Download from actor-centred theories

Lecture 10
Summary
Ana Rico, Associate Professor
Department of Health Management and Health Economics
[email protected]
2005
Health Politics:
Types of WS and HC systems
- Policy instruments
- Impact: Social outcomes
2005
THE DEPENDENT VARIABLES:
1. THE WS, POLITICS & MARKETS: Definition
GOVERNANCE & POLITICS
INTEREST
GROUPS
2005
DEMOCRATIC
GOVERNMENT &
INSTITUTIONS
THE MARKET
Financial markets
PRIVATE FINANCERS:
Banks, insurers, citizens
PUBLIC & SOCIAL
INSURANCE
Product markets
PRIVATE PROVIDERS: Hospitals,
doctors, schools, nursing homes
PUBLIC WELFARE
SERVICE
PRODUCTION
THE
WS
2 & 3. TYPES OF WS : Instruments and consequences
+
UNIVERSAL
Pure liberal:
Public insurance
for the poor
% Covered
Based on Esping-Andersen, 1990
Pure Christian
Democratic:
Employees
Outcomes
Pure ChisDem:
Non-employed
RESIDUAL
REGRESSIVE
Pure liberal:
Private insurance
for the non-poor
-
EGALITARIAN
2005
Pure (unmixted)
Socialdemocratic
Pure CD:
Private insurance
for employers
2005
Source: McKee, 2003
CHANGES IN WELFARE POLICY
 WS expansion
 WS retrenchment
Decrease in coverage, benefits and expenditure
 WS resilience
Stable in coverage, benefits and expenditure. Resistant to change
 WS re-structuring
Change in distribution of benefits & expenditure across social
groups
2005
Expansion of coverage, benefits and expenditure
HC in CRISIS: Canada & US
2005
HC IN CRISIS? Canada, gov. approval
2005
2005
THE INDEPENDENT VARIABLES:
- The political sysem
- Context, actors, instits. , action
Political, policy/sociopolitical and social systems
SOCIAL CONTEXT
CULTURE
POLICY (SUB-) SYSTEM
Social organiz.
Sociopol. actors:
* Ideologies
* Ideas
• IGs, Prof Ass., Unions
• Citizens, Mass media
• Political parties
* Org.Struct.
* Subcultures
/pol.identities
Social groups
- Communities
- Ethnia, gender
- Social classes
b
THE POLITICAL SYSTEM
a
Policy
change
c
Policy actors:
•STATE-, POL. PARTs (IGs)
CONSTITUTION
HC
SYSTE
M
Interactions:
• Coalitions/competit.
Institutions:
• Const. (interorg.)
• Organiz. Struct.
• Leadership/strategy
Outputs
e
d
f
INPUTS
a.
b.
c.
Outcomes
POLITY
Demands and supports
Access to the political system
Decision-making
POLITICS
POLICY
d. Institutional change
e. Impact of policy
f. Distribution of costs and benefits
OUTPUTS
2005
Associations
• Churches
• Firms
•
Policy
MACRO: Political
actors
Citizens’
Associations
2005
MESO:
Sociopol. actors
The political game
$
Political
parties’
members
Advisors and
managers
IGs
- Bussiness
- Insurance
Profes. +
providers’
Assoc.
The socio-political context
MICRO:
Social
actors
The social context
Patients’
Assoc.
Patients’
ACTION-CENTERED THEORIES. 1.1. RQs
REPRESENTATIVE DEMOCRACY
State context
RQ 2. Who
influences
policy?
Policy context
Social context
RQ 4.
How it
governs?
RQ 1. Who participates? (=
seeks to influence policy)
2005
RQ 3. Who
governs?
“DIRECT” DEMOCRACY
2005
THE THEORIES:
- Concepts
- Hypotheses
- Causal maps
CONCEPTS (4): The state
 SOCIAL CONTEXT: The state as a ‘transmission belt’ of social pressures
 STATE-SOCIETY: The state as a set of political representatives and policy
experts with preferences and action partly independent, and partly
determined by a wide range of social actors’ pressures
 INSTITUTIONALIST: The state as a set of political institutions; or as a set of
elites with preferences and actions mainly determined by institutions
 ACTION: As a set of political organizations which respond to context,
sociopolitical actors and institutions; and which compete and cooperate
(=interact) to make policy

