Claudia Landwehr

Five types of OECD healthcare systems: Empirical results of a deductive classification

This article classifies 30 OECD healthcare systems according to a deductively generated typology by Rothgang and Wendt [1]. This typology distinguishes three core dimensions of the healthcare system: regulation, financing, and service provision, and three types of actors: state, societal, and private actors. We argue that there is a hierarchical relationship between the three dimensions, led by regulation, followed by financing and finally service provision, where the superior dimension restricts the nature of the subordinate dimensions. This hierarchy rule limits the number of theoretically plausible types to ten. To test our argument, we classify 30 OECD healthcare systems, mainly using OECD Health Data and WHO country reports. The classification results in five system types: the National Health Service, the National Health Insurance, the Social Health Insurance, the Etatist Social Health Insurance, and the Private Health System. All five types belong to the group of healthcare system types considered theoretically plausible. Merely Slovenia does not comply with our assumption of a hierarchy among dimensions and typical actors due to its singular transformation history.

Institutional Determinants of Deliberative Interaction

A central assumption of deliberative theory is that political preferences are endogenous to decision-making processes in which they are transformed by communicative interaction. We identify discursiveness and coordination of interaction as central determinants of preference change and develop a typology of political modes of interaction that affect the likelihood of preference change differently. These properties are in turn influenced by institutional characteristics of the fora in which communicative interaction takes place. To illustrate our approach empirically we present a comparative analysis of two extreme modes of interaction, ‘debate’ and ‘deliberation’, providing a case study of a parliamentary debate and a citizen conference on the same conflict: the import of embryonic stem cells in Germany. We assess the discursiveness and coordination as well as the amount of preference transformation in both forums.

Democratic Meta-Deliberation: Towards Reflective Institutional Design

Theories of deliberative democracy are popular for their promise that in a deliberative polity, democracy can realise both participatory politics and rational policies. However, they are also confronted with the allegation that by qualifying essentially non-democratic practices as deliberative, they inadvertently (or not) become accomplices in the trend towards post-democratic governance. A central example of such a development is the rise of non-majoritarian bodies to which governments delegate decision making, thereby de-politicising conflicts and turning democratic discourses into technocratic ones. This article adopts a systemic perspective on deliberative democracy, asking whether non-majoritarian forums can be legitimated in a democratic system and whether they can contribute to their deliberative quality. It is argued that the legitimation of delegated decision-making is not possible without a culture and practice of democratic meta-deliberation which enables reflective institutional design.

The uncertain potential of policy-learning: a comparative assessment of three varieties

This article reviews recent conceptual debates on cross-national and cross-sectoral policy-learning in the political science literature. It proceeds from the argument that the existing literature is characterised by the absence of a comparative assessment of the risks and potentials of different strategies of policy learning. This sin of omission does not only have significant implications for the study of policy learning but also for its practice. The authors use the normative concept of improvement-oriented learning to assess the risks and potentials of three learning strategies: imitation, Bayesian updating and deliberation. They observe that the distribution of risks and potentials is most advantageous in deliberative learning strategies, but that imitation is the most risky learning strategy, and Bayesian updating ranges somewhere in-between.

What explains 'generosity' in the public financing of high-tech drugs? An empirical investigation of 25 OECD countries and 11 controversial drugs

In times of increasing cost pressures, public healthcare systems in Organisation for Economic Co-operation and Development (OECD) countries face the question of whether and to which extent new high-tech drugs are to be financed within their public healthcare systems. Systematic empirical research that explains across-country variation in these decisions is, however, almost non-existent. We analyse an original dataset that contains coverage decisions for 11 controversial drugs in 25 OECD countries using multilevel modelling. Our results indicate that the ‘generosity’ with which controversial new drugs are publicly financed is unrelated to a country’s wealth and general expenditure levels for healthcare. However, healthcare systems financed through social insurance contributions tend to be more generous than tax-financed ones. Moreover, we uncover evidence suggesting that the institutional characteristics of the decision-making process matter systematically for decisions on whether to finance controversial drugs.

