance the value of NHI, Global Budget Payment System (GBPS) has been implemented gradually at different sectors from 1998 to 2002. Payment reform is very complicated and often failed due to the providers’ resistance.
As the major architect of GBPS reform in Taiwan, I will share Taiwan’s reform experience based on my long-time participatory observation (more than ten years as director of Payment System Division of NHI Task Force at Department of Health and also as a scholar) and on the analysis of the relevant documents to address the following issues: 1. to what extent did the development of the GBPS followed the “deliberative democracy” norm? 2. How to build-up the “trust”, the most essential for successful reform, between the providers’ groups and the government? 3. How to enhance providers’ participation by applying “delegation of power and responsibility” principle? 4. How did scientific researches and education empower providers to develop consensus regarding the understanding of the problems, the choice among policy alternatives to address them, or the rules to achieve self-disciplinary? 6. What kind of incentives had been provided for the providers to finally accept GBPS reform?
By applying the so-called “silent revolution” model described above, we had successfully persuaded providers’ associations to accept GBPS reform gradually. This valuable experience may shed some light on countries, especially in Asia, which still use FFS as predominated unit of payment and are seeking means to control costs.
3.
Ståle Opedal ,Senior Researcher in Political Science, Rogaland Research,
Stavanger, Norway
E-mail: staale.opedal@rf.no
Comparing Hospital Reform in England, New Zealand and Norway –
how is political control and enterprise autonomy balanced?
In 2002 responsibility for the Norwegian hospitals was transferred from the regional counties to central government. The ownership was thereby centralized to a single body – the state. The reform also set up new management principles for the hospitals based on a decentralized enterprise model. Norway has been seen as a reluctant reformer. But since the mid-1990s greater structural devolution have become major components in the Norwegian-style New Public Management.
This paper focuses on the balance between superior governmental control and enterprise autonomy by examining the hospital reforms in England, New Zealand and Norway. The focus of this paper is on the balance between superior governmental control and autonomy for the health enterprises. We ask how the trade-off between control and autonomy is practiced in England, New Zealand and Norway. The reforms involves a strengthening of overall central government ownership control simultaneously representing a decentralized system of management. We describe the models in each country and give a short description of the policy instruments that the government, as the owner, has for exercising power and control vis-à-vis the health enterprises.
The theoretical basis of the study is three perspectives on administrative reforms. New Public Management is still a dominant reform paradigm in our time focusing primarily on an instrumental concept of public administration. The reform ideas are that the executive leadership deliberately can design and implement the reform measures based on market, management and efficiency. It represents a holistic reform package which is not paying particular attention to contextual factors like internal administrative traditions or external pressure from political actors. Our argument is that culture and environment need to be integrated into the NPM approach to understand the hospital reforms. A contextualization process that stresses the uniqueness of the national system in general and the health systems in particular have to be taken into account. Thus, we use three different theoretical approaches to explain and support our arguments: an structural-instrumental approach emphasizing the formal and hierarchical aspects of the reform; an (neo-)institutional approach stressing the cultural features of the reform and the health sector, and an environmental approach bringing up arguments connected to characteristics of political processes and policy types.
4.
Dr. Pauline Vaillancourt Rosenau, Management, Policy, and Community Health
UT Houston - School of Public Health
E-mail: Pauline.Rosenau@uth.tmc.edu
U.S. Newspaper Coverage of the Canadian Health System – A Case of
Seriously Mistaken Identity?
Quantitative
and qualitative methods were employed to assess U.S. newspaper coverage
of the Canadian health system between 2000 and 2005. Fifty articles from
the New York Times and the Wall Street Journal met strict criteria for
inclusion. Each was compared with what is known from already-published
research. Errors of fact were identified.