2005
 STATE-CENTRIC: The state as a unitary, independent actor with formal
monopoly of (residual) power over policy-making
SOCIAL & POLITICAL THEORIES
1950s/60s:
SOCIAL
CONTEXT
SOCIAL PRESSURES
L7
OLD INSTITUTIONALISM
Formal political institutions
L2, L4
SOCIAL ACTORS
(IGs: dependent on
social pressures)
L5
POLITICAL ACTORS
(STATE: independent
of social pressures)
L6
1990s:
INSTITUTIONALISM
(+state-society)
SOCIOP. ACTORS
(STATE-SOCIETY:
interdependent)
L9
2000s:
ACTION
THEORIES
POWER-CENTRED
THEORIES
(interactions among
collective actors &
social structure)
L7
NEW INSTITUTIONALISM
(state institutions &
state/PPs/IGs’ organization)
L4, L9
RATIONAL
CHOICE
(interactions
among
individuals
L7, L9
ACTOR-CENTERED
INSTITUTIONALISM
(interactions among
institutions & elites)
2005
1970s/1980s:
ACTORCENTRED
L3
CAUSAL MAPS
Social context & social actors theories
Proposals of
politically
active groups
2005
Socioeconomic
& cultural
changes
Changing class
structure &
new social
needs
Government
action/Policy
change
State-centered theories
State formation
(bureaucratization,
democratization
Changing group and
social needs
How state
organizations &
parties operate
Government
action/Policy
change
What politically
active groups
propose
Source: Orloff & Skocpol, 1984
CAUSES OF THE WS
Social
structure
Coalition formation &
Political competition
* Electoral campaigns
* Policy campaigns
Socialdemocratic
parties, unions &
voters
Liberal parties,
progressive (state)
elites, social protest
SOCIAL
2005
Dominant
national
subcultures
Christian &
conservative
parties, insurers,
unions & voters
SOCIOPOL.
POLITICAL
Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987
Policy
change
POLICY
2005
THE THEORIES (2):
- Old and new debates
SOCIAL vs. POLITICAL THEORIES
“FATE”
POLITICAL ACTORS
(as representatives) 
independent of social groups
SOCIAL CONTEXT
Convergence theory

Structural theories:
capitalist/working class
strength depends on
distribution of ownership


Cultural theories:
INTEREST
GROUPS
(as delegates
of social
groups 
dependent on
mandate)
2005

SOCIOPOLIT.
ACTORS 
CHOICE
interindependent
national (anti- or statist)
cultures inherited from
history

Bussiness associations & Unions

Professional associations
Contextual theories:

Policy experts
unusual conjunctures,
policy windows

Citizens´ preferences (= PO)

Mass media

Social movements
CHANCE
ACTORS & ACTION ACROSS THEORIES
POWER
ACTION
ACTOR-CENTRED
THEORIES (statecentric/state-society)
Public interest
(officials’ autonom.
prefs./socioP infl.)
State/SocioP
capacity: inst + fin
+ know + CA res.
Autonomous/
INSTITUTIONAL
THEORIES
Institutional norms
& values
Formal institutions Induced –
‘socialized’
RATIONAL CHOICE
Game theory
Private (self-)
Interests
Financial
Resources
Strategic
ACTOR-CENTRED
Ideas, interests &
INSTITUTIONALISM institutions
Instit. (+ fin &
know) resources
Strategic/
Induced
POWER-CENTRED
THEORIES
Fin + know +
instit + org. + CA
resources
Strategic/
Dependent
on socioP infl.
Resources
(ideas), interests
& ideologies
Dependent on
socioP influen.
2005
PREFERENCES
ACTION-CENTERED THEORIES
Positions in the main debate on causation in policy sciences:

Interaction
models
Rational
models
Power-centred theories
• Social groups
• Power resources
• Collective action
• Coalitions
Institutionalism
• Organizations
• Rules & norms
• Expectations
• Formal power
From actor-centered (simple) to action-centered (complex):