The Europeanization of Health Care Coverage Decisions: EU-Regulation, Policy Learning and Cooperation in Decision-Making

Abstract The paper presents two cases of Europeanization in health policy – an area that has so far been viewed as hardly affected by European integration. We show that even in the less likely case of coverage decision-making, some traces of Europeanization can be found. This is possible because the Commission has a strong interest in further integration in this field and all other relevant actors have motives to at least engage in cooperation. Our first case deals with the EU’s transparency directive and shows that this has forced member states to establish formal decision-making procedures, but did not result in a harmonization of decision-making processes and institutions, which is why the Commission has fostered cooperation and networking. The second case looks at the Europeanization of health technology assessment, demonstrating how cooperation and policy learning take place and how the Commission has successfully promoted the emergence of a new policy field.

Value congruence in health care priority setting: social values, institutions and decisions in three countries

Most developed democracies have faced the challenge of priority setting in health care by setting up specialized agencies to take decisions on which medical services to include in public health baskets. Under the influence of Daniels and Sabins seminal work on the topic, agencies increasingly aim to fulfil criteria of procedural justice, such as accountability and transparency. We assume, however, that the institutional design of agencies also and necessarily reflects substantial value judgments on the respective weight of distributive principles such as efficiency, need and equality. The public acceptance of prioritization decisions, and eventually of the health care system at large, will ultimately depend not only on considerations of procedural fairness, but also on the congruence between a societys values and its institutions. We study social values, institutions and decisions in three countries (France, Germany and the United Kingdom) in order to assess such congruence and formulate expectations on its effects.

Demokratische Legitimation durch rationale Kommunikation

Die Kernaussage deliberativer Demokratietheorien klingt viel versprechend: Unter den Bedingungen tief greifender gesellschaftlicher Konflikte und groser Unsicherheit soll durch den Austausch von Argumenten in einem machtfreien Diskurs Verstandigung oder sogar ein Konsens erzielt werden, wobei zugleich erwartet wird, dass eine solche Losung unter sachlichen und moralischen Gesichtspunkten rational ist. Deliberation als eine Form der politischen Interaktion bildet damit das Zentrum einer Demokratietheorie, die auf Gedanken aus liberalen und republikanischen Theorien zuruckgreift und diese um kommunikations- und erkenntnistheoretische Uberlegungen erganzt.

Reconciling credibility and accountability: how expert bodies achieve credibility through accountability processes

ABSTRACT Arguments about the legitimate role of expert bodies in Europe often centre on the following question: Does their independence help to make policies credible or should they be made democratically accountable to principals and stakeholders? This article claims this is a false dichotomy. It does so by arguing theoretically that credibility can be achieved through accountability processes. Then, drawing on exemplary case studies, this article identifies distinctive accountability processes for ensuring credibility: revisable competencies, deliberation over institutional design, and engagement in public justification. Credibility and accountability are thus not conflicting, but co-constitutive aims of delegation to expert bodies. The analysis provides European policy makers and others with a guide for thinking beyond the contrast between ‘democratic accountability’ and ‘independent credibility’.

Where Democrats Disagree: Citizens’ Normative Conceptions of Democracy:

While support for the essential norms of liberal electoral democracy is high in almost all developed democracies, there is arguably also a gap between democratic aspirations and democratic practice, leading to dissatisfaction among citizens. We argue that citizens may hold very different normative conceptions of democracy which are equally compatible with support for liberal democracy, but lead to different expectations where institutional design and democratic practice are concerned. Satisfaction with democracy may thus depend on congruence between such normative conceptions and institutionally entrenched norms. Drawing on survey data from Germany with a comprehensive item battery on attitudes towards democratic decision-making, we identify four distinct factors leading to disagreements over democratic decision-making. We explore how these are related to personality, styles of cognition and political attitudes, and show that different expectations arise from them, such that regime support is affected by the normative conception(s) of democratic decision-making individuals subscribe to.