Suchergebnisse

The spread of privatization in almost every country over the last decade reflects a rapid and fundamental change in patterns of policy instrument usage. Yet the literature on policy instruments has almost nothing to say on this perhaps most significant development in public policy in recent times. This paper's objective is to aid in the development of a theory of policy instrument choice which is capable of dealing with instances of long‐term, cross‐national changes in policy instrument usage. It will be argued that reconceptualization of instrument choices in terms of policy learning can aid in this theoretical project.

Am Beispiel der Frage der Privatisierung und der Einführung von Marktstrategien wird in dem Beitrag die Frage gestellt, wie eine Theorie des Instrumentenwandels entwickelt werden kann, die geeignet ist, den länderübergreifenden, längerfristigen Wandel in der Instrumentenwahl zu erklären. Von Interesse sind dabei die Prozesse, die hin zu der Wahl marktwirtschaftlicher Instrumente führen. Ausgehend davon, daß die politikwissenschaftliche Literatur zwar die Entscheidung für oder gegen ein spezifisches Instrument, jedoch nicht Veränderungen im Instrumentengebrauch im internationalen Maßstab erklären kann, wird gezeigt, daß eine Theorie der Instrumentenwahl die spezifische Natur des Problems, die Merkmale der verfügbaren Instrumente und eine lerntheoretische Argumentation verbinden muß, in der die sich verändernden Präferenzen der administrativen Agenten des Wandels eine zentrale Rolle spielen. Vor diesem Hintergrund wird die Tatsache, daß marktwirtschaftliche Instrumente gleichzeitig in mehreren Ländern eingeführt wurden, als multipler Lernprozeß verstanden, in dessen Rahmen nationale und internationale Policy Communities negative Erfahrungen über die Verwendung von Gebotsinstrumenten und Verbotsinstrumenten und dem Betreiben staatlicher Unternehmen austauschen und als Folge eine Veränderung im staatlichen Instrumentarium in die Wege leiten. (ICA)

Abstract
Fee-for-service remains a popular mode of paying for healthcare despite widespread knowledge of its ill effects. This has resulted in a gap between policy knowledge (understood as consensus among experts) and policy practice (actual policy measures to implement the consensus) in healthcare. The existing literature attributes such gaps to a range of factors, including the stakeholders' different interests, incentives, ideas, and values. Our focus on this debate is through the lens of policy capacity, specifically the ability of public actors to utilize policy knowledge and inform policy practice. We show that the observed knowledge–practice gap is rooted in the complexity of healthcare payment reforms. While actors agree on the problematic condition, there is a deep disagreement on what to do about it. Agreeing on and adopting alternate payment arrangements are challenging because reformers need to anticipate and respond to the future while accommodating the interests of the current providers who benefit from the status quo. In such instances, the capacity of public actors to devise reforms and overcome resistance to them is critical. We argue that the knowledge–practice gap in healthcare payments exists because of deficiencies in the analytical abilities of governments to devise workable alternate arrangements and shortcomings in their political capacity to overcome the resistance to proposed reforms. Put differently, we argue that no amount of evidence or consensus among stakeholders is sufficient when the analytical and political capacities to act on the evidence are lacking. The arguments are illustrated with reference to payment reforms in South Korea and Thailand.

Après avoir laissé la question de côté pendant des décennies, le gouvernement indien a lancé en 2008 un programme national d'assurance maladie pour répondre aux besoins de la majeure partie de la population qui ne pouvait pas s'offrir des soins de santé. Ce programme a été suivi par le lancement d'un autre programme national en 2018, qui élargissait encore la couverture d'assurance. Ces programmes envisagent un vaste système à payeur unique, basé sur l'assurance, couvrant environ 110 millions de familles. L'objectif principal du présent article est d'évaluer la capacité du gouvernement à mettre en œuvre ces programmes ambitieux. Nous utilisons le cadre des capacités politiques développé par Wu et al. pour examiner les types de capacités nécessaires pour atteindre les objectifs souhaités dans le secteur de la santé. L'argument principal de l'article est qu'il existe des déficits critiques de capacité, en particulier dans les dimensions opérationnelles. Nos conclusions sont généralisables à d'autres pays à revenu intermédiaire qui sont en train de mettre en œuvre des réformes similaires de la politique de santé avec paiement prospectif. Remarques à l'intention des praticiens Cet article souligne la nécessité pour les gouvernements de donner la priorité à la capacité de mise en œuvre des réformes des politiques de santé. Les efforts nécessaires pour atteindre et maintenir les soins de santé universels dépendent non seulement d'une conception appropriée des politiques, de la mobilisation des ressources nécessaires et de l'obtention d'un soutien politique, mais aussi de la capacité à surmonter les déficits de mise en œuvre. Le cadre présenté dans le présent article sert d'outil utile aux gouvernements pour diagnostiquer les forces et les faiblesses dans les différents types de capacités (analytiques, opérationnelles et politiques) nécessaires à la couverture sanitaire universelle.

