1 / 34

Actor-centered theories: III. State-society theories Lecture 6

Actor-centered theories: III. State-society theories Lecture 6. Hepl-course 5 (2004/2005) The Politics and Policies of Health System Reform Ana Rico Room L4-46, rico@bmg.eur.nl. OUTLINE OF THE SESSION (1). I. ANALYSIS 1 . State-society theories Comparison with other theories

tehya
Télécharger la présentation

Actor-centered theories: III. State-society theories Lecture 6

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Actor-centered theories:III. State-society theoriesLecture 6 Hepl-course 5 (2004/2005) The Politics and Policies of Health System Reform Ana Rico Room L4-46, rico@bmg.eur.nl

  2. OUTLINE OF THE SESSION (1) I. ANALYSIS 1. State-society theories • Comparison with other theories • Types of state-society theories: 2. Interest groups theories (originally context-centred, later re-formulated as actor-centred) • Pluralist theory: all social groups compete on equal ground • Collective action theory and neocorporatism: unions, bussiness & the state should co-rule 3. Democratic theory • Political parties and party systems  links with cleavages • Public opinion (voters’ preferences) & media experts • Democratic participation & social movements 4. Social learning theories (the most action-centred) • Ideas (policy models, paradigms) and policy experts

  3. OUTLINE OF THE SESSION (2) 5. Evidence by type of theory 6. Criticisms 7. Policy implications II. DESCRIPTION & ANALYSIS  The role of public opinion 1. Relevance 2. Determinants 3. Trends & data 4. Conclusions

  4. STATE-SOCIETY THEORY • MAIN THESES: State action is the result of powerful socioP actors; policy change results from changing links between state and society • COMPARISON WITH OTHER THEORIES: • NOTE: First time that links between elites, organizations & groups explicitly modelled (=analized)  collective actors not assumed to be individuals, but made of different interdependent collectives (vs. IGs/state-centric: elites fully dependent/independent) which must be in agreement to become unitary actors • 1) From social actors (as delegates of social groups) to socioP actors (political elites heading socioP organizations who represent social groups). • 2) With state-centred theory: • - The state is the main political actor, but it is only partly autonomous from social forces, and only to change the technical details of policy • - For big policy change it depends on the support of citizens, granted by socioP actors • - SocioP actors can only change policy by influencing state actors Sources: Hall, 1993; Jacobs, 1992

  5. 1. INTEREST GROUP THEORY • MAIN THESES: Policy is the result of the political pressures of private interest groups on the state, who needs their financial, knowledge and support resources in order to change policy • ARGUMENTS: • 1) PLURALISM: • All social groups with a shared interest will organize & mobilize politically, and exert pressure upon the state  the result depends on competition • 2) COLLECTIVE ACTION THEORY: Only small social groups with plenty of resources (bussiness, profs.) self-organize; special measures (regulation, incentives) are needed to organize other groups • 3) NEOCORPORATIST THEORY: Formal regulation should be in place to allow Unions, Bussiness Associations and the state co-rule; as an strategy to (a) reinforce Unions’ power; (b) eliminate or reduce direct bussiness/ professionals pressures on the state.

  6. 2. DEMOCRATIC THEORY • MAIN THESES: Policy is the result of key socioP actors (political parties, media experts, activists) which mediate the relationships between the main formal political actors in representative democracies: state elites and citizens. • ARGUMENTS: • 1) PARTISAN THEORIES: • Political parties’ (as socioP actors) are the main cause of policy; policy decisions are made and taken within (and among) parties, rather than within Parliament; they directly organize IGs & protest action; and actively shape social cleavages • 2) PUBLIC OPINION THEORY: the state mainly responds to public opinion (PO) = voters’ preferences, which are modelled by policy experts, the mass media and poll experts; (pro-WS) PO reinforces state autonomy as it counterbalances IG pressures • 3) SOCIAL PROTEST/POL. PARTICIPATION/SOCIAL MOVEMENT THEORIES: Citizens’ direct political protest action is the main cause of policy change, via impact on PO and state action. Protest is increasingly led by loose organizations of activists (not aligned with parties, IGs or unions) called social movements. They have become experts in decreasing the direct costs of political participation, and increasing their inmediate rewards Sources: Manin 1989, Chapter 6

