The small ministry with the large reach: Using relationships to extend organisational capacity

Abstract

The Ministry of Pacific Island Affairs is charged with identifying the aspirations and needs of Pacific people residing in Aotearoa/New Zealand, providing high quality policy advice to governments and their ministries, and with advising ministries on how these might be achieved. With a large, dispersed client population, a small staff and limited resources, this represents a major task for the Ministry. However, the Ministry has been able to deliver these by forming a network of co‐operative relationships with both its communities and the other ministries and agencies charged with formulating policy and delivering services to the communities. But limited resources prevent the Ministry mediating each of these relationships on a continuing basis.

This paper focuses on the ways in which the Ministry of Pacific Island Affairs went about forming and using a web of “partnerships” with Pacific communities, social policy agencies, and service providers to overcome some of the challenges which a small ministry with limited resources faces. This paper attempts to show how a larger web of relationships became central to the Ministry's community development mission.

The Ministry formed and nurtured a series of local partnerships between communities’ representatives and the ministries which deliver local programs. The arrangements free the Ministry to monitor the relationships and the performance of the ministries and agencies. Previously, we have described the organisational model as an apogāleveleve, or spider web, in which the web is a series of defined relationships created and maintained by the “centre” for a specific purpose: obtaining the best possible outcomes for constituent communities. Each operative relationship is connected via the centre, and mediated by the centre, which also monitors the performance of the system as a whole and moves to repair damage anywhere it occurs to ensure that the web as a whole continues to deliver outcomes. The network of co‐operative relationships, or partnerships, has made it possible for the Ministry to achieve significant results relatively quickly with limited resources.     

Standing Up for Health? Health Departments in EU Health Policy Formulation

When are health departments and ministers influential across policies? This article looks for an explanation in the variable ability of the French, German and UK health departments to influence their states' approaches to EU health policy‐making. It proposes that the extent of departmental power within government and the likelihood that the government imposes a single line across all its departments explain the variable success of the three health departments in influencing EU policy – some have voice in their government's overall stance on EU matters, as in the UK, some have the ability to escape central control and pursue their own agendas in Brussels, and some have neither, and sometimes find themselves pursuing overall strategies that conflict with their analyses and preferences, as in France. The framework, using exit and voice, should be generalizable to the overall influence of health or other ministries in general government policy.     

The Organization of Health Policy Functions in the German Federal Government

This article gives an account of the organizational history of the German federal ministry of health (and its predecessors) since the beginnings of public policy intervention in health care. In doing so it analyses the role of ministerial organization and examines the functional and political rationale underlying acts of reorganizing the tasks and resources of federal ministries. This analysis has two sides: the first concerns the expressive function of organizational form, as revealing something about the scope and perceived importance of the policy field, while the second interrogates the policy‐shaping role of organization and the political influence of the federal health ministry in health policy‐making. The article thus considers the organizational location of health issues in the central executive from the perspective of what it reveals about government goals and priorities. Then it examines possible policy implications. It looks at resources and the size of the ministry as a first attempt to learn something about the ministry's political weight. The question of policy implications draws our attention away from organization and resource allocation and back to a focus on policy‐making and policy outcomes. The final section therefore examines substantive policy implications that might have emanated from the organizational consolidation of the federal health ministry. It concludes that one such policy implication might be the erosion of the social insurance model as a regulatory idea in health‐care services and financing.     

Ideas and Institutional Change in Social Security: Conversion,Layering, and Policy Drift*

Objectives. In recent years, social scientists such as Kathleen Thelen and Jacob Hacker have introduced new concepts to assist in the understanding of institutional change. Fostering some of these concepts, this article proceeds to augment the theoretical debate on institutional change in social science and policy research. A discussion of Social Security development in the United States advances the article's main objective: to uncover the relationship between ideational processes and policy development. Methods. Qualitative and historical analysis is offered to examine three major policy episodes: the enactment of the 1939 amendments, the first mandate of the Nixon Administration (1969–1972), and the push for Social Security privatization that emerged in the 1990s. Results. First, the analysis suggests that, through the process of institutional conversion, the 1939 amendments and the Nixon‐era reforms altered the nature of Social Security. Second, the discussion on Social Security privatization stresses the impact of layering and policy drift on public and private pensions. Conclusions. The concepts of conversion, layering, and policy drift receive further empirical support through the presented analysis. Moreover, this article suggests that, for a full understanding of institutional change, a systematic analysis of ideational processes is necessary.     