From monocausal explanations: emphasys on one actor as key determinant
To multicausal models which:
 Compare the relative preferences & power resources of actors
 Analize the interactions between institutions, past policy and context
 Map actors’ changing choices and strategies
 Examine actors’ interactions in the political process...
2005
Rational choice
• Individuals
• Interests
• Resources $
• Competition
Incremental
models
TOWARDS TWO MAIN THEORIES?
ACTOR-CENTRED INSTITUTIONALISM
POWER-CENTRED TEORIES
 FROM (EC.) ACTION THEORIES:


Changing strategy & resources as key causes of
policy change

Actors as complex coalitions of political
organizations and social groups steered by
political leaders & enterpreneurs



Choice & strategy as key causes of policy
change
Political actors as individuals  links with
society reduced to basic resources ($, vote) +
internal cohession assumed rather than
investigated
Preferences as the main actors’ feature +
formal institutional power resources
Politics as a balanced game: interests compete
on equal terms, none has permanent
advantage
 FROM ACTOR-CENTRED THEORIES:

Dominant actors (with formal, institutional
political power) explain policy change
 FROM STRUCTURAL THEORIES:

Social power resources as the main actors’
characteristic

Politics as an unequal, oligopolistic game in
which stakeholders have permanent advantage

Access and strength of stakechallengers &
weakest social groups explains policy change
 Stakeholders must be divided
2005
 FROM (EC.) ACTION THEORIES:
CAUSES OF POLICY CHANGE:
Operationalization in WS/HC research
 Access
 Conjunctural
factors: ec crisis, wars
Socioeconomic structure:
• Ownership, income
• Education, knowledge
• Social capital (status, support)
• Sociopolitical structure:
• Cleavages and political identities
Values: Culture and subcultures
•
CONTEXT
•

Interest groups
 Profesional assocs.
 Poilitical parties
 State authorities
 Citizens: PO/SM
 Mass media
Preferences
Resources

Distrib. of formal pol. power:
electoral law, constitution,
federalism, corporatism
 Contracts and org. structures
 Norms of behaviour
 Sanctions/incentives
POLITICS:
Strategies,
Interactions
POLITICAL ACTORS
INSTITUTIONS
Individual and collective
-
Formal and informal
POLICY
Adapted from Walt and Wilson 1994
Entitlements & rights
 Regulation of power, ownership,
behaviour, contracts)
 Redistribution: Financing & RA
 Production of goods & services

2005
& participation
 Policy strategies
 Coalition-building
 Competition and cooperat.
 Changing resources
 Learning
2005
EVIDENCE:
DETERMINANTS OF
WS EXPANSION
EVIDENCE
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
First incorporation of political institutions (‘constitutional structure’)
Strength of federalism: low, medium, high

Strength of bicameralism: low, medium, high

Existence of presidentialism: yes, no

Electoral system: Majoritarian, proportional modified, proportional

Popular referendum: yes, no

Left corporatism: degree

(Openess of voting regulation: estimated via voter turnout)

First disaggregation of the DV: The outcome we should study is not pro-WS
or anti-WS but but rather the type of welfare policies: eg.

Expenditure in Social Security benefits (total)

Expenditure in transfer payments (cash transfers; excludes health care)

Government revenue (indicator of state capacity  state ownership)

Entitlements: who are the beneficiaries, on which basis (income,
employment, citizenship)  Decommodification index (L1)

Benefits equality (vs. Benefits proportional)  REDISTRIBUTION
2005

EVIDENCE
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
1. Socioeconomic context (as control variables)

Aged, unemployed, economic growth, price & profits level

Socialdemocratic government boost expenditure, universalism & public
provision of services + weak effects on cash transfers

Christian Democratic parties boost cash transfers proportional to income
3. Actors (2): Statist theory

Strong + effects of state fiscal capacity

Weaker effects of state employment capacity
4. Institutions: Statist/institutionalist theory

Inconsistent effects of government centralization and corporatism

Significant effects of constitutional structure (number of veto points)
5. Process and action

Strong + effects of political mobilization (voting) of the lower classes

But not of social protest
2005
2. Actors (1): Partisanship theory
EVIDENCE
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
General findings on causal mechanisms behind WS expansion
A. Some factors have direct, clear effects:

Strength of Social & Christian Democracy (strong subcultures + parties)

Constitutional structure (institutional concentration of state power)

State fiscal capacity (financial power resources of the state)

B. Other factors have less direct effects, either contingent (on
conjuncture/country) and/or conditional (on interactions with other vars.)


