Negotiating authority: a comparative study of reform in medical training regimes

Recently the medical profession has faced increased outside pressure to reform postgraduate medical training programs to better equip young doctors for changing health care needs and public expectations. In this article we explore the impact of reform on professional self-governance by conducting a comparative historical-institutional analysis of postgraduate medical training reform in the United Kingdom and the Netherlands. In both countries the medical training regime has shifted from professional self-regulation to coregulation. Yet there are notable differences in each country that cannot be explained solely by diverging institutional contexts. They also result from the strategic actions by the actors involved. Based on an assessment of the recent literature on institutional transformation, this article shows how strategic actions set negotiating authority processes into motion, producing new and sometimes surprising institutional arrangements that can have profound effects on the distribution and allocation of authority in the medical training regime. It stresses the need to study the interactions among political context, the properties of institutions, and negotiating authority processes, as they are crucially important to understanding institutional transformation.     

Market-oriented health care reforms and policy learning in the Netherlands

In this article we analyze the evolution of market-oriented health care reforms in the Netherlands. We argue that these reforms can be characterized as policy learning within and between competing policy programs. Policy learning denotes the process by which policy makers and stakeholders deliberately adjust the goals, rules, and techniques of a given policy in response to past experiences and new information. We discern three distinctive periods. During the first period (1988-1994), the prevailing corporatist and etatist policy programs were seriously challenged by the proponents of a new market-oriented program. But when it came to political decision making and implementation, the market-oriented program soon lost its impetus because it was technically too complex and could not provide short-term solutions to meet the urgent need for cost containment. During the second period (1994-2000), the etatist program regained its previously dominant position. In parallel to a strengthening of supply and price controls, however, the government also persevered in creating the technical and institutional preconditions for regulated competition. Moreover, public discontent over waiting lists and the call for more autonomy by individual providers and insurers strengthened the alliance in favor of regulated competition. This led to the revival of the market-oriented program in a 2001 reform plan. We conclude that the odds of these new post-2001 reforms succeeding are substantially higher than in the first period due to the technical and institutional adjustments that have taken place in the past decade.