Pension privatization in crisis: Death or rebirth of a global policy trend?

From 1981 to 2007, more than thirty countries worldwide fully or partially replaced their pre‐existing pay‐as‐you‐go pension systems with ones based on individual, private savings accounts in a process often labelled “pension privatization”. After the global financial crisis, this trend was put on hold for economic, ideational, and institutional reasons, despite a rise in critical indebtedness that has facilitated pension privatization in the past. Is the global trend towards pension privatization dead or in the process of being reborn, perhaps in a somewhat different form? Several recent trends point to rebirth as policy‐makers scale back public and private pension systems, attend to minimum pensions and “nudge” rather than mandate people to save for retirement.     

Events,Politics and Patterns of Policy‐Making: Impact of Major Incidents on Health Sector Regulatory Reforms in the UK and Japan

This article examines the major malpractice incidents in the late 1990s through early 2000s in the UK and Japan, comparing how these incidents opened up pathways for a new type of hospital regulation in each case. Applying John Kingdon's three‐stream model of agenda‐setting and policy change, the article argues that governance arrangements as well as the policy instruments that a government has at its disposal determine how an event could be translated into a political agenda by throwing light on the problems within the public domain. The long‐term effect of such adverse events is therefore determined by how open the relevant institutional arrangements are, and is enhanced if actors constantly scrutinize the system by proactively setting the agenda. A higher level of political accountability in the UK led to British politicians taking a greater role in promoting patient‐led reforms than Japanese counterparts. However, a political system with clear accountability is more conscious of its own involvement and any potential blame it might receive for policy failures. Therefore, the political class could become more engaged in continuous reforms and the delegation of tasks rather than a constant search for remedial actions. The article sheds light on the interactive aspects of the particular triggering events discussed through the decade of regulatory developments in the two health‐care systems.     

Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

Balancing Efficiency and Legitimacy: Institutional Changes and Rural Health Organization in China

The aim of this article is to contribute to the understanding of the institutional arrangements within which China's rural health facilities are embedded and of the contribution of policy to the creation of these arrangements. Information collected through field observations and in‐depth interviews with the managers, staff and patients of a township health centre indicates that with the gradual evolution of markets, encouraged by state policies, health care in rural China took on more of the characteristics of a commodity. In order to adapt to this change, the health centre and its employees are adjusting their behavioural norms and reconstructing an institutional network within which daily activities of simultaneously fulfilling public health responsibilities and pursuing economic gain are legitimized. This article focuses on the interwoven relationship between politics and markets at the micro level and examines the negotiations between stakeholders in constructing new institutional arrangements. It also describes how health sector managers are creating regulations to influence the performance of their facility. The article argues that while government policies play a crucial role in shaping the direction of development, institutional arrangements strongly influence the attempts by rural health organizations to implement them. It concludes that it is critical to take institutional factors into account in analyzing China's rural health‐care reforms.     

Involvement of Ministries of Health in Health Service Coverage Decisions: Is England an Aberrant Case?

This article examines the involvement of ministries of health in making health service coverage decisions in Denmark, England, France and Germany. The study aims to inform debate in England about the feasibility of reducing perceived ministerial and bureaucratic ‘interference’ in decisions affecting the National Health Service, based on interviews with senior government officials and other health system stakeholders. Ministries of health differ in their involvement in health system governance and coverage decisions (‘the benefits package’), reflecting differences in institutional arrangements. In all four countries, organizations at arm's length or independent from government are either involved in providing technical advice to the ministry of health or have been mandated to take these decisions themselves. However, ministries of health occasionally intervene in the decision‐making process or ignore the advice of these organizations. The Department of Health in England is not an aberrant case, at least in relation to coverage decisions. Indeed, ministries of health in Denmark and France play a larger role in making these decisions. Public pressure, often amplified by the media, is a shared reason for ministerial and ministry involvement in all four countries. This dynamic may thus limit the feasibility of attempts to further separate the NHS from both the Department of Health and wider political pressures.     