Eg.: Federalism, social protest, economic context, state employment
capacity
C.Other factors are so correlated to each other that is difficult to know about
their independent effects on policy

Eg.: Aging and left vote; consensual democracy and corporatism
2005

ACTION-C. THEORIES. 4. Evidence
1. Interactions among IVs  or need to split into two (recodification)

1. Social protest (* social groups):
Mobilization of lower classes: + WS

Mobilization of upper classes: - WS

Mobilization aparently no signficant effects on WS

Need to model the interaction= No. Mobilized * Predominant upper (0) /
lower (1) classes

Or split the varible No. mobilized lower classes/Idem upper
2005

2. Correlations between Ivs (multicollineality): need to ommitt some

1. Ec. development, old age and left vote:
Direct or indirect effects of aging?

2. Openess of the economy, left & ChD vote, corporatism, WS expenditure
Aging
WS expansion
Left vote
ACTION-CENTRED THEORIES. 4. Evidence
A. Power-centred theory: Hichs & Mishra (cont.) :
RESOURCES
ANTI-WELFARE
 Central government
Left & (ChD) center parties
Right parties
 Interest organization
Organized pro-W group activism
Organized a-W group activ.
 Political mobilization
Social protest (lower classes)
Direct action (upper classes)
 Voting mobilization
Newly mobilized voters
Low voter turnout
 Territ. centralization
Unitary countries
Federal/devolved countries
 Statutory access of Igs
YES: Left corporatism
NO: Pluralism
Financial resources
High profit rates, inflation (?)
Low profit rates, deflation
State fiscal & fin. capacity
High revenue as % of GDP
Low revenue as % GDP
State involvmnt as
producer
High public as % tot employment
Low % public employment
Policy legacy-social
learning–national culture
High status civil service,
collectivism, equity
Corrupted bureaucracies,
individualism, freedom
Political-CA resources
Institutional resources
2005
PRO-WELFARE
2005
THE FUTURE:
THE BATTLE FOR PUBLIC OPINION
IN HEALTH POLITICS
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.
2005

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 1920s1960s; 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
2005

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, AND perceptions of process &
equity problems are indicators of bad performance of
public HC

Perceived performance constitutes the most important
cause=input of HC reform for policy-feedback theory
2005

DETERMINANTS

Interests: social structure vs. choice

Values  CULTURE
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) 
POLITICS

Performance  POLICY

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
2005

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

Media and industry more influential; doctors & peers less;
government depends

More educated = autonomous citizens?
2005

DETERMINANTS OF SUPPORT FOR STATE
INVOLVEMENT,
24 OECD countries, ISSP 1997
PUBLIC HC
Woman
.15*
.09*
Age
.004
.02*
Unemployment
.36*
.03
Egalitarian ideology
.76*
.37*
Unemployment
.17*
.12*
National ideology
.29*
.03
INDIVIDUAL LEVEL
NATIONAL LEVEL
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.
2005
PUBLIC UNEM. POLICY
PO: SUMMARY & CONCLUSIONS
2005
 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 decisionmaking 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
WHO PARTICIPATES?
 At the aggregate level, the decision to engage in
collective action depends on
 2. the extent to which there are political elites/organizations who
actively mobilize (and represent) their constituencies (power
resources theories  actor/action);
 3. ... which in turns depends on the extent to which state policies
grants equal political & social rights to under/priviledged groups
(policy feedbacks)
 4. the openess of democratic institutions to direct political
participation (institutionalism), eg voting regulations,
neocorporatism, popular legislative initiative, referendum
NOTE: Olson’s thesis are compatible with all the above
2005
 1. the intensity of political conflict across social cleaveages
(class/income, religion/values, community/ethnia), ideologies and
political issues (social structuralism) and ...