Changing forms of management and governing of national health care in Europe: towards new roles for the state?

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1 Workshop proposal for ECPR, Helsinki, 2007: Changing forms of management and governing of national health care in Europe: towards new roles for the state? Outline of the topic The last decades have seen a wave of healthcare reforms in Western industrialised countries. The call for reforms has been spurred by a number of factors. Most importantly, the increasing financial burden of governments combined with a desire to improve the resource allocation to health services has put much pressure on the public health sector. This development has been paralleled by a rise in ideology, most notably associated with the market-oriented reform wave washing over the public sector of many countries under the term New Public Management, questioning the legitimacy and role of government. Also the introduction of new medical technology and therapies, combined with patient and citizen concerns over the access to and quality of health care, have given rise to new demands within health services. Health economists have furthermore displayed much concern over the inefficiency of health services, as there is little evidence of significant improvements in health outcomes despite the ever increasing health spending. Main elements in many of the reforms are increased competition between health care providers combined with the use of incentive-based contracts, and higher degree of patient influence both through increased freedom to choose between different providers and guarantees of elective treatments within certain time limits. In continental Europe, especially the changes in social-insurance funded countries like Germany and Netherlands fit well with the above description. Both countries have implemented modifications in their social insurance systems, with the essence being the promotion of increased competition among insurers and the added development of systems for risk adjustment. These efforts to reorganise the incentive structure for providers have been accompanied by a growing body of regulatory measures. In the planned market models of Northern Europe, the challenge has been to generate a degree of autonomous management within the system of public hospitals. In Norway the responsibility for providing specialised health services has been transferred from locally elected county councils to the central government. While political responsibility and control with the services rest with the state, implementation of policies lies within five regional health authorities, organised as central governmentally owned enterprises. The reform also implemented major changes in the mode of control with services, introducing corporate principles of organisation. Denmark is now strongly considering following Norway and shifting hospital

2 ownership from the regional to the central level. The most recent NHS reforms in the United Kingdom have followed a somewhat different path, promising a third way between the old command-and-control model and the competitive contracting model. By dismantling the internal market, the ambition is rather to shift emphasis from competition and choice to an emphasis on cooperation. The health care sector thus represents a tremendous opportunity for studying an institutional arena undergoing rapid and profound changes, and an increasing number of political scientists are now affiliated with research related to the management and organisation of the health sector. The changing public and private roles and the developing modes of financing, managing and delivering health services pose several important questions from the perspective of political science. With this workshop we wish to focus on the new role of the state in European health care systems. The state has traditionally played an important role in national health policymaking in the European context, and many will argue that the centrality of the state is given for any modern healthcare system. The essential question is how the state will continue to carry out this essential task. Many will argue that the central role of the state in modern healthcare is given, and that the essential question instead is related to how the state in practice can maintain this role. We therefore wish to attract papers that focus on the developing relationship between the state and healthcare actors such as politicians, insurers, providers, physicians, patients, and suppliers. The supranational level and the relationship to national regulation is an increasingly important but somewhat under-researched field. Health policy making at the EU level and the impact on national health systems is a particularly interesting field. The dynamics of the internal market and the free movement of goods, services and persons may create tensions with national planning and regulation efforts. It may also give rise to new multinational actors in health services. In both cases this gives rise to issues of policy dynamics and accountability in democratic processes. At the national level, the most interesting aspect is related to the new role of the state in terms of regulation and interaction with new organizational forms such as decentralization, autonomization and creation of quasi market structures. How will governments prioritise between the often competing considerations of efficiency, equity and government control? What incentives are needed to ensure that government, insurers, purchasers, and health service providers are accountable for their decisions? A common characteristic of many of the developing European health care systems is the replacement of hierarchies of power based on traditional political institutions with a more flexible pattern of public decision-making based on semigovernmental and private actors. An accountability problem thus arises since power

3 and responsibility is transferred from central authorities to bodies that are not democratically elected: on the one hand, elected representatives find it harder to control public decisions, while it on the other hand becomes more difficult for patients, voters and interest groups to hold the health care decision makers accountable. Political leadership may therefore experience a crisis in the wake of a more complex public health policy, more fragmented institutions and growing decision-making networks. The important challenge is how the changing roles of formal government organisations can enable citizens to identify responsibility and hold people accountable in the health care pyramid. The institutional level has for some reason had a tendency to be overlooked by political scientists so far. Yet, in order for health reforms to be successful, changes in legislation and institutional environment must naturally be accompanied by changes in organisation and management in the production units. This can be changes in the division of tasks between hospitals, introduction of incentive contracts, implementation of new and innovative technological solutions, changes in the internal organisation, new negotiating systems, introduction of benchmarking procedures, and changes in leadership and organisational cultures. It is of particular interest how the developing institutional arrangements will affect the efficiency of the health services. Are the resources allocated to health services being deployed in a more optimal fashion in the wake of the reforms, and is it possible to observe improvements in health outcomes? Also studies of the hospitals department level are important in this respect, with potential themes covering aspects such as the effects of changes in internal management and organisation, factors facilitating or hampering internal changes, the use of quality documentation and benchmarking, and the turn over of hospital patients in various medical fields. Relation to existing research The workshop theme relates to several different sets of literature on health policy, regulation and organization. Kieran Walshe, Richard Freeman, Blank and Burau are examples of recent comparative studies of health policy making. The WHO European Observatory has taken a mostly thematic perspective on comparative analysis and has published several studies including comparative analysis of entrepreneurial behaviour, funding, social health insurance and effective purchasing. Regional and national studies can be found in most European countries as illustrated on two recent issues of JHPPL (vol. 30, Numbers 1-2, February-April 2005) and Health Economics (vol 14, number 51, September 2005). In terms of organizational studies there are several ongoing Nordic research projects including the Danish based FLOS network ( and Centre for Health Management, the Swedish based SOND network