  7. 3. SOCIAL LEARNING THEORIES • MAIN THESIS: Policy models made by policy experts (academics) are the main determinant of policy change: “A coherent policy paradigm... dictates the optimal course of policy...[and] provides a set of criteria for resisting some societal demands while accepting others” • - “State autonomy... may depend...on a coherent policy paradigm” • ARGUMENTS: • - “The key agents pushing forward the learning (=policy change) process are policy experts, working from within the state or advising it from priviledged positions at the interface between the bureaucracy and the intellectual enclaves of society” • - Policy change results from the nature of the links (policy models & policy/electoral campaigns) between state (elites) and society (PO): “... policy changes not as a result of autonomous action by the state, but in response to an evolving societal debate that soon became bound up with electoral competition” • - “When policy paradigms become the object of open political contestation, the outcome depends on the ability of each side to mobilize a sufficient electoral coalition in the political arena” Source: Hall, 1993

  8. EVIDENCE ON US HC (1) • 1. Interest group theory • * Starr 1983; Navarro 1989; Quadagno 2004; : small, powerful IGs (first professionals, then bankers & bussiness) block US HC reforms in the 1930s, 1960s and 1990s • 2. Public opinion theory: • Jacobs 1992: undivided and unambiguous PO in favour of reforms (UK 1945 vs US 1965); • Jacobs 2003: unmanipulated PO is increasingly difficult due to mass media & IGs’ campaigns, vs.  pol. participation & state campaigns (1990s: Harry & Louise television campaign, run by insurance companies undermined support for Clintons’ HC reform); • Quadagno 2004: IGs’ PO campaigns are in place since 1940s (PO support for state-run HC decreases from 75% in 1945 to 21% in 1949 due to doctors “National Education Campaign”) to the 1990s ($15 million invested in Harry & Louise, shift of PO support from 59% in sept. 1993 to 44% in • 3. Theories on political parties • ●Esping-Andersen, 1990:Majority SD Parties’ access to gov. causes the WS; • ●Maioni, 1997:Minority SDPs matter in some institutional contexts

  9. EVIDENCE ON US HC (2) • 4. Theories of social protest: • Industrial strikes and mass demonstrations preceded the advent of the WS/HC in most countries (Jenkings and Brents, 1987; Briggs, 1969) • They were originally led by Unions and other citizens’ associations; then by political parties; and nowadays by social movements (loose partnerships of independent activists) • Are they also the main cause of failed attempts at retrenchment? • 5. Theories of social learning: • Weak influence on state decisions of policy experts vs IGs in the US vs. Sweden (Weir & Skocpol, 1983)  pro-state policy paradigm (keynesianism) less developed and less consensual in the US (based on Hall, 1993) • Expert’s evidence on poverty & market failures distorted by IGs’ campaigns (Briggs, 2000; Jacobs, 2003; Quadagno, 2004; Alesina and Glaeser 2004)

  10. CRITICISMS • Still the logic of actor-centred theory  one powerful socioP actor as main cause, via its relations with the state & PO • Pay little attention to institutions and... • Disregard action strategies, coalition forming, and interactions between adversarial coalitions as main cause  Leave many unanswered questions: • E.g. Why are some socioP actors more influential than others? • Little details on participating actors & their strategies: “To move forward, we need more nuanced views of how society and the state can be linked. Only then the conditions under which governments are more or less autonomous will become clear” “The stark dichotomy between state & society... should be revised to allow a significant role to the political system defined as the complex of political parties and interest intermediaries that stand in the intersection between state and society in democratic politics” (Hall, 1993)