The Organization of Decision-making and the Dynamics of Policy Drift: A Canadian Health Sector Example

This historical‐institutionalist case study of public–private change in the rehabilitation health sector in Ontario, Canada, seeks to build on literature about the politics of policy drift, particularly with respect to health care systems. Rather than turning to higher‐order institutional factors, such as federalism and overall financing agreements between states and the medical profession, or to economic indicators such as change in expenditures, however, it posits that the particularities of how welfare‐policy sectors are organized with respect to their decision‐making contribute to drift. Such organization is framed by two factors. The first is the set of rules by which the public–private boundary is drawn, and the second is the structuring of public institutions that set legislation and regulation, and organize the policy networks attendant on them, around these boundaries. The degree of coordination or fragmentation among these, this case suggests, is a factor in the politics and dynamics of drift.     

Social health protection in Cambodia: Challenges of policy design and implementation

The Government of Cambodia is implementing ambitious reform initiatives to improve the country's social health protection system. In January 2018, it was announced that the Health Equity Fund (HEF), which is fully subsidized by a joint government‐donor initiative for the reimbursement of user fees for the poor at public health facilities, is to be expanded to some segments of informal workers belonging to associations, as well as to commune and village chiefs. Since 2017, the National Social Security Fund (NSSF) has provided social health insurance for formal economy workers in enterprises with eight employees or more. In January 2018, it was expanded to civil servants and all employees regardless of the size of the enterprise. However, this article highlights that the new ambitious reforms are not accompanied by careful planning as regards funding, service delivery, human resources and institutional design. This article therefore aims to examine key policy issues and challenges for Cambodia's ambitious reform of its social health protection system in terms of resource generation, population coverage, strategic purchasing and governance.     

Public Satisfaction with the Health System and Popular Support for State Involvement in an East Asian Welfare Regime: Health Policy Legitimacy of Hong Kong

The legitimacy of social policies has gained increasing attention in the past decade, against the backdrop of fiscal austerity and retrenchment in many nations. Policy legitimacy encompasses public preferences for the underlying principles of policies and the actual outcomes as perceived by citizens. Scholarly knowledge concerning the legitimacy of health policy – a major element of modern social policy architecture – is, unfortunately, limited. This article seeks to extend the scholarly debates on health policy legitimacy from the West to Hong Kong, a member of the East Asian welfare state cluster. A bi‐dimensional definition of health policy legitimacy – encompassing both public satisfaction with the health system and the normative expectation as to the extent of state involvement in health care – is adopted. Based on analysis of data collected from a telephone survey of adult Hong Kong citizens between late 2014 and early 2015, the findings of this study demonstrate a fairly high level of satisfaction with the territory's health system, but popular support for government responsibility presents a clear residual characteristic. The study also tests the self‐interest thesis and the ideology thesis – major theoretical frameworks for explaining social policy legitimacy – in the Hong Kong context. Egalitarian ideology and trust in government are closely related to both public satisfaction with the system and popular support for governmental provision of care. However, the self‐interest thesis receives partial support. The findings are interpreted in the context of Hong Kong's health system arrangements, while implications for the territory's ongoing health policy reform are discussed.     

