PUBLIC‐PRIVATE PARTNERSHIP CONTRACTS: A TALE OF TWO CITIES WITH DIFFERENT CONTRACTUAL ARRANGEMENTS

This paper analyses regulation by contract in public‐private partnerships (PPPs) for infrastructure services. Although the benefits of competition for the market and subsequent regulatory contracts are recognized, the literature also identifies contract design failures. When considering these limitations, it is useful to distinguish between contracts associated with purely contractual PPPs (concessions) and contracts for institutionalized PPPs (mixed company). Two cases from the Portuguese water sector are used to illustrate problems arising in the preparation of public tender documents: the ‘best’ bidder is often not the winner. Often, risks are not allocated correctly nor is effective monitoring ensured. Comparisons between the two types of contracts show how external regulation can be useful in mitigating contractual problems. This examination of bidding procedures and contract design yields several implications for policy‐makers; in addition, the study presents recommendations for improving regulatory contracts.     

THE EUROPEANIZATION OF HEALTH CARE GOVERNANCE: IMPLEMENTING THE MARKET IMPERATIVES OF EUROPE

The paper examines the Europeanization process and the impact of the European Union (EU) on national healthcare policies, using the example of Denmark. The analysis reveals that although health policy formally falls within the competence of member states, the impact of the EU is becoming increasingly conspicuous and has contributed to a gradual restructuring of healthcare boundaries as well as of some of its organizing principles. Furthermore, the process and impact have a de‐structuring effect on the more traditional governance tools used in relation to healthcare. The paper concludes that the EU has a significant impact and that we may be witnessing the formation of a new institutional legacy that represents the initiation of a Europeanized healthcare model: a model emerging around a new set of stakeholders, principles and structures, which includes the market, principles of free movement, patient choice and patient rights institutionalized and safeguarded by the EU.     

DECIDING HOW TO DECIDE: THE CASE OF HEALTH CARE RATIONING

One of the challenges awaiting health care systems around the world is the containment of expenses in the face of exploding costs for new drugs and treatments. In most countries, the allocation of health care has not been politicized so far and the problem is still treated as a purely regulative one. However, there is increasing interest in the procedures used for priority-setting. The paper argues that while normative standards for their evaluation are desirable, more attention should be paid to institutional factors and their effects. I identify two demands on decision-making—discursiveness and coordinativeness—from which I derive four ideal-typical procedures. By way of international comparison, corresponding empirical cases are analysed. I conclude with considerations on whether efficient and publicly accepted decisions over the allocation of health care are possible and, if yes, by means of what type of procedures and in what forum(s) they can be taken.     

NATIONAL HEALTH INSURANCE: A CASE STUDY IN THE USE OF PRIVATE NON-PROFIT MAKING ORGANIZATIONS IN THE PROVISION OF WELFARE BENEFITS

Some of the key features of co-operation between the State and other sectors (private, voluntary and informal) in providing welfare benefits are illustrated in the experience of the National Health Insurance scheme which operated in this country between 1911 and 1948. This is the only example in the UK of a major welfare scheme operating over a considerable period which utilized private, if non-profit making, organizations as responsible agents for administration. Under the scheme certain categories of working people were compelled to insure themselves against sickness. The scheme was administered and benefits paid through a multiplicity of independent 'approved societies', with insured people free to choose which society they belonged to. Contributions were paid by employers as well as employees, with a state subsidy on top. This study indicates that any future development of joint welfare provision with the private sector must overcome certain inherent divergencies in values between the public and private sectors.     

THE ODYSSEY OF ADMINISTRATIVE REFORMS IN GREECE, 1981–2009: A TALE OF TWO REFORM PATHS

In Greece, two distinct reform paths led to institutional building and economic managerial types of reform. These two reforms, with the exception of the period 1996–2004, when both institutional and economic reforms were attempted, did not attract the same degree of attention. Institutional reforms were more successful than attempts at managerial reforms; reform implementation on the other hand varies. Economic and managerial reforms can be observed with regard to economic competition, the opening up of the market, and reducing the size of public sector, all areas where pressure from the EU has been stronger. Decentralization reforms were more important politically than administratively. Citizens' rights and service delivery were conceived as reforms of democratization and modernization rather than as managerial reforms. ‘Agencification’ amounted to circumventing existing ministerial structures. Change was incremental, and reforms were minimally guided by the New Public Management paradigm, because of little emphasis on changes imbued by managerial and economic values. Reform dynamics benefited not only from outside pressures but also from the operation of internal, ‘modernizing’ forces.     

PERSONAL EXPERIENCE AND THE EVALUATION OF PARTICIPATORY INSTRUMENTS IN SPANISH CITIES

The article examines the role that personal experience with participatory mechanisms plays in the explanation of the perceived efficacy of these instruments. The first part demonstrates that , contrary to most expectations, citizens who have direct experience with these processes have a more negative evaluation of their performance. Where does this frustration effect come from? The second part analyzes three potential explanations of why this pattern emerges: (1) overly high prior expectations; (2) the existence of an underdeveloped institutional participatory context; and (3) the design of participatory mechanisms. We use a public opinion survey representative of the Spanish adult population living in medium sized cities to test these hypotheses. Results show that participants' overly high expectations are not crucial. On the other hand, people who live in more participatory cities and those who participate in individually based mechanisms do not feel the same disappointment with participatory experiences.     