  11. POLICY IMPLICATIONS • NOTE: Radically different policy implications depending on the socioP actor considered more powerful! • But generally: the state is led by political parties, and needs to coopt the support of independent policy experts, citizens, and organized IGs in order to change policy • POLICY ADVICE: • *1. Interest group theory: pro-WS policy change requires equal, free competition among socioP organizations representing all social groups  support to less resourceful social groups, who face higher collective action problems, is required (NOTE similar to pro-mkt competition policies) • * 2. Democratic theory: • a) PPs theory: pro-WS policy requires strong, democratically organized political parties who represent the disadvantaged  the state could support them; • b) PO theory: pro-WS policy requires persuading public opinion through state-run campaigns & sound public WS performance; • c) Social movements: pro-WS policy requires direct citizens’ mobilization  state support for political activities/mobilization organized by independent activists • *3. Social learning: pro-WS policy requires that the state invests in a) policy research and policy models which support good state performance in WS/HC; b) public opinion campaigns, led by media experts

  12. THE ROLE OF PUBLIC OPINION IN HEALTH CARE

  13. WHY IS RELEVANT? (1) Public opinion = citizens’s preferences and perceptions 1. AS AN INPUT in health care (HC) reform • Citizens as voters (voice), users (exit) and tax-payers (loyalty) in democracies • Main input in politicians’ utility functions • An independent determinant of policy? The debate on manipulation: Schumpeter vs. Jacobs • A critical determinant of policy when... • Well-established, non-ambivalent attitudes resulting from active interpretation & discussion (political mobilization and civic culture) • Democratic competition: divergent elites & messages • Very popular or impopular policies (issue salience) Schumpeter JA (1950): Capitalism, Socialism and Democracy, NY: Harper. Jacobs (2001): Manipulators and manipulation: Public opinion in a representative democracy, Journal of Health Politics, Policy and Law, 26, 6, 1361-1373.

  14. WHY IS RELEVANT? (2) In health care: • critical for electoral success & democratic legitimacy • intense preferences but high asymmetric information In health care reform: • Jacobs 1992: undivided and unambiguous PO reinforces state autonomy as it counterbalances IG pressures (UK 1945 vs US 1965); • Navarro 1989/Quadagno 2004: powerful IGs in the USA (AMA 1920s-1960s; Insurers 1980s-2000s; both) invest substantial resources in counter-reform PO campaigns (=Immergut 1992 on Switzerland) • Jacobs 2003: Harry & Louise against the Clintons: unmanipulated PO requires competitive mass media + political mobilization (soc. mov.) • Briggs 2000 (/Hall 1993/Weir & Skocpol 1984) : Social scientists, unions and policy enterpreneurs played a critical role in counterbalancing IGs campaigns in Europe

  15. WHY IS RELEVANT? (3) 2. As a PROXY of PROCESS • Access, Pathways, Management • Information, Trust, Shared decision-making 3. AS AN OUTCOME of HC (reform) • Equity, financing and distributive justice • Satisfaction, quality of life and productive efficiency NOTE: • Citizens’ disatisfaction & perceptions of process & equity problems are in turn indicators of bad performance of public HC • Perceived performance constitutes the most important cause=input of HC reform for policy-feedback theory

  16. DETERMINANTS • Values • As core beliefs: solidarity, equality, safety • Varying by ideological subcultures: • Social-democracy: universality, solidarity • Political liberalim: equality of opportunity • Progressive conservatism: responsibility, safety • Peers, Media, Elites (politicians, doctors, industry), • Performance • experienced and perceived • egocentric and sociotropic Based on: Maioni A (2002): Is public health care politically sustainable?, Presentation for the Canadian Fundation for Humanities and Social Sciences; and

  17. RECENT TRENDS • Its role is expanding... • In health policy: ideas, evidence, leadership • In health politics: conflict over resouces, deciding on rules and responsibilities, battle for public opinion ... Due to increased salience & more informed citizens (Maioni, 2002; reference in previous slide) • Its shape is changing... • Increased perception of crisis (finance, access, quality) • Satisfaction with medical care received high • Stable or expanding core values: HC as a social right • Expansion of viable policy alternatives • Media and industry more influential; doctors & peers less; government depends • More autonomous, educated citizens

