Health Care Reform in Britain and Germany: Recasting the Political Bargain with the Medical Profession

Health care systems in the postwar period have been governed by political bargains between the state and the medical profession that have delinzated their respective powers and jurisdictions. Recent health care cost containment reforms in Britain and Germany are altering these bargains, and thereby challenge the prerogatives and autonomy of the medical profession in health policy formulation and in administration of the health care systems. But these challenges to doctors' power and autonomy vary between the two countries. Britain's 1989 “internal market” reforms attack the corporatist bargain with physicians by introducing market mechanisms into the National Health Service and, at the same time, strengthening central state control of the health care system. In Germany, on the other hand, the government's 1992 reforms only partially breached the corporatist bargain with doctors in order to strengthen rather than destroy this governance arrangement. The government has tried to curb what it views as excessive power of doctors while still allowing them a significant degree of corporatist self-governance. The reform efforts in both countries highlight some of the problems with different governance arrangements in health care systems and, more specifically, the difficulties associated with a market in health care.     

Between regulatory field structuring and organizational roles: Intermediation in the field of sustainable urban development

Recent contributions in the domains of governance and regulation elucidate the importance of rule‐intermediation (RI), the role that organizations adopt to bridge actors with regulatory or “rulemaking” roles and those with target or “rule‐taking” roles. Intermediation not only enables the diffusion and translation of regulatory norms, but also allows for the representation of different actors in policymaking arenas. While prior studies have explored the roles that such RIs adopt to facilitate their intermediation functions, we have yet to consider how field‐level structuring processes influence (and are influenced by) the various and changing roles adopted by RI. In this study we focus on the mutually constitutive relations between field‐level change processes and the evolving roles of RIs by studying the rise of the International Council for Local Environmental Initiatives (ICLEI)/Local Governments for Sustainability, an RI serving as a bridge for sustainable urban development policies between the United Nations and local authorities. Using ICLEI as an illustrative case, we theorize four different processes of regulatory field structuration: problematization, role specialization, marketization, and orchestrated decentralization. We discuss their implications for RI roles in the field and further theorize the changing dynamics of trickle‐up intermediation processes as an RI gains power and influence.     

Measuring multi‐level regulatory governance: Organizational proliferation,coordination, and concentration of influence

As regulation increasingly results from the interplay of a wide array of different actors operating at different levels, it has become crucial to focus on how these constellations of regulatory actors operate. Although this research field presents huge potential for theoretical development, we still lack the measurement techniques to allow systematic comparative research. We contribute to filling this gap with four indices measuring crucial characteristics of multi‐actor regulatory arrangements: (i) the scope of organizational proliferation; (ii) the extent of coordination between regulatory actors; (iii) the amount of influence that each individual regulatory actor has on the sector regulation; and (iv) the extent to which the regulatory influence is concentrated in the hands of one or a few actors. We argue that our indices are sufficiently systematic, reliable, and flexible to be applied in a variety of research contexts relating to multi‐level and multi‐actor regulatory governance.     

The effectiveness of NGO self‐regulation: theory and evidence from Africa

Non‐governmental organizations (NGOs) play an increasingly important role in public service provision and policy making in sub‐Saharan Africa, stimulating demand for new forms of regulatory oversight. In response, a number of initiatives in NGO self‐regulation have emerged. Using cross‐national data on 20 African countries, the article shows that self‐regulation in Africa falls into three types: national‐level guilds, NGO‐led clubs and voluntary codes of conduct. Each displays significant weaknesses from a regulatory policy perspective. National guilds have a broad scope, but require high administrative oversight capacity on the part of NGOs. Voluntary clubs have stronger standards but typically have much weaker coverage. Voluntary codes are the most common form of self‐regulation, but have the weakest regulatory strength. This article argues that the weakness of current attempts to improve the accountability and regulatory environment of NGOs stems in part from a mismatch between the goals of regulation and the institutional incentives embedded in the structure of most self‐regulatory regimes. The article uses the logic of collective action to illustrate the nature of this mismatch and the tradeoffs between the potential breadth and strength of various forms of NGO self‐regulation using three detailed case studies. Copyright © 2008 John Wiley & Sons, Ltd.     

