Models of governance for the health sector Commonwealth Health Partnerships 2015 111 Governance refers to state–society interactions. The state steers society through control of critical resources and by co-ordinating interests, rather than through having authority based on legal powers. Some previous typologies and attempts to describe governance change indicate that institutional, political and regulatory dimensions will be important (Treib et al., 2007). Others have noted that these are interrelated: ‘Institutional structures affect configurations of political power which in turn constrain the choices of types of regulatory tools used in specific circumstances’ (Howlett et al., 2009: p. 386). Another study by Capano et al. (2012) examined governance change as a contrast between monocentric (state-centric, hierarchically organised, legally prescribed and mutually exclusive jurisdictional mandates) versus polycentric (decentralised, multi-level, multi-actor) modes of governing and the three dimensions outlined above to assess governance change. A governance change framework These studies provide some starting points for a comparative examination of governance change. First, the shift from monocentric to polycentric arrangements is widespread across both nations and policy sectors. Second, and related to the first point, the political dimension (the balance of power between state and non-state actors) provides insights into governance arrangements in comparative terms. Third, the institutional context is a significant structural constraint, with other dimensions nested within it. Finally, it is clear from attempts to classify governance change that the initial starting point of any nation matters a great deal. Policy instruments are central to governance change. They are often regarded as solid entities, like regulation or output-based funding. But policy instruments can be both technical and social, shaping relations between the state and society (Lascoumes and Le Galés, 2007). This broadens the view of instruments from concrete tools (e.g. funding, legislation) to a broader range of devices that orient relations between state and society. The realm of ideation, which is often ignored in the literature on governance change, is also important in analysing change across nations with regard to a particular policy sector. Each policy sector has a core set of ideas that underpin it, affecting policy development and governance shifts. Examining ideational change means examining a sector’s foundational ideas and assessing whether these have been challenged. Hence, to analyse governance change, this article proposes a framework with three interrelated dimensions: 1. Institutions – the historical and sociological institutional features of a state’s set of governing arrangements 2. Politics – the relations of power between state and non-state actors, and how states negotiate and communicate with important actors 3. Ideation – the dominant ideas underpinning a policy sector that draw boundaries around what is discussed and who has legitimacy Health policy The health policy sector is distinguished from others by its salience with the public (because matters of life and death are involved), its large (and increasing) share of public budgets, and the presence of large and powerful professions. It has tended to develop from fragmented and unstructured beginnings, into densely populated, self-organising systems (Lewis, 2005). Governments have increasingly tried to steer the sector as they have become more involved in financing health care, and as those costs have escalated. A major driver of reform in many wealthy nations has been concern about the rising costs of health systems, associated with apparently unlimited demand and ageing populations. In relation to the three intertwined dimensions of the governance change framework, this article concentrates on universal health care (institutions), the relationship between the state and the medical profession (politics), and models of health and illness (ideation). The two nations that are compared represent similar health systems in regard to them both having universal health care, a similar mixture of public and private funding and provision of health care, similar foundational models of health, and similar challenges associated with increasing demand for health care, partly associated with an ageing population. However they also have interesting differences in terms of how state–profession relationships are constructed, the type of universal health care reforms that have been introduced and discussion about changing to a new model of health. Figure 1 provides a summary of the analysis that follows. Institutions Crucial decisions become enduring features of the rules of governing in different nations and policy sectors, and these establish the context in which subsequent decisions are made. All new policy is bound by the legacy of these institutional histories. With regard to health policy, institutional analyses have been Jenny M. Lewis This is an abbreviated version of a book chapter that is currently in press: Lewis, J. M. ‘Governance change across policy sectors and nations’. In: T. R. Klassen, D. Cepiku and T. J. Lah, eds, forthcoming. The Routledge Handbook of Global Public Policy and Administration. New York: Routledge.
Commonwealth Health Partnerships 2015
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