Newspaper articles presume that the Canadian health system is unitary
and federally determined though this is an oversimplification. In fact,
the Canadian health system remains a work-in-progress between the federal
and provincial governments. U.S. newspapers incorrectly imply that Canadian
federalism is the same as that in the U.S. The Canadian health system
is assumed to be socialist or left wing. This leads to confusion. In fact,
the Canadian health system is based on fee-for-service (piece-rate), not
socialist forms of payment. The government does not own the hospitals
nor employ the doctors. Canadian hospitals are largely private-nonprofit
rather than private-for-profit but ownership is not socialist. Finally,
U.S. press coverage is incomplete because French-speaking Quebec and several
other provinces, are often left out. Ontario receives more coverage in
U.S. newspapers than all the other provinces put together. Overall, U.S.
newspaper reports about the Canadian health system are found to be oversimplified,
often incomplete, and frequently confused, driven by assumed public interest
in politically sensitive themes as much as by episodic, event-related
stories. Anecdotal information plays a greater role than evidence. These
inadequacies mean that the public is sadly misinformed with regard to
the Canadian health system
5.
Dr. Hal K. Colebatch, Department of Public Policy and Administration,University
of Brunei Darussalam; and School of Public Health and Community MedicineUniversity
of New South Wales
E-mail: hal@fbeps.ubd.edu.bn or h.colebatch@unsw.edu.au
Autonomy and system in the organizing of medical work:
analytic questions and empirical evidence
Two central questions for health policy have been the control of costs and the assurance of quality in medical care. They have come together in a concern for the governing of clinical practice, and the place of evidence about efficacy in clinical decision-making, giving rise to projects aimed at collectively generating shared commitments of patterns of integrated and evidence based practice, often referred to as ‘clinical pathways’. This is a new approach to the tension between claims for professional autonomy, and demands for managerial control generated by the institutional structures within which clinical work is done, including hospital, government agencies and health funds. In the UK, the political science concept of ‘governance’ has been widely applied to these attempts to develop new patterns of negotiated order in health care (‘clinical governance’), which aim for the systematisation of health care through the framing of parameters for professional practice which are collectively-negotiated and evidence-based. This paper comes out of a UK-based project which is exploring the way that this approach is transforming the management of health care. It sets out the analytical framework underlying this shift, reports on the empirical evidence of challenge and change in clinical management, and explores the broader implications of these changes for the governing of the human services in general.
§ § § §
RC 25-4 Restructuring Junctures of Public & Private Health
Chair: Dr. Angela S. Burger, University of Wisconsin Colleges
E-mail: aburger@uwe.edu
Presenters
and Papers:
1. Dr. James Bjorkman , Social Science Institute, Hague, and Dr. Venkat
Raman, Faculty of Management Studies at Delhi University.
E-mail: bjorkman@iss.nl or avr_fms@yahoo.co.in
Public/Private Partnerships in Health Care Delivery in India.
The well-documented inefficiencies of public health systems can be overcome by changes in the organization and management of health care. India has had substantial growth in its private health sector that, although inequitable, expensive and largely unregulated by the state, is popularly perceived to be better managed, more efficient, and higher quality. As budgetary constraints erode the capacity of the public health system, policymakers are exploring alternatives to improve its efficiency, performance and quality through health sector reforms. The options include alternative financing (user fees, community financing, health insurance); better institutional management (autonomous hospitals, partial privatization); innovative personnel management systems (incentives, contract staffing); decentralization of administrative control (facility maintenance, water supply, sanitation); and collaboration with the private sector (Public-Private Partnership, contracting, joint ventures).
Based on empirical case-studies in nine Indian states, the paper explores the relative efficacy of encouraging the private sector (health care providers, contractors, NGOs, charitable institutions, industrial establishments, local governments, and community associations) to participate in provision of services under different kinds of formal arrangements. It is argued that PPP improves efficiency through competition, greater accountability, enhanced quality of services at lower costs, improved accessibility for the poor, and a sense of commitment from each partner.
2.
Dr. Gwendolyn Gray, Senior Lecturer in Political Science and International
Relations, Australian National University
E-mail: Gwendolyn.Gray@anu.edu.au
Democratic Elitism Down under: The Case of Health Policy
Held against a procedural view of democracy, as a method of governing in large societies, rather than as an end in itself, Australian health policy can be viewed as a product of democratic processes. According to this formulation, democracy is little more than the means through which leaders compete for the people’s vote: citizens’ involvement in politics is limited to choosing the leaders who will rule over them at infrequent elections (Schumpeter 1949). However, once the notion of democracy is infused with the idea that power, and the right to exercise it, belongs to the people and that people should participate in decision-making or at least exercise some influence on decision making processes, then a very different picture emerges. In this latter perspective, Australian health policy more resembles democratic elitism (Bachrach 1972) or even decision making by an "elective dictatorship" (Evans 1995). Australia has a long tradition of health decisions made "behind closed doors" among political and medical elites, giving the system a strong hospital and medical focus. Major policy changes have been implemented, including the complete dismantling of a national health insurance system, when there was no public call for such changes. Parties, elected on a promise, take an opposite course in office, notwithstanding opinion poll evidence of voter preferences. The configuration of power in the Australian health policy arena sits oddly with participatory or deliberative approaches to democracy
3.