PROFESSIONAL AUTONOMY AND PASTORAL POWER: THE TRANSFORMATION OF QUALITY REGISTERS IN SWEDISH HEALTH CARE

In the context of the recent transformation of control in Swedish health care, the changing role of quality registers are analysed as a vivid example of how professional groups become involved in new modes of regulating professional work. Based on a critical appraisal of the main currents in the research on NPM, it is argued that understanding ‘the productive side of power’ is an underexploited theme. The main part of the article is devoted to a detailed analysis of how a seemingly insignificant, but in its consequences important, professional practice was transformed from a resource for clinical research, an entirely professional concern, to a tool for hierarchical control. In the concluding sections, a number of important conditions for the successful use of ‘soft power’ in modern societies are identified and discussed.     

THE CONDITIONS FOR HEALTH AND SOCIAL CARE POLICY: ROUTINES AND INSTITUTIONS IN THE DUTCH CASE OF NEED ASSESSMENT

By focusing on institutions (rules for action) and routines (patterned behaviour) our intention is to contribute to the understanding of government policy and its outcomes in health and social care. We analysed data to show how the relationship between a new idea for a routine and new rules from the government on the one hand, and existing rules and routines in society on the other, as well as the interaction between rule makers and rule takers (i.e. those who are governed by those rules), have an impact on the change or maintenance of routines. The data concern the case of government policy for need assessment (that is, assessment of needs) in The Netherlands. As our discussion will show, even a national government, however, is not able to completely impose its will on other agents in order to change existing routines. The concept of ‘negotiated order’ helps us to understand why. In the case reported here, the Dutch government and the home care agencies had to exercise give and take, the outcome being a suboptimal result for both.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

PERFORMANCE, EVALUATION AND THE NHS: A CASE STUDY IN CONCEPTUAL PERPLEXITY AND ORGANIZATIONAL COMPLEXITY

This paper adopts a comparative perspective towards the analysis of performance evaluation in the National Health Service. The NHS, it is argued, is best seen as an organization which is not unique but which ranks high on a number of dimensions: uncertainty about the relationship between inputs and outputs; heterogeneity of activities and aims; the ambiguity of the available information. These factors help to explain why performance evaluation in the NHS is both conceptually and organizationally problematic, and fragmented and professionalized in practice. By looking at the same factors in other organizations, it may be possible to start constructing a framework for examining the problems of performance evaluation in different settings.     

ORGANIZATIONAL REDUNDANCY? A CRITICAL APPRAISAL OF THE GEAR PROJECT

'Area approaches' have become a new conventional wisdom for dealing with urban deprivation. Such thinking is evident in Michael Heseltine's Liverpool 'initiative'. This article contributes to an emerging critique of such approaches, by highlighting some political and organizational problems rather than stressing their incipient economic difficulties. Arguably the biggest anti-deprivation project in Western Europe, the Glasgow Eastern Area Renewal scheme (GEAR) is taken as a case study. Official claims of success are juxtaposed against an alternative perspective outlining possible weaknesses and dilemmas. Critical analysis leads to the conclusion that the GEAR constellation of organizations may be best regarded as a mutually non-effective organizational set. The persistence of such an institution, while serving short-term political and administrative needs, may unwittingly produce longer-term negative political and social consequences. The authors argue that if such problems are to be avoided in the future, the political and organizational drawbacks of this type of initiative must be appreciated.     

ECONOMIC DISCOURSE AND THE MARKET: THE CASE OF COMMUNITY CARE

The UK government has introduced fundamental reforms into the provision of social care. The'community care'programme, which was fully implemented in 1993, requires local authorities to assess the needs of potential users, to design an individual package of care that reflects those needs, and to purchase the package from a range of statutory, voluntary and private providers. Thus the new arrangement introduced a'quasi-market'in community care, along the lines of those already operating in other areas of the UK public sector, such as health and education. Hitherto, much analysis of the functioning of such markets has been conducted within a neo-classical economic framework. This article examines the relevance to the complex new community care market of three alternative theoretical perspectives: the transaction costs literature, the Austrian school and the new economic sociology. It is concluded that, although neoclassical economic discourse has been influential in shaping policy, no single perspective can capture all the issues relevant to analysing the market in community care. Therefore, in evaluating the reforms, an eclectic theoretical approach will be required which draws upon a variety of economic discourses.     

THE ENTERPRISE FORMULA,NEW PUBLIC MANAGEMENT AND THE ITALIAN HEALTH CARE SYSTEM: REMEDY OR CONTAGION?