Pressure,Legitimacy, and Innovative Behavior by Public Organizations

According to New Public Management (NPM) doctrines, public organizations involved in service delivery and policy implementation will be induced to innovative behavior if they have enough managerial autonomy and simultaneously are subjected to managerial pressure, such as result control by government or competition of other providers. This NPM pressure‐response model is tested by using survey data on 84 Flemish public organizations. These tests provide evidence for the assumed effect of NPM‐like pressure on the innovative behavior of public organizations. However, the empirical model shows more complex relationships as is assumed by NPM doctrine. These complex relationships are corroborated and explained by making reference to a multiple‐case study of four Flemish public organizations. An expanded political/administrative pressure‐response model, referring to legitimacy as a motivational force, is suggested in order to explain innovative behavior by public organizations. This model may help to understand the preconditions for spontaneous adaptation of public organizations.     

Global nanotechnology regulatory governance from a network analysis perspective

Over the last decade, there has been a proliferation of nanotechnology regulatory initiatives, developed to ensure the responsible development of nanotechnology applications. This article examines the emergence and diffusion of environmental, health and safety (EHS) policies dealing with nanotechnology. Drawing on a citation network analysis of global nanotechnology regulatory governance, the article analyzes the role of key organizations at multiple levels and their interplay in initiating and diffusing occupational safety and health policies. It shows that private international standard‐setting organizations become “centers of information,” which play a strategic role as intermediaries that diffuse national policies globally. Through this process, these centers help to shape supranational policies. Such an understanding of the role of international private standard‐setting organizations sheds new light on the current debate over the privatization and internationalization of EHS governance.     

International diffusion of regulatory governance: EU actorness in public procurement

This paper attempts to go beyond actor‐centered explanations of the European Union's (EU) presence in regulatory politics by examining the role of the EU in the diffusion of regulatory norms and practices. We explore the international diffusion of public procurement policy, to which multiple organizations and especially the EU and the World Trade Organization have made an active contribution. Using the “opportunity‐presence‐capability” scheme, we argue that the EU is actively co‐shaping the global agenda on public procurement, mainly as a result of the “opportunity” and “presence” dimensions of its global actorness and its role in the horizontal diffusion of public procurement regulations between international organizations. For “EU as a global actor” literature to offer valuable explanations, an in‐depth analysis of its relationship with other international organizations, such as the World Trade Organization, reveals significant interactions and the co‐shaping of policy agendas.     

Does formal independence of regulators change? Evidence from Portuguese agencies

The rise of the regulatory state has led to the global diffusion of independent regulatory agencies (IRAs). IRAs are the result of the tension between the functional demands of regulatory capitalism and the need of politicians to control policies. Their life cycles have not been linear. Their legal statuses have changed over time, affecting their degrees of independence. This article revisits Gilardi's formal independence index, makes an in‐depth diachronic and cross‐sectorial analysis of 11 regulatory bodies in Portugal, and searches for explanations for the observed variations. It concludes that the formal independence of IRAs tends to increase due to external pressure and the need of governments to project credible commitment, but principals only grant as much independence as they see fit to satisfy those (external) demands (for change).     

Pedagogy of regulation: Strategies and instruments to supervise learning from adverse events

Diverse scholars have argued that standards and performance measurements are “instruments of control” that have a profound influence on the day‐to‐day lives of individuals and organizations, causing constitutive effects. Regulatory bodies increasingly use standards to oversee and monitor the regulated. This paper discusses the Dutch Health and Youth Care Inspectorate's use of both standards and a performance measurement system introduced to monitor how Dutch hospitals investigate and learn from serious adverse events. Rather than focusing on how standards affect regulated practices and organizations, our study examines how the use of these instruments affects the standard maker, that is, the Inspectorate. We explore how the Inspectorate's work practices, standards, and coupled performance measurement system influence its regulatory pedagogy, reviewing practices, and decisionmaking. We conclude that standards and performance measurement systems are not by definition “instruments of control” as their constitutive effects are (under)determined by the relationships in which they are enacted.     

Dysfunctional institutions? Toward a New Agenda in Governance Studies

There is a wide‐spread perception among academics and commentators that institutional dysfunction has become increasingly common in important social, political, and economics arenas. Opinion polls show a decline in trust and confidence in major actors and institutions, including inter‐governmental organizations, governments, firms, NGOs, and religious organizations. For some, the core of the problem is that the hitherto well‐functioning states have become less effective in aggregating and acting upon citizens' preferences. Many policy initiatives of the 1990s – deregulation, privatization, new public management, private regulation, regional integration, civil society, and so on – seemed to have failed to meet expectations. This symposium seeks to identify important theoretical and empirical questions about institutional failure, such as why do institutions fail, why are they not self‐correcting, what might be a clear evaluative yardstick and analytic approach by which to measure performance, and to what extent contemporary theories of institutional evolution and design are useful in examining institutional restructuring and institutional renewal? Symposium essays by leading social science scholars offer important insights to inform future work on institutional performance and outline an agenda for institutional renewal and change.     