Dr. Don-yun Chen, Department of Public Administration, National Chengchi
University, Taipei, Taiwan.
E-mail: donc.nccu.edu.tw
with
Chun Liu, Kainan University, Taoyuan County 338, Taiwan.
E-mail: chun0820@ms55.hinet.net
and
Chao-Yin Lin, National Taipei University, Taipei
E-mail: : cylin@mail.ntpu.edu.tw
and
Naiyi Hsiao, National Chengchi University, Taipei
E-mail: nhsiao@nccu.edu.tw
Stakeholder Participation in the Formation of Policy Solutions: An
Exploratory Assessment of Political Feasibility in the “Second Generation
National Health Insurance” Reform in Taiwan, 2000~2003
Health care reforms are more of political than pure technical problems. Since the adoption of the Taiwan’s National Health Insurance (NHI) in 1995, the system has gained high popularity among the people but at the same time its financial problem is also gradually surfaced. The health administration finally decides in 1999 to launch a three-year reform effort, called “the second generation NHI (2G-NHI)” to cope with the coming crisis.
However, since the adoption of the NHI, Taiwan has transformed from a soft-authoritarian into a democratic state. Especially the occurrence of the first party turn-over in 2000 as the fifty-year long ruling party KMT lose presidential election, the policy environment for the NHI reform has changed dramatically. As a result, the usual way of top-down and expert-oriented of policy solutions formation process has been challenged and a more deliberative and participatory way of reform efforts is adopted. This paper is a report of a distinct effort to design a feasible way to access the political feasibility of the 2G-NHI reform plan.
The purpose of this paper is three-folds. First, authors will introduce the landscape of the health policy as well as political environment in Taiwan as the background for following discussion. Especially, we will focus on the issue of designing a new financial scheme for the NHI by the 2G-NHI reform. Second, we will present the theoretical rationale, the method, and the results of our efforts to access political feasibility by combining stakeholder analysis, policy network analysis, and opinion survey. Lastly, we will evaluate the accessing plan from pluralist viewpoints included experts, politicians, and bureaucrats to see whether the efforts of political feasibility assessment and stakeholder participation is useful, feasible or even, possible for searching for policy solutions in a democratic system.
4.
Dr. Peter Nan-shong Lee, Department of Political Science, National Chung
Cheng University, Taiwan
E-mail: polnsl@ccu.edu.tw
Privatizing Medical Care Provision in China
Since the onset of the reform period in 1978, there has been a salient policy trend of privatization of medical care provision in China in terms of transformation from a traditional bureaucratic mode of management to a corporate mode.
The transformation is marked by two stages. The first stage began from 1978 onward, being characterized by a drastic reduction of “differentiated quota” of state financial appropriation to hospital units and an expansion of hospital’s franchises of medical service and pharmaceutical retails. This first stage led to a new managerial style of “one-arms-length” by de-linking hospital units from the bureau management in budgeting and personnel arenas. There was, as well, an increasing tendency of “marketization” of medical service together with an emphasis of client orientation and users’ choice. This stage has also resulted in uncontrolled spiral of medical costs and unbearable burden on many enterprises and working population in urban China. Starting in 2000s, the second stage witnessed an entirely new trend in the change from an organizational mode of “service unit” (or taken as non-departmental public entity) to corporate and private form of hospital units coupled with introduction of new ownership systems on top of “state ownership”.
This proposed paper will be devoted to an analysis of the trend of privatization of medical care provision, focusing on its process of transformation, the main features of traditional and new managerial styles, and consequences of such change. On the basis of a dialogue with authors in New Public Management as well as those of the New Right leaning, the paper will also examine the theoretical issues on different organizational and managerial modes on the basis of empirical study of policy implementation in China. The paper will make comparison of Chinese case with its counterpart in the West and Taiwan.
