Market Reforms in Europe: Dynamics Market Reforms in Europe: Dynamics of Policy Fashionof Policy Fashion

Michael I. Harrison*Michael I. Harrison*Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Presented at Academy Health Annual Research MeetingPresented at Academy Health Annual Research MeetingJune 6, 2004, San Diego. June 6, 2004, San Diego.

*Email: mharriso@ahrq.gov*Email: mharriso@ahrq.gov

EXPLAINING DYNAMICS EXPLAINING DYNAMICS OF POLICY FASHIONOF POLICY FASHION

Observations: Observations:

– Policy makers in Britain, Sweden, and the Netherlands adopted Policy makers in Britain, Sweden, and the Netherlands adopted market reform policies quickly and uncritically. market reform policies quickly and uncritically.

– Decision makers and their constituencies soon became disenchanted Decision makers and their constituencies soon became disenchanted with market reforms, once the proposed changes proved hard to with market reforms, once the proposed changes proved hard to implement. implement.

– The health policy agenda shifted quickly, as policy makers explored The health policy agenda shifted quickly, as policy makers explored new options.new options.

Research question: Did the rapid rise and decline of political Research question: Did the rapid rise and decline of political support for market reforms in health care reflect the support for market reforms in health care reflect the dynamics of policy fashion? dynamics of policy fashion?

POLICY FASHION DEFINEDPOLICY FASHION DEFINED

The rapid rise and decline in political support for a set of The rapid rise and decline in political support for a set of policy-related beliefs, principles, programs, or techniques is policy-related beliefs, principles, programs, or techniques is called policy fashion when these shifts reflect the dynamics called policy fashion when these shifts reflect the dynamics and interactions of fashion setting, policy formation and and interactions of fashion setting, policy formation and adoption, and policy implementation.adoption, and policy implementation.

DYNAMICS OF POLICY FASHIONS

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Fashion Setting

Support for Policy Trend

Demand For Policy Fashions

Policy Formation

and

Adoption

Policy Implementation

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FASHION SETTINGFASHION SETTING

Fashion setters --policy gurus, universities, consultants, media Fashion setters --policy gurus, universities, consultants, media -- actively promote new policies.-- actively promote new policies.

Setters define favorite new policies as progressive and Setters define favorite new policies as progressive and rational.rational.

Initial discourse is enthusiastic and uncritical.Initial discourse is enthusiastic and uncritical.

FORMATION AND ADOPTION FORMATION AND ADOPTION OF POLICY FASHIONOF POLICY FASHION

Advocates in governments and agencies urge adoption of Advocates in governments and agencies urge adoption of policies promoted by high-status setters and used by high-policies promoted by high-status setters and used by high-status organizations and sectors. status organizations and sectors.

Policy makers alter fashions from other sectors to fit target Policy makers alter fashions from other sectors to fit target sector.sector.

Proponents build supporting coalitions. Proponents build supporting coalitions.

FORCES CREATING DEMAND FOR FORCES CREATING DEMAND FOR POLICY FASHIONSPOLICY FASHIONS

Norms of progress and rationalityNorms of progress and rationality

Budgeting processes and career ladders in public agenciesBudgeting processes and career ladders in public agencies

Economic cyclesEconomic cycles

Organizational and technical contradictions (e.g., public Organizational and technical contradictions (e.g., public accountability vs. professional autonomy; disease intervention accountability vs. professional autonomy; disease intervention vs. wellness)vs. wellness)

FORCES AFFECTING SUPPORT FOR FORCES AFFECTING SUPPORT FOR POLICY TRENDSPOLICY TRENDS

Trends in political beliefs and valuesTrends in political beliefs and values Social and cultural changeSocial and cultural change Electoral politicsElectoral politics Interactions among policy actorsInteractions among policy actors Organizational and technical conditionsOrganizational and technical conditions Policy precedents and institutional commitmentsPolicy precedents and institutional commitments

   

FORCES UNDERMINING SUPPORT FOR FORCES UNDERMINING SUPPORT FOR IMPLEMENTED POLICY IMPLEMENTED POLICY

Implementation complications and strugglesImplementation complications and struggles Disappointment with resultsDisappointment with results

–   Outcomes below expectationsOutcomes below expectations–   Costs beyond estimatesCosts beyond estimates

Outcomes of policy fashions Outcomes of policy fashions alwaysalways fall below original expectations (and stated objectives) and fall below original expectations (and stated objectives) and costs costs alwaysalways exceed estimates, exceed estimates, because initial expectations were unrealistic and overly optimisticbecause initial expectations were unrealistic and overly optimistic. .

Changes in forces affecting demand for policy trend.Changes in forces affecting demand for policy trend. Competition from other policies, including new policy fashions.Competition from other policies, including new policy fashions.

IMPLEMENTATION COMPLICATIONS & IMPLEMENTATION COMPLICATIONS & STRUGGLESSTRUGGLES

Shifts in involvement of main actors bring changes in Shifts in involvement of main actors bring changes in implementation needs, views, and priorities. implementation needs, views, and priorities.

Main actors:Main actors:– Policy makersPolicy makers– ImplementersImplementers– RecipientsRecipients– Nonparticipating stakeholders, e.g., unions, voluntary groups, voters. Nonparticipating stakeholders, e.g., unions, voluntary groups, voters.

Implementation barriers emerge.Implementation barriers emerge. Policy contradictions surface.Policy contradictions surface. Conflicts emerge between policy and other strongly held Conflicts emerge between policy and other strongly held

values.values. Actors learn about policies and implementation. Actors learn about policies and implementation.

IMPLEMENTATION BYPRODUCTSIMPLEMENTATION BYPRODUCTS

Discourse becomes critical. Discourse becomes critical.

Supporting coalitions grow weaker or fragment.Supporting coalitions grow weaker or fragment.

Popular disaffection grows with policies and policy makers.Popular disaffection grows with policies and policy makers.

Fashion setters and policy makers search for alternative policy solutions. Fashion setters and policy makers search for alternative policy solutions.

CONSEQUENCES OF FASHIONCONSEQUENCES OF FASHION

Challenge taken-for-granted routines and ideas.

Encourage experimentation.

Successive waves of fashion can produce significant changes.

FASHION’S COSTS AND RISKSFASHION’S COSTS AND RISKS

Discourages diagnosis of problems and analysis of program feasibilityDiscourages diagnosis of problems and analysis of program feasibility

Blocks improvement during implementationBlocks improvement during implementation

Wastes resourcesWastes resources

Fails to attain objectivesFails to attain objectives

Burdens the implementersBurdens the implementers

Creates cynicismCreates cynicism

LIVING WITH POLICY FASHIONLIVING WITH POLICY FASHION

Involve those responsible for implementation in policy formulation and planning.

Experiment with policy options before full-scale rollout.

Sponsor research and rapid feedback on implementation.

Train all levels in diagnostic and critical thinking about policies and their implementation.

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