When doctors shape policy: The impact of self‐regulation on governing human biotechnology

This paper investigates the development and adoption of governance modes in the field of human biotechnology. As the field of human biotechnology is relatively new, voluntary professional self‐regulation constituted the initial governing mode. In the meantime, with the exception of Ireland, all Western European countries have moved toward greater state intervention. Nevertheless, they have done so in contrasting ways and the resulting governance modes for assisted reproductive technology and embryonic stem‐cell research vary greatly. Instead of imposing their steering capacity in a “top‐down” fashion, governments have taken pre‐existing self‐regulatory arrangements in the field into account and built up governance mechanisms in conjunction with private actors and pre‐existing modes of private governance. Our analysis demonstrates that the form and content of the initial self‐regulation explain why the self‐steering capacity of the medical profession was largely or at least partially preserved through hybrid governance systems in Britain and Germany, while in France the self‐regulation was entirely replaced by governmental intervention.     

Decentralization by default: Local governance and the view from the village in The Gambia

Policies to decentralize government activities in The Gambia have been on the agenda for more than a decade but no decisions have been taken. During this period the quality of government services to rural areas has declined dramatically. The linchpin of provincial administration, the divisional commissioner, has become redundant as far as development is concerned. The activities of line ministries have deteriorated as their expenditures have been reduced and they lack the funds to permit staff to operate at village level. Area councils that were previously regarded as wasteful are now totally discredited. Village development committees (VDCs) have been formed, but the results are mixed and often they are ineffective. By default, decentralization in the 1980s and early 1990s in The Gambia has been achieved by non-governmental organizations (NGOs), which have rapidly grown in number and significance. This article explores the perceptions of villagers in The Gambia about the various organizations that are meant to serve their needs. Its conclusion speculates on proposals to implement a new decentralization policy in the country and points to the need for aid agencies to adopt a less simplistic approach to the issue of local governance.     

Intermediary roles in regulatory programs: Toward a role‐based framework

This paper develops a role‐based framework of intermediaries in regulatory programs. In examining the types of roles that organizations adopt in regulation and governance, we argue that roles have important implications for understanding organizational and program level dynamism and outcomes. We use the Regulator–Intermediary–rule‐Taker framework to describe how organizational roles can be adopted through assignment, appropriation, or promotion. We then go deeper into how intermediaries adopt a variety of different roles in key regulatory programs. We examine generic intermediary roles across programs that involve four main groups of activities: creating and/or organizing, coordinating between programs, supporting implementation, and voicing an opinion. All in all, our role‐based framework allows for a novel relational way to understand interorganizational and institutional dynamism in complex, interactive, and ever‐changing regulatory regimes.     

Building Capacity in Election Administration: Local Responses to Complexity and Interdependence

Public administration research has identified networks, professionalization, and collaboration with community interests as potential principles by which public organizations can enhance their capacity and effectiveness. This article explores the implementation of these principles by election administrators at the local level, where their ability to conduct elections is the subject of current scrutiny. Findings indicate that election administrators established networks, professional organizations, professionalization requirements and community collaborations prior to the passage of the Help America Vote Act of 2002. Findings also suggest that local election efforts may become more effective as a result of certain provisions of the act that promote centralization and information dissemination. Local election administrators may also continue to build capacity by applying these public administration principles.     

The role of independent regulators in policy making: Venue‐shopping and framing strategies in the EU regulation of old wives cures

This article addresses debates on the formulation of public policy, building upon a body of literature which has focused on the interconnectedness between the venues of policy action and the way issues are defined. It does so by focusing on the strategic role of policy actors in a policy subfield and their attempts at manipulating either frames or venues in order to shape policy. The novelty here consists in pointing to the involvement of regulators in such strategic action. An emerging body of research has indeed shown that the activity of formally independent regulators is not necessarily limited to the implementation of delegated regulatory competencies and that they are increasingly engaged in policy‐making activities. Thus, by resorting to the agenda‐setting and framing literature, the article sheds light on novel pathways through which regulators intervene in policy‐making activities, making a claim that they have very good ‘tools’ at their disposal in order to shape policy. These dynamics are examined in the case of the last piece of the EU's pharmaceutical framework – the 2004 Directive on Traditional Herbal Medicines – which provoked intense debate among manufacturers of herbals, retailers, consumers, and both EU‐level and domestic‐level regulatory authorities.     

Information, market government, and health policy: a study of health data organizations in the states.