5. Dr. Angela S. Burger, Professor Emerita, Political Science,
University of Wisconsin Colleges.
E-mail: aburger@uwc.edu or drburger@dwave.net
Coping with Contagion: New strains on Public vs. Private Health Relations
Disease outbreaks in recent years demonstrate the conflict between the power of Westphalian states, civil organizations, corporations, and multiple international regimes. In contrast to Garrett’s assertion that global public health has collapsed, we maintain that conflict over the shape of global healthcare in the future is being waged between multiple public and private institutions, some state-based and others either international or global, with each stressing specific values. Paper analyzes the claimants and their successes and failures to demonstrate that different types of contagious diseases benefit specific actors, while decisions in other arenas limit abilities to cope with pandemics. The conflict between goals and values of plural entities suggest an inchoate global public health system. Paper identifies particular problems that must be addressed for coping with pandemics.
Discussant:
Dr. Christa Altenstetter, CUNY Graduate School, New York
For
details, please visit the IPSA website.
IPSA RC 25: Comparative Health Policy
Regulation of Health Care
Industries and Patient Care
June
20-22, 2002
Maison des Sciences de L’Homme
RC 25: Comparative Health Policy met for an
inter-congress meeting ahead of the World Congress of IPSA in
This meeting would not have
been possible without the support of Dr. Hinnerk
Bruhns, Vice-Director of the Maison
des Sciences de L’Homme, who hosted the two-day
workshop in an inspiring environment. We express our gratitude.
IPSA RC 25: Comparative Health Policy
Panel 1: Health
Care Reform in Comparative Perspective
The study of health
care reform is a growing field of scholarly interest around the world. Health
care reform has become a permanent item on the agenda of international organizations,
governments, and some delay, even on the agenda of the European Union. This
is most clearly expressed in the European Commission’s diverse research programs.
The introduction of market-oriented reform strategies for stabilizing health
expenditures in many countries and numerous measures to respond to demographic
developments, and increasing demands for health care services have provoked
renewed interest in explanatory approaches of the efficacy of available policy
options and instruments in health care reform: interventions through the state,
market, or community. The impact on equity in access to services is open to
questions. All papers presented at this panel were genuinely comparative and
included evaluations of economic, political and cultural factors undergirding
the respective reforms.
Convenor:
Christa Altenstetter,
Papers:
·
Implementation
of Provincial Healthplans Within the framework of the Canadian Health Act
Howard A. Palley, the
·
Health care reform in
Diane
Duffy
·
Health
Care Reform in
Antonia
Maioni, Center for European Studies,
Franca Maino, Univesita
di Pavia
·
The
Politics and Policies of Health
and Long-term Care for the Prison Population
Cynthia
Massie Mara
Panel 2: Globalization and European Integration: What
Impact on the Social Model of Medical Care?
The competencies of the European
Union in health-related matters have traditionally been restricted and are
primarily reserved to the member states. However, the construction of a unified
European market led to multiple harmonization efforts and to the emergence
of public health issues which called for governance mechanisms at the European
Union level. They have evolved piecemeal, are highly dispersed across a number
of directorates general in the European Union, and are typically outside the
traditional realm of the welfare state framework centered on the organization
and financing of the medical care system. The aim of this panel is to explore
the Europeanization of health policies which are
driven by a dual logic: the regulation of the market versus safety, quality
and efficacy standards. Both have profound implications for public health
and the financing of health care. Among the topics to be discussed are the
pharmaceutical and medical device industries, biomedical ethics, and public
health issues related to the food supply.
Convenor:
Monika Steffen, Universite
Pierre-Mendes-France
Papers:
·
Global
Industry and Local Health Care Traditions: The Utilization of Medical Devices
in Patient Care
Christa
Altenstetter,
·
Regulating
the Pharmaceutical and Biomedical Industries
N.N., European Observatory on Health,
·
Europeanization of Public Health: Issues and Governance
Juhani Lehto,
WHO European Centre for Health Policy
·
Towards a European Policy
of Bioethics? Institutional Frameworks and Policy Responses
Francois
D. Lafond, Charge
d’etudes, Groupe d’etudes
et de recherche “Notre Europe”