4 ( and the Norwegian HORN Project ( and ATM project ( Karsten Vrangbæk is among other projects involved in comparative health policy research on regulation of health care: Governing doctors, the impact of decentralization in European health systems and current policy trends in the Nordic countries. Pål E. Martinussen is associated with HORN, which is a research programme financed by the Norwegian Research Council that focuses on the effects of the reforms in Norwegian specialist care. Participants The workshop intends to combine the insight, experience and research of political scientists from all spectres of health management and organisation, and is therefore initially open to everyone. Yet, we wish to give priority to papers that address the topics stated above. Type of paper The overall aim of the workshop is to contribute to an increased understanding of the new forms of healthcare organisations, with its new modes of regulation, financing, managing and delivering services, and the changing role of the state following from this. We therefore welcome papers that focus on the developing relationship between the state and healthcare actors such as politicians, insurers, providers, physicians, patients, and suppliers. Key issues may concern the character of state behaviour in the health sector, the types of decisions made, the degree of effectiveness or noneffectiveness of those decisions, and the range of policy alternatives that could be substituted for present policy decisions. Funding If accepted for the ECPR Joint Sessions in Helsinki, we will apply for funding of the workshop from the Norwegian and Danish Research Councils. Biographical note: Karsten Vrangbæk a) Current research interests and projects: Regulation of health care: comparative research project on Governing Doctors (With Viola Burau, Århus University and Brian Salter, University of East Anglia). Evaluation of health system reforms in Denmark. (with Allan Krasnik, University of Copenhagen).

5 Comparisons of Nordic health care reforms (with researchers from the ATM project at Stein Rokkan Center in Bergen). Decentralization trends in European health care. Co-author of WHO Observatory anthology (with Professor Richard Saltman, Emory University). European health policy trends. b) Most recent publications: Vrangbæk, K. og Martinsen, Dorthe S. (2005). Sporskifte i dansk sundhedspolitik?. Økonomi og Politik. Nr. 1, april. Årgang pp Vrangbæk, K. og Christiansen T. (2005). Health Policy in Denmark: Leaving the Decentralized Welfare Path?. Journal of Health Policy, Politics and Law. Vol 30, Numbers 1-2, February-April 2005, pp Stoop, A, Vrangbæk, K. og Berg, M. (2005). Theory and Practice of waiting time data as performance indicator in health care. Health Policy 73 (2005) Jakob Bjerg Larsen, Karsten Vrangbæk and Janine M. Traulsen (Forthcomming). Advocacy coalitions and pharmacy policy in Denmark Solid cores with fuzzy edges. Accepted for publication in Social Science and Medicine. Vrangbæk, K. og Beck, M. Organizational responses to the introduction of DRG rates for extended choice hospital patients in Denmark. - Health Policy 67 (2004) Jakob Larsen, Jeanine Mount, Poul Kruse, and Karsten Vrangbaek (2004). "Dynamics of Pharmacy Regulation in Denmark, : A Study of Profession-State Relations". Pharmacy in History. Vol 46, no. 2, pp c) Academic affiliation: Associate professor at Department of Political Science, University of Copenhagen. External Lecturer, Copenhagen Business School. d) Academic status: Ph.d. in Political Science (1999). MA economics. Adjunct professor. Biographical note: Pål E. Martinussen a) Current research interests:

6 Hospital organisation and reorganisation efforts, hospital efficiency, health care reforms and their effects, hospital financing systems. b) Most recent publications: 2005 Ny rolle for fylkespolitikerne: fra eier til ombud? [New roles for county politicians: from owner to ombudsman?], in I. M. Stigen & S. Opedal (eds.), Helse-Norge i støpeskjeen: søkelys på sykehusreformen [Norwegian healthcare in the making: focus on the hospital reform]. Bergen: Fagbokforlaget Hospital waiting time in Norway: what is the role of organisational change?, Scandinavian Journal of Public Health 33: With Linda Midttun Nedlegging av en politisk arena: fylkeskommunal helsepolitikk før statlig overtakelse av sykehusene [The closing down of a political arena: regional health politics before the central take over of hospitals], Norwegian Political Science Journal 4: With Bård Paulsen. c) Academic affiliation: Researcher at SINTEF Health Research, Trondheim / Post Doc scholarship at Institute of Health Management and Health Economics, University of Oslo. d) Academic status: Ph. D. in political science from the Norwegian University of Science and Technology (NTNU), 2003.