Information is essential to the success of market-oriented policies. Information on health care costs and quality is collected and distributed by state governments through health data organizations (HDOs) to enhance competition and lower costs in the medical industry and to improve consumer choice among medical alternatives. This article examines the information collected, produced, and distributed by state health data organizations in Colorado and Pennsylvania. Findings reveal that information was not the objective determinant of choice and competition as market-oriented policy designers had hoped. Nor did market-oriented bureaucracies produce and distribute data readily accessible for public choice. Instead, information produced and distributed by these HDOs was the result of political and bureaucratic exercises that conform much more to classic interest group policymaking and captured bureaucracies than to contemporary market-oriented government ideals. The findings underscore the extraordinary difficulties facing federal-level policy designers as they contemplate introducing market-oriented health care policies on the national level.     

Reversing delegation? Politicization,de-delegation,and non-majoritarian institutions

Elected governments and states have delegated extensive powers to non-majoritarian institutions (NMIs) such as independent central banks and regulatory agencies, courts, and international trade and investment organizations, which have become central actors in governance. But, far from having resolved the balance between political control and governing competence or removed certain issues from political debate, NMIs have faced challenges to their legitimacy by elected officials and sometimes attempts to reverse delegation through “de-delegation”. Our special issue studies the politicization of NMIs, and then whether, why and how it leads to de-delegation through reducing the formal powers of NMIs or increasing controls over them. In this article, we examine how to analyze de-delegation, how politicization of NMIs has developed, and how it has affected de-delegation. We underline not only institutional rules that constrain elected officials but also the actions of NMIs themselves and their relationships with other NMIs as part of multi-level governance systems. We find that politicization has varied, but even when strong, elected officials have not introduced widespread and long-lasting de-delegation; on the contrary, they have frequently widened the powers of NMIs. Insofar as elected politicians have sought to curb NMIs, they have often preferred to use existing controls and non-compliance. Finally, we consider the wider implications of the combination of politicization and lack of de-delegation for broader issues of governance such as the division of powers between the elected and unelected and democratic accountability.     

Looking a Gift Horse in the Mouth: Challenges in Managing Philanthropic Support for Public Services

Collaborations between nonprofit and public sector organizations have become an increasingly important phenomenon in state and local public service delivery since the publication of the Winter Commission report in 1993 . This article focuses on one of the less studied types of public–nonprofit collaborations, those in which philanthropic support from nonprofit organizations supplements the resources and activities of public agencies. Drawing on the case of “nonprofit‐as‐supplement collaborations” that support park services in New York City, this article documents the benefits and drawbacks associated with such collaborations. While they can provide increased resources and encourage management innovations, they also can lead to inequities in the availability and quality of services, the preponderance of particularistic goals over the broader public interest, and the politicization of previously bureaucratic decision making. The authors offer two strategies for public managers to realize more effectively the benefits yet mitigate the shortcomings of these collaborations.     

Managing in the Regulatory Thicket: Regulation Legitimacy and Expertise

Although the influence of government regulation on organizations is undeniable, empirical research in this field is scarce. This article investigates how the understanding of and attitudes toward government regulation among public, nonprofit, and for‐profit managers affect organizational performance, using U.S. nursing homes as the empirical setting. Findings suggest that managers’ perceptions of regulation legitimacy—views of regulation fairness, inspectors’ effectiveness, and internal utility of the mandates—positively affect service quality. Subgroup analysis suggests that managers’ views of regulation matter in nonprofit and for‐profit organizations but not in public organizations. In nonprofit homes, performance declines when managers report higher regulatory expertise—better knowledge of the regulatory standards. In for‐profit facilities, frequent communication with regulators lowers quality. These findings suggest that the regulated entities’ views of government regulation are central to their success, which necessitates improvements in the regulatory process.     

Co‐enforcing Labor standards: the unique contributions of state and worker organizations in Argentina and the United States

Labor inspection is a central response to the tremendous gap between formal regulations and outcomes for workers throughout the world. Scholarly and policy debates on labor regulation have focused on improving the targeting of enforcement, changing strategies of street‐level agents, and creating private alternatives to state regulation. This paper argues that these proposals, while important, fail to systematically incorporate the potential contributions of worker organizations and, as a result, overlook opportunities for co‐enforcing labor standards, a key element of labor inspection. By contrast, we develop a framework to analyze the relationships between worker organizations and state regulators that underpin co‐enforcement. We ground this framework empirically in comparative cases, set in Argentina and the United States, presenting two cases of co‐enforcement in highly different institutional contexts. In so doing, we seek to illuminate key attributes of labor inspection and guide attempts to enhance enforcement by forging partnerships between regulators and worker organizations.