  18. SOURCES OF DATA • Europe: • Eurobarometers, 1996, 1998, 1999 • European Social Survey 2001-2003, 2003-2005 • Commonwealth (1998, 2002) • USA, Canada, Australia, New Zealand, the UK • OECD: • Europe, Commonwealth and Japan: National surveys with similar questions e.g. Blendon + World Value Survey + International Social Service Programs (Role of government, I, II, III) GENERALLY: A few questions, low quality data, barely explored by social sciencists

  19. EUROPE • Satisfaction growing in AUS, BEL, FRA, UK, ITA • Satisfaction decreasing in GER, DEN, FIN, SWE • Associated with expenditure, but increments non-related • Expansion of access and benefits could plausibly explain changes

  20. % CITIZENS SATISFIED WITH THE HEALTH CARE SYSTEM Canada 1998 US 1998 Source: Eurobarometers. Data provided by H Dubois (European Observatory, EOHSP) and A Dixon (LSE, EOHSP). On the US: Blendon R Kim M Benson J (2001) The public vs. WHO on health system performance, Health Affairs, 20, 3: 10-20.

  21. CITIZENS SATISFACTION WITH THE WAY THE HEALTH SYSTEM WORKS IN 21 COUNTRIES, 2002-2003 AVERAGE (SCALE 1-10) Source: European Social Survey 2002-2003. Data provided by M Fraile, UAM Madrid

  22. COMMONWEALTH • A growing perception of crisis at the macrolevel (except in UK), even if individual satisfaction with services • Cost (and access) mainly

  23. HC in CRISIS: Canada & US

  24. HC IN CRISIS? Canada, gov. approval

  25. HC IN CRISIS? Commonwealth/EU Main source (1998 data): Donelan L Blendon R Schoen C Davis K, Binns K (1999) The cost of health system change: Public discontent in 5 nations, Health Affairs, 18, 3: 206-218.

  26. Source: Schoen C (2003). The Value of International Comparisons and the Potential of Surveys to Add a Missing Perspective. In OECD, A Disease-based Comparison of Health Systems: What is Best and at What Cost?, Paris: OECD.

  27. OECD National culture vs. Cleavage subcultures • The 3 (+1) worlds of welfare show different attitudes (national culture) towards the WS; but attitude differences across cleavages (subcultures) are marked, & similar across countries General trends across countries • Increasing or stable support for state intervention in health care versus decreasing support in ‘jobs for all’ • (Egalitarian ideology) and unemployment at the national vs. Individual level as the main determinants of support for state intervention

  28. THE 3 + 1 WORLDS OF WELFARE Svallsfors (1997)

  29. THE 3 + 1 WORLDS OF WELFARE Svallsfors (1997)

  30. THE 3 + 1 WORLDS OF WELFARE Svallsfors (1997)

  31. THE 3 + 1 WORLDS OF WELFARE Svallsfors (1997)

  32. Preferred state intervention in health care/jobs for all 0: Individual responsible 5: State responsible Doring 1993, Public perceptions on the proper role of the state, West European Politics

  33. DETERMINANTS OF SUPPORT FOR STATE INVOLVEMENT, 24 OECD countries, ISSP 1997 (The role of government III) Source: Blekesaune M and Quadagno J (2003): Public attitudes towards welfare state policies: A comparative analysis of 24 nations, European Sociological Review, 19, 5: 415-427.

  34. SUMMARY & CONCLUSIONS • Public opinion (citizens’ preferences and perceptions)… • Plays a critical role in democracy: responsiveness, accountability, quality of democracy • Is also useful as a HC input & outcome + to track process • Sits at the centre of politicians’ utility functions, and is a critical determinant of public policy (veto) • Is increasingly the target of IGs public opinion campaigns • Requires active political mobilization, information and shared decision-making to become an effective, independent force • Future challenges • Should the state invest in guaranteeing an independent, effective PO? How? Media anti-trust policy & citizens’ associations? • Should the state counterbalance IGs’ media campaigns? How? • A substantial public investment in data, information and research on PO (and professionals’ one!) is required • Analysis of routine national series is a high priority

More Related