Real reform begins within: an organizational approach to health care reform

Health care systems are under pressure to control their increasing costs, to better adapt to evolving demands, to improve the quality and safety of care, and ultimately to ameliorate the health of their populations. This article looks at a battery of organizational options aimed at transforming health care systems and argues that more attention must be paid to reforming the delivery mechanisms that are so crucial for health care systems' overall performance. To support improvement, policies can rely on organizational assets in two ways. First, reforms can promote the creation of new organizational forms; second, they can employ organizational levers (e.g., capacity development, team-based organizations, evidence-informed practices) to achieve specific policy goals. In both cases organizational assets are mobilized with a view to creating complete health care organizations -- that is to say, organizations that have the capacity to function as high-performing systems. The challenges confronting the development of more complete health care organizations are significant. Real health care system reforms may likewise require implementing ecologies of complex innovation at the clinical, organizational, and policy levels. Policies play a determining role in shaping these new spaces for action so that day-to-day practices may change.     

Health care system change and the cross-border transfer of ideas: influence of the Dutch model on the 2007 German health reform

To increase understanding of the cross-border transfer of ideas through a case study of the 2007 German health reform, this article draws on Kingdon's approach of streams and follows two main objectives: first, to understand the extent to which the German health reform was actually influenced by the Dutch model and, second, in theoretical terms, to inform inductively on how ideas from abroad enter government agendas. The results show that the streams of problem recognition and policy proposals have not been predominantly influenced by the cross-border transfer of ideas from the Netherlands to Germany. The Dutch experience was taken into consideration only after a policy window opened by a shift in politics in the third, the political, stream: the change of government in 2005. In many respects, the way Germany learned from the Netherlands in this case sharply contrasts with an image of solving policy problems by either lesson drawing or transnational deliberation. Instead, the process was dominated by problem solving in the sphere of politics, that is, finding a way to prove the grand coalition was capable of acting.     

The roles of non-state actors in climate change governance: understanding agency through governance profiles

Globalization processes have rendered non-state actors an integral part of global governance. The body of literature that has examined non-state actor involvement in global governance has focused mainly on whether and how non-state actors can influence states. Less attention has been paid to the comparative advantages of non-state actors to answer questions about agency across categories of non-state actors, and more precisely what governance activities non-state actors are perceived to fulfil. Using unique survey material from two climate change conferences, we propose that different categories of non-state actors have distinct governance profiles. We further suggest that the different governance profiles are derived from particular power sources and that agency is a function of these profiles. The study thereby contributes to a strand in the literature focusing on the authority of non-state actors in climate governance and broadens the methodological toolkit for studying the “governors” of global governance.     

Health care financing reforms in Germany: the case for rethinking the evolutionary approach to reforms

Health care reform has been a perpetual issue in German politics since reunification. Reform initially focused on restructuring the health care system of the former East Germany. It has subsequently focused on questioning whether the financing of the German social health insurance (SHI) system is sustainable, in light of economic malaise that characterized the 1990s and heightened global competition. In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.     

Key actors in UN environmental governance: influence,reform and leadership

In the introductory article it was concluded that the effectiveness of the UN environmental institutions studied was quite low. Key actors, especially the US and the EU, play a considerable role in explaining the course of development in these institutions. However, this does not mean that these processes are mainly state-driven as a number of other factors matter. The potential for reform and increased effectiveness is limited as the main actors, the US the EU and G-77/China have very different interests and perceptions as to the future directions of these institutions.

Tort reform proposals: a toolbox for change

Tort reform is controversial because of the need to balance cost considerations with the legitimate needs of plaintiffs who have suffered malpractice injury. In addition, proponents and opponents of the different proposals often formulate their positions based largely on anecdotal evidence and concerns of special interest groups rather than careful studies. As a result, it may be some time before malpractice reform is addressed comprehensively at the federal level, leaving the states to their own reform devices.     

Access and allocation in earth system governance: water and climate change compared

A significant percentage of the global population does not yet have access to safe drinking water, sufficient food or energy to live in dignity. There is a continuous struggle to allocate the earth’s resources among users and uses. This article argues that distributional problems have two faces: access to basic resources or ecospace; and, the allocation of environmental resources, risks, burdens, and responsibilities for causing problems. Furthermore, addressing problems of access and allocation often requires access to social processes (science, movements and law). Analysts, however, have tended to take a narrow, disciplinary approach although an integrated conceptual approach may yield better answers. This article proposes a multi-disciplinary perspective to the problem of access and allocation and illustrates its application to water management and climate change.