Externalizing an ‘Asset Model’ of Activation: Creative Institutional Work by Frontline Workers in the Norwegian Labour and Welfare Service

The past two decades have brought significant shifts in Norwegian activation policy towards a joined‐up and employability‐enhancing approach to labour market inclusion in order to promote return‐to‐work despite health problems or disabilities. Utilizing a concept from health promotion, we term this approach an ‘asset model’ of activation. The Norwegian Labour and Welfare Service (NAV) and its local offices are the main agents implementing the new policy. This article aims to investigate the strategies that the frontline workers of NAV engage in, in order to externalize an ‘asset model’ in the adjacent medical field and to the general practitioners (GPs) in particular. We analyze these strategies as forms of creative institutional work – the purposive actions undertaken to change existing presumptions and opinions among relevant actors. We argue that although the new activation policy is not theirs to develop, in order to bring about changes in practice, ‘creating’ institutional work by the frontline workers is required. Our findings show that the frontline workers develop strategies in order to externalize an asset model to the GPs, as part of operationalizing an ‘activation’ reform into practice. We identify four forms of ‘creating’ institutional work undertaken by the frontline workers: ‘defining’ – enacting legislation and regulation in relation to GPs; ‘constructing normative networks’ – creating a more collaborative relationship with the GPs; ‘educating’ – teaching the GPs about the rules and regulations, and the opportunities and assistive measures they can offer to the injured; and thereby also ‘changing normative associations’ of GPs towards the activation policy.     

Class politics in the sandbox? An analysis of the socio‐economic determinants of preferences towards public spending and parental fees for childcare

This article analyses the socio‐economic determinants of public preferences towards public spending and parental fees for childcare and how they are conditioned by institutional contexts. Previous studies of childcare policy preferences have focused on attitudes regarding the provision of care. However, when it comes to questions of financing, we know astonishingly little about how supportive individuals actually are of expanding pre‐school early childhood education and care, and how support varies across different socio‐economic groups in society. This is an important research gap because childcare provision and how it is financed have redistributive implications, which vary depending on the institutional design of childcare policy. Using novel and unique survey data on childcare preferences from eight European countries, we argue and show that preferences towards expanding childcare are more contested than it is often assumed. The institutional structure of childcare shapes how income matters for preferences towards how much should be spent and how provision should be financed. Where access to childcare is socially stratified, the poor and the rich develop different preferences towards either increasing public spending or reducing parental fees in order to improve their access to childcare. The findings in this article suggest that expanding childcare in systems characterised by unequal access can be politically contested due to diverging policy priorities of individuals from different social backgrounds.     

Social Enterprise – A New Phenomenon in the Field of Economic and Social Welfare?

Drawing upon insights from historical institutionalism, this article critically examines the origins of social enterprise and its emergence into the mainstream policy arena. It begins by relating the social enterprise idea to major non‐state/non‐private institutional traditions, including the European social economy, US non‐profits and the UK charitable sector, and places it within the specific field of economic and social welfare. In so doing, the article contests the idea that social enterprise is a new phenomenon in the social welfare field and proposes instead that the supposed ‘novelty’ of social enterprise as an organizational form and a subject of public policy lies primarily in the nature of the socio‐political and economic context of the 1980s–1990s, during which time it became ‘en vogue’. The process of institutionalization of social enterprise and its ascension into the mainstream policy arena is examined in more detail in the case of England during the time New Labour was in office and beyond, and lessons are drawn from this experience concerning both the role that social enterprise plays or is expected to play as a vehicle to address economic and social needs, and how this is intertwined with both a dominant neo‐liberal discourse, as well as alternative perspectives that emphasize more equalitarian and sustainable development paths. The article concludes with some reflections in relation to the apparent consensus that seems to exist around social enterprise as a legitimate subject of public policy and the resulting social enterprization of public services which is currently taking place in England.     

Public–Private Partnerships in European Old‐Age Pension Provision: An Accountability Perspective

Over the last few decades, the boundary between public and private responsibility in old‐age pension provisions has been redrawn throughout Europe. A new, public–private mix has emerged, not only in pension policy, but also in pension administration. The purpose of this article is to map and conduct a comparative analysis of the administrative design of public–private partnerships (PPPs) in European pension regimes, with a specific focus on how accountabilities are institutionally enforced within the PPP design. Previous literature has recognized accountability as an important factor in promoting trust in mandated pension schemes. However, as the literature on PPPs suggests, institutional arrangements of accountability are more complex in the case of PPPs than has been suggested by previous studies on pension administration. Thus, there is a need for further elaboration of existing comparative models. This study's analysis examines 19 old‐age pension schemes that existed in 18 European countries at the beginning of 2013. The findings suggest that significant variations in accountability structures exist, even among schemes that are similar in terms of their pension policy targets. It is concluded that various schemes suffer from ineffective accountability structures that may compromise the legitimacy and sustainability of PPP‐type pension schemes.     

