“Promotion tournament 2.0”: Why local cadres expand health‐care provision in China

Previous research has attributed the delayed welfare development in China to the government's traditional obsession with GDP growth target as the principal criteria for cadre promotion. Yet why has health‐care provision significantly expanded since the 2000s? This article argues that as central policies adjusted to incorporate health care as a priority, the cadre assessment system subsequently made it a “hard target,” and thus the competition for office has compelled local cadres to implement health‐care expansion. Apart from the importance of local leaders in policy change as the literature suggests, this article elaborates on the pivotal role of technical bureaucrats by innovatively introducing the “promotion tournament 2.0” model, which emphasizes the knowledge–power coalition between these political actors. By investigating the case of health‐care expansion, this article illustrates the local politics of policy change with various forms of data collected from semi‐structured interviews, newspaper archives, political documents, and official statistics.     

Recentralization and vertical alignment in the French health‐care system

In foreign exemplars, key new public management (NPM) features such as decentralization and devolution of health‐care responsibilities had outcomes below expectations. Other NPM traits such as the patient as overseer of reforms or the empowerment of patient remained elusive. In France, the integration of public values such as greater participation of patients and local actors (NGOs and elected officials) and NPM‐driven private values such as performance evaluation has yet to be seen. Taking advantage of NPM's failings and austerity agenda, a French welfare elite regained control over health‐care policy decisions at the expense of regions and other local actors. NPM outcomes were below expectations. Austerity cures led to weakening of the regional decision spaces, which can be explained under the principal–agent relationship. Accountability shifted to managerial (the professionalization of hospital managers) and legal (governance via regulations) forms in a bid to restore central government control. A democratic recess results from the lack of public engagement in recent health reforms.     

Differential effects of high‐quality child care

In policy research a frequent aim is to estimate treatment effects separately by subgroups. This endeavor becomes a methodological challenge when the subgroups are defined by post‐treatment, rather than pre‐treatment, variables because if analyses are performed in the same way as with pre‐treatment variables, causal interpretations are no longer valid. The authors illustrate a new approach to this challenge within the context of the Infant Health and Development Program, a multisite randomized study that provided at‐risk children with intensive, center‐based child care. This strategy is used to examine the differential causal effects of access to high‐quality child care for children who would otherwise have participated in one of three child care options: no non‐maternal care, home‐based non‐maternal care, and center‐based care. Results of this study indicate that children participating in the first two types of care would have gained the most from high‐quality center‐based care and, moreover, would have more consistently retained the bulk of these positive benefits over time. These results may have implications for policy, particularly with regard to the debate about the potential implications of providing universal child care. © 2002 by the Association for Public Policy Analysis and Management.     

National styles of regulation: Child care in three countries

An analysis of child care regulations in Germany, Sweden, and the United States reveals distinctive national policy styles. A ‘social constructionist’ perspective, with its emphasis on variable problem definitions, helps to explain such differences. However, a full understanding of regulatory differences requires attention to regulatory solutions as well. By disaggregating the concept of regulation, we are able to demonstrate rather different rank-orderings of our three countries in their regulatory solutions. We attribute these differences to cultural, institutional, and political characteristics of the three countries.     

Long-term care: common issues and unknowns

All industrialized countries are grappling with a common problem—how to provide assistance of various kinds to their rapidly aging populations. The problem for countries searching for models of efficient and high-quality long-term care (LTC) policies is that fewer than a dozen countries have government-organized, formal LTC policies. Relatively new surveys focused on the elderly populations of about 25 countries could become the basis for research on which LTC policy design choices have desired outcomes for individuals and society and might be replicable in other countries. As in earlier decades when U.S. researchers created the Current Population Survey (CPS) modules and the Survey of Income and Program Participation to answer policy questions, researchers and policy analysts are now at a point where a concerted effort is needed to generate questions that international comparative research on LTC could answer as well as the data needed to address the questions.     

The decentralization of health care in developing countries: organizational options

The complex ways in which decentralization is practised in the field of government health services are examined. Organizationally, decentralization means a choice between different types of public institution, which vary in terms of: the areas over which they have jurisdiction, the functions delegated to local institutions; and the way decision-makers are recruited, so producing institutions. There is little agreement about the optimum size of areas, either in terms of population or territory. Areas cannot be delimited without consideration being given to the powers to be exercised at each level. The specification of functions always assumes certain things about who will exercise the delegated powers. The two issues cannot be separated. Five structures of decentralization are distinguished, each of which could in principle be created at regional, district and village/community level: the multi-purpose local authority, the single-purpose council, the hybrid council, the single purpose executive agency, the management board, field administration, health teams, and interdepartmental committees. Whatever the institutions used for decentralization, the choice of structures and the ensuing process of decision-making will be highly charged politically. © 1997 John Wiley & Sons, Ltd.     

Policy convergence and divergence in Belgium: Education and health care

Due to the far-reaching devolution of policy competences, Belgium allows for a structured comparison of policy convergence or divergence between Flanders and Wallonia. Focusing on the link between the federal state and the development of policy-making in the regions, this article establishes far-reaching policy divergence between the Flemish and French Communities for education policy, and a beginning of divergence in health care. Radical changes in Flemish education policy have redefined the role of the state. In health care, divergence grows in terms of regulating access to the medical professions and defining the output of medical care. The explanation for this policy divergence lies in political factors more than in policy-related features. Political entrepreneurs play a determining role in seizing upon opportunities to trigger and support change.     

Quality of care assessment: policy relevant issues

This paper reviews the quality assessment literature, presents a study which compares five different methods of assessing quality of care, and proposes policy recommendations. Results are: (1) Most quality assessment issues are a century old. (2) The results of assessment of quality of care are dependent on the method used; therefore, more methodologic research is needed. (3) The use of lists of criteria, concerning what a physician does, to assess quality of care could result in decreased efficiency in the health system by requiring the performance of ineffective procedures. (4) It is not certain that examination of the level of care rendered will increase the health level of the population; therefore, any national program which assesses quality of care must be prospectively evaluated. (5) A quality assessment system must be concerned with both the population who received services at the institution, and the population who did not but for whom the institution is responsible.From the Carnegie-Commonwealth Clinical Scholar Program of the Johns Hopkins University.Supported in part by grants 5R01HS00110 and 5T01HS00112 from the National Center for Health Services Research and Development and by the Carnegie Corporation and Commonwealth Fund. Dr. Brook was a Carnegie-Commonwealth Clinical Scholar and is now a Commissioned Officer in the U.S. Public Health Service stationed at the National Center for Health Services Research and Development. This paper does not represent the official position of this agency.