Health care services represent an extraordinary experimental ground for introducing wider political and institutional transformations of the state. The adoption of entrepreneurialism into European health care systems has strengthened technocratic decision making over traditional mechanisms of political control. In Italy, in the midst of a severe legitimacy crisis affecting the administrative and political systems at the beginning of the 1990s, New Public Management ideas seemed ‘the’ remedy against the pathological politicization of distributive politics. Much hope has been placed since in a new and ascending group of general managers, entrusted with the ambitious mission of running health care services more efficiently and with the unenviable expectation of resuscitating public trust in welfare institutions. By analysing the 1992 Amato government’s landmark health care reform in its substantive changes, this paper explores the last decade’s main reform trajectories of Italian health care reforms that irreversibly transformed its institutional arrangements and organizational structure, namely the enterprise formula and the regionalization of the health care sector. The paper suggests that the political turmoil of 1992–94 served as catalyst for radical policy change and argues that the single most important explanation for the enactment of New Public Management‐type reforms rests in a new executive reinterpretation of its legislative prerogatives and function.     

THE POVERTY OF SCIENCE: A CRITICAL ANALYSIS OF SCIENTIFIC AND INDUSTRIAL POLICY UNDER MRS THATCHER

The present government's policy for publicly funded science, which centres on selectivity and centralization, could damage Britain's capacity to innovate. The policy follows from a desire by government to control the scientific community and from the advice of some scientists and science policy experts. This paper details the contradictions in the government's thinking on industrial and scientific questions, and challenges the central, and usually unexamined, assumptions which are used to justify existing policy for science.     

VARIETIES OF NEW INSTITUTIONALISM: A CRITICAL APPRAISAL

New institutionalist approaches reflect a common commitment to the significance of institutional arrangements and a common criticism of atomistic accounts of social processes. Beyond these core assumptions, new institutionalism is characterized by a great variety of positions, which are sometimes complementary and sometimes conflicting. The different positions can be captured in six'vignettes': the mythic institution, the efficient institution, the stable institution, the manipulated institution, the disaggregated institution, and the appropriate institution. The vignettes differ in the significance they accord to: formal and informal institutional rules; change and stability within institutions; and the role of rational action and norm-governed behaviour in creating and sustaining institutions. The comparative critical assessment of the vignettes can provide the basis for a multi-theoretic approach to the study of institutions and institutional change.     

THE PARADOX OF POLICY DIVERSITY IN A UNITARY STATE: COMMUNITY CARE IN BRITAIN

Studies of policy-making and management in health and related fields have generally been confined to England even when professing to embrace Britain or the United Kingdom. The assumption of a unitary state in which the policy lead is given by Westminster/Whitehall is shown to be grossly misleading in the case of community care policy. Considerable variations exist not only in policy means but also in policy ends. The paper demonstrates the limitations of studying health and personal social services adopting a unitary state perspective. It argues for more intra-Britain comparative work aimed at evaluating the costs and benefits of service variations in different policy fields.     

CONTRACTORS' EXPERIENCE OF COMPULSORY COMPETITIVE TENDERING: A CASE STUDY OF CONTRACT CLEANERS IN THE NHS

Compulsory competitive tendering (CCT) has been an important instrument of Conservative government economic policy since 1979. Its effectiveness in generating cost-effective services depends on competition to supply the service in question.
The NHS domestic market is large and, prior to the introduction of CCT, promised to be profitable for contractors. Many contract cleaners with office cleaning experience entered. In the event the costs of entry were heavy, and the profit margins of established firms were reduced. When contracts have been awarded to firms, they tended to be to those with a track record. Many firms therefore withdrew; and the few that remained have profit margins in the NHS little different from those found elsewhere. Of more than by firms with a serious interest in entry, probably no more than a handful can have come out of the experience in net profit in the first seven years.
The experience of CCT in the market for NHS domestic services has shown that a degree of competition in the market can be achieved, arguably because of the presence of direct service organizations. Competition for this market, on the other hand, can be limited by the high costs of entry.     

BENCHMARKING IN THE PUBLIC SECTOR: A CRITICAL CONCEPTUAL FRAMEWORK

How can we critically address benchmarking? By conceptualizing benchmarking as a normalizing governing technology, a space is cleared for analysing some of the power relations brought into play in benchmarking activities. As a device of power, benchmarking depends upon the production of normalizing knowledge and the freedom or self‐governing capacities of those who are benchmarked. The fruitfulness of this conception is illustrated through an example from the Danish hospital system.     

PUBLIC EXPENDITURE AND POLICY IMPLEMENTATION: THE CASE OF COMMUNITY CARE

This article explores the contention that the conventions of public expenditure accounting conceal, rather than reveal, the real nature and implications of resource trends. A benchmark — a constant level of service output — is established as a basis for examining the relationship between trends in expenditure inputs and service outputs. Changes in unit costs are identified as the major source of deviation between expenditure and output trends. The impact of resource constraint on policy and policy-implementation is then examined in relation to one, essentially stable, area of policy in the personal social services: community care.
The meaning of the term'policy' is far from straightforward and community care is best understood as the interaction of relatively independent streams of policy, towards service outputs and resource inputs, extant in both central and local government. Mechanisms by which policy streams could be reconciled are of particular interest and an innovative example — joint finance — is examined in some detail.