Big Business in a Thin Market: Understanding the Privatization of Residential Care for Children and Youth in Sweden

This article analyzes the transformation of Swedish residential care for children from a regionally coordinated, public social service system into a thin, but highly profitable, national spot market in which large corporations have a growing presence. Marketization and privatization are theorized as complex processes, through which the institutional structure and logics of this small, but significant, social policy field changed profoundly. Using official documents, register data, media reports and existing research, three consecutive phases in the development of the children's home market are identified since the early 1980s. Change was driven on one hand by policies inspired by New Public Management, which shifted public authority horizontally to the private sector, and vertically to local authorities (funding) and to the state (regulation). On the other hand were the responses of local authorities and private actors to the changing incentives that policy shifts entailed. During the first two phases, both the proportion and size of for‐profit providers increased, and the model of family‐like care was replaced by a professional model. Cutting across the trend of privatization in the third phase was establishment of a parallel system of homes for unaccompanied refugee children – mostly in public ownership. Similarities with privatization in the English system of children's care homes are noted. By showing how the Swedish market for residential care has been created by policy and by actors’ responses to those reforms, the article provides a foundation for thinking through how the predictable, significant and well‐documented problems of such care markets might be addressed.     

“Respect for each gender”: Gender,equity and backlash in Australia's male health policy

Australia is one of the few countries which has specific health policies for boys/men and girls/women as distinct groups. In this article I present an analysis of the discourses of gender, equity and disadvantage drawn upon in Australia's men's health policy. Through comparison with the women's health policy, I show that a dual focus on the essential differences between men and women and the ways in which the health system has failed men contribute to an adversarial gender politics, positioning men and women as rivals with competing needs. Reflecting broader debates concerning the negative impact of societal change on boys/men, I argue that, in its current form, Australia's health policy both taps into and, crucially, legitimises backlash politics, enabling it to ‘pass’ as sound public policy.     

The distributive impact of private pensions in the context of the institutional designs of public pension systems across OECD countries

Income inequality has been increasing across the developed world for the last few decades. The welfare state has played an important role in reducing income inequality, but it has now entered into an era of transformation. The shift from public to private pension schemes is one of the main policy instruments in this shift. An increase in private pensions is expected to create an increase in income inequality. Therefore, using data from OECD SOCX, this study examined how the effect of private pensions on income inequality might be changed by the institutional design of public pension systems. The results suggest that the effect of private pensions differs when the institutional design of the public pension system is considered. An increase in private pensions is related to an increase in income inequality when the public pension has a low level of coverage and a high level of earnings‐relatedness.     

Social Policy in Greece: Rhetoric versus Reform

This paper reviews the major social policy developments in Greece during the 1980s and 1990s, focusing on social security, health and employment policies. It argues that the concept of social policy and the practice of politics have been distorted in this country. Social policy reflects the legacy of a heavily politicized and centralized policy‐making system, an impoverished administrative infrastructure and poorly developed social services. Its emergence is characterized by the pursuit of late and ineffective policies. It lacks continuity, planning and coordination, being oriented towards short‐term political expediency. It is largely insurance‐based, reproducing huge inequalities and institutional arrangements which are behind the times. It provides mainly cash benefits, low‐quality but rather expensive health services and marginal social welfare protection. Moreover, the lack of a minimum income safety net confirms the country's weak culture of universalism and social citizenship. By implication, complex policy and interlocking interest linkages have tarnished the “system” with a reputation for strong resistance to progressive change. At the same time, sources of change such as globalization, demographic developments, new household and family/gender patterns, unstable economic growth, fiscal imperatives, programme maturation, as well as persisting unemployment, changing labour markets and rising health care costs, have produced mounting pressures for welfare reform.