医疗系统改革与路径依赖:观念如何制约南非国家医疗保险政策进程的变革

IF 3.8 3区 管理学 Q1 PUBLIC ADMINISTRATION
Eleanor Beth Whyle, Jill Olivier
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引用次数: 0

摘要

路径依赖理论认为,复杂的系统,如卫生系统,是由先前的条件和决定形成的,对变革具有阻力。因此,重大的政策变革,如卫生系统改革,往往只有在政策窗口期才有可能--过渡或背景危机的时刻,可以重新平衡社会权力动态,使新的政策理念得到考虑。然而,即使在政策窗口期,变革也会遇到阻力。在本文中,我们将探讨思想在制约变革中的作用。我们借鉴了政治学中关于前景理念(政策方案和框架)与背景理念(根深蒂固的集体认知和规范信仰)之间动态关系的理论,以更好地理解理念是如何独立于产生理念的环境条件或支持理念的行动者而施加影响的。为此,我们研究了南非国家医疗保险政策过程中两个明显的政策窗口。分析揭示了观念如何在组织和程序(如政策工具或提供者网络)以及无形的文化规范中制度化--成为霸权和无争议的观念,塑造政策参与者的态度和观点。通过这种方式,观念作为独立变量发挥作用,制约着整个政策窗口的变化。虽然卫生政策分析师越来越认识到意识形态变量在政策过程中的影响,但他们倾向于将意识形态概念化为行动者推动变革的工具。这项分析揭示了将观念(价值观、规范和信仰)视为制约行动者的决策环境的持久特征的重要性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Health system reform and path-dependency: how ideas constrained change in South Africa’s national health insurance policy process

Path-dependency theory says that complex systems, such as health systems, are shaped by prior conditions and decisions, and are resistant to change. As a result, major policy changes, such as health system reform, are often only possible in policy windows—moments of transition or contextual crisis that re-balance social power dynamics and enable the consideration of new policy ideas. However, even in policy windows there can be resistance to change. In this paper, we consider the role of ideas in constraining change. We draw on political science theory on the dynamic relationship between foreground ideas (policy programmes and frames) and background ideas (deeply held collective cognitive and normative beliefs) to better understand how ideas exert influence independently of the contextual conditions that give rise to them or the actors that espouse them. To do so, we examine two apparent policy windows in the South African National Health Insurance policy process. The analysis reveals how ideas can become institutionalised in organisations and procedures (such as policy instruments or provider networks), and in intangible cultural norms—becoming hegemonic and uncontested ideas that shape the attitudes and perspectives of policy actors. In this way, ideas operate as independent variables, constraining change across policy windows. While health policy analysts increasingly recognise the influence of ideational variables in policy processes, they tend to conceptualise ideas as tools actors wield to drive change. This analysis reveals the importance of considering ideas (values, norms, and beliefs) as persistent features of the policy-making context that constrain actors.

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来源期刊
Policy Sciences
Policy Sciences Multiple-
CiteScore
9.70
自引率
9.40%
发文量
32
期刊介绍: The policy sciences are distinctive within the policy movement in that they embrace the scholarly traditions innovated and elaborated by Harold D. Lasswell and Myres S. McDougal. Within these pages we provide space for approaches that are problem-oriented, contextual, and multi-method in orientation. There are many other journals in which authors can take top-down, deductive, and large-sample approach or adopt a primarily theoretical focus. Policy Sciences encourages systematic and empirical investigations in which problems are clearly identified from a practical and theoretical perspective, are well situated in the extant literature, and are investigated utilizing methodologies compatible with contextual, as opposed to reductionist, understandings. We tend not to publish pieces that are solely theoretical, but favor works in which the applied policy lessons are clearly articulated. Policy Sciences favors, but does not publish exclusively, works that either explicitly or implicitly utilize the policy sciences framework. The policy sciences can be applied to articles with greater or lesser intensity to accommodate the focus of an author’s work. At the minimum, this means taking a problem oriented, multi-method or contextual approach. At the fullest expression, it may mean leveraging central theory or explicitly applying aspects of the framework, which is comprised of three principal dimensions: (1) social process, which is mapped in terms of participants, perspectives, situations, base values, strategies, outcomes and effects, with values (power, wealth, enlightenment, skill, rectitude, respect, well-being, and affection) being the key elements in understanding participants’ behaviors and interactions; (2) decision process, which is mapped in terms of seven functions—intelligence, promotion, prescription, invocation, application, termination, and appraisal; and (3) problem orientation, which comprises the intellectual tasks of clarifying goals, describing trends, analyzing conditions, projecting developments, and inventing, evaluating, and selecting alternatives. There is a more extensive core literature that also applies and can be visited at the policy sciences website: http://www.policysciences.org/classicworks.cfm. In addition to articles that explicitly utilize the policy sciences framework, Policy Sciences has a long tradition of publishing papers that draw on various aspects of that framework and its central theory as well as high quality conceptual pieces that address key challenges, opportunities, or approaches in ways congruent with the perspective that this journal strives to maintain and extend.Officially cited as: Policy Sci
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