After decades of neglect, in 2008, the Indian government launched a national health insurance programme to address the needs of the bulk of the population that could not afford healthcare. This was followed by the launch of another national programme in 2018 that further expanded insurance coverage. These schemes envision a large single-payer, insurance-based system covering about 110 million families. The central objective of this article is to assess the government's capacity to implement these ambitious programmes. We employ the policy capacity framework developed by Wu et al. to examine the types of capacities needed to achieve desired objectives in the health sector. The central argument of the article is that there are critical capacity deficits, especially along operational dimensions. Our conclusions are generalisable to other middle-income countries currently in the process of implementing similar prospective-payment health policy reforms.Points for practitionersThis article highlights the need for governments to prioritise the capacity for implementing health policy reforms. Efforts to achieve and sustain universal healthcare are contingent not only on appropriate policy design, mobilising required resources and building political support, but also on overcoming capacity deficits in implementation. The framework presented in this article serves as a useful tool for governments to diagnose strengths and weaknesses in the specific types of capacities (analytical, operational, and political) needed for universal health coverage.

AbstractThe past two decades have witnessed unprecedented policy effort to improve access to medical services and strengthen financial protection from catastrophic healthcare expenditure. Despite billions of dollars in health spending, many – especially across the developing world – continue to remain vulnerable to financial impoverishment. What accounts for this poor performance? To respond to this question, we turn to the design literature in public policy, which emphasises the role of policy tools or combination of tools in addressing a social problem. In this paper, we focus on two inter-related aspects of the design orientation to explain outcomes: a) the appropriateness of the policy tool and b) the capacity of government agencies. We apply a framework, which integrates vital questions on both these aspects along three common dimensions (analytical, operational and political) to assess healthcare reforms in India and Thailand. The case studies illustrate the importance of both these aspects of the design orientation in explaining outcomes, and show how they are commonly overlooked in the health and social policy literatures, and in reforms underway.

SummaryHealthcare reforms often result in disappointing failures due to the misguided goals they pursue and the flawed means they employ. The paper proposes that effectiveness—defined as universal access to essential healthcare at a cost affordable to society—is a worthwhile and achievable objective. But to realize effectiveness, reformers need to discard their a priori preferences for markets or governments and instead select a range of policy tools targeting different problems. The paper will argue that a concerted use of regulatory, fiscal, informational and organizational tools shaping the behaviour of healthcare providers, insurers and users can achieve effective healthcare. The paper will highlight the use and misuse as well as non‐use of these tools in China to shed light on tools' approach to health policy reforms. Lessons from China are highly relevant to developing countries around the world trying to reform their health sector. Copyright © 2017 John Wiley & Sons, Ltd.

AbstractThis article evaluates the efforts underway in India to achieve universal health care coverage and the conditions that fostered its contemporary evolution. It finds that India's health system is characterized by private provision and financing, horizontal and vertical fragmentation, and weak governance arrangements. The article argues that these defining characteristics, which have solidified over time, account for poor health outcomes and make the system impervious to reforms as they deny the government levers to intervene and shape outcomes in the sector. While the government's recent efforts of increased public funding of national programmes have helped to reduce out of pocket spending, these are unlikely to work in the long run unless the government addresses the sources of the problems. The article argues that building health care governance, strengthening regulatory architecture, and stewardship over the system, in conjunction with increased public spending, are essential if the health care system is to provide affordable care to the entire population.

India's first health policy document in 1946 envisaged an ambitious health system comprising delivery of public health programs by the national governments and primary and secondary care by the state governments. Nearly seven decades later, neither of the ambitions have been realised. The delivery of public health programs is limited and uncoordinated, whilst primary and especially secondary care is of poor quality and unaffordable to the bulk of the population. This article assesses India's health policy reforms and argues that at each juncture the policy instruments it utilised were inconsistent with the goals it was trying to achieve. The health care sector required more intervention than the central and state governments offered. The meagre funds allocated to public health programs and the unwillingness and inability of state governments to shoulder responsibility for primary and secondary care led to the dominance of the private sector in delivery, out-of-pocket financing, and fee-for-service payment to providers. Recent reforms have made some progress in addressing the lacunae but are handicapped by the pervasive dominance of the private sector which severely limits the choice of policy tools available to the government.