Besturing PDF

# Besturing ## Box 5.1 Variaties in besturing - The minister of public health decides on the benefits package of the Health Insurance Act. - The minister receives advice from the Healthcare Institute Netherlands. - This institute has an independent board whose members are appointed by the minister...

# Besturing ## Box 5.1 Variaties in besturing - The minister of public health decides on the benefits package of the Health Insurance Act. - The minister receives advice from the Healthcare Institute Netherlands. - This institute has an independent board whose members are appointed by the minister. - The board is assisted by committees with representatives from the healthcare sector. - With the introduction of regulated market forces in healthcare, healthcare insurers are expected to enter into contracts about the provision of care to their insured persons, taking into account their statutory duty of care. - Under the Social Support Act (Wmo), a number of tasks in the field of long-term care have been transferred to municipalities. - The Wmo gives municipalities considerable policy freedom in the exercise of their tasks. - They receive a discretionary budget from the government for their task. - With a view to improving the quality of nursing care, the Quality Framework for Responsible Care was established in 2007. - The signatories include the government, the Inspectorate for Healthcare, and umbrella organisations for healthcare providers, clients and health insurers. - The Broad Healthcare Governance Code sets out a number of principles for transparent governance of healthcare institutions. - The code is an initiative of a number of umbrella organisations for healthcare providers. ## 5.1 Inleiding - Box 5.1 shows some of the diversity in the governance of healthcare in the Netherlands. - Every example shows the governance differently. - The minister is formally in charge of making decisions about the benefits package. - Municipalities perform a variety of administrative tasks under the Wmo. - In the regulated market model, health insurers negotiate on behalf of their insured persons with healthcare providers about a healthcare contract. - The Quality Framework for Responsible Care shows that governance should not be equated with governance by the government. - The Broad Healthcare Governance Code came into being without the direct involvement of the government. - These examples give a first impression of the diversity in governance. - In addition to government bodies, various societal actors are involved. - Governance encompasses much more than hierarchical governance by the government: consultation and negotiation with the field are unavoidable. - In addition to vertical coordination, horizontal coordination also exists. - Governance takes place at different levels and occurs both within formalized frameworks and within looser structures. - Furthermore, governance is not static but dynamic. ## 5.2 Besturing - This chapter is dedicated to governance. - After considering what we mean by governance, we will look at the theme of institutional efficiency and legitimacy. - Five alternative governance models are then considered: anarchy, hierarchical governance, network governance, self-governance and market governance. - The chapter concludes with some examples of governance in practice. - Governance is described in chapter 1 as the totality of rules relating to a policy process and the way in which actors deal with these rules in practice. - Governance rules regulate collective action by actors in tackling policy problems. - The set of governance rules for addressing a particular problem is referred to as the governance or institutional structure. - Every policy process takes place within a particular institutional structure. - The rules provide actors with certain behavioural options for carrying out their tasks, putting their vision into practice, pursuing their interests, etc. - They also ‘define’ a particular power structure. - Although rules determine behaviour, actors can deal with them differently. - For example, a person's authority does not automatically result in its use; there may be good reasons for deploying certain instruments such as consultation and persuasion first, and then only resorting to more forceful instruments, such as instructions, if consultation and persuasion are ineffective. - Similarly, societal actors may or may not decide to take legal action to force a decision or prevent one. - In her study into the development of social health insurance in Europe, Immergut shows that medical associations in Switzerland have historically used the referendum instrument to prevent changes they find unacceptable.¹ - Institutional structures thus never provide a complete explanation for the behaviour of actors. 2 - Governance is not only subject to formal (written) rules, but also to informal (unwritten) rules. - An informal rule is one that holds good in policy practice, but is not formalized anywhere. - An example of this in Dutch administrative relations is ‘polderen’. - Cooperation is preferred over hierarchical management. - If necessary, behind-the-scenes consultations are held in an informal setting to resolve a conflict and reach an agreement. - The development of the Five-Party Agreement on specialist incomes is a case in point here. - Formal decision-making in the COTG process had been prepared in the informal Five-Party consultation (box 4.2). - Trust also implies an informal rule: actors expect each other not to take steps that serve their own interests but at the same time harm the interests of others. - Formal and informal rules bring a certain degree of predictability to administrative relations between actors. - Actors know to a certain extent what they can expect from each other. - They also indicate what is possible and what is not. - Without this predictability, governance would quickly degenerate into chaos. - Also, administrative or transaction costs (costs of consultation, contracting, monitoring, sanctioning, etc.) would probably increase explosively. - The rules that are central to this chapter are of an administrative nature. - They regulate relations between the actors involved in a policy process. - There are all sorts of administrative rules. - Here is a brief selection: - rules for the inclusion and exclusion of actors - rules for the organization of decision-making - rules for the division of tasks and responsibilities - rules for coordinating activities - rules for compliance (enforcement) of agreements - rules for accountability - rules for legal protection - Administrative rules must be distinguished from substantive rules. - This second type of rule governs, for example, access to long-term care (indication rules), which forms of care do or do not fall under the Health Insurance Act (rules for claims), the allocation of the national budget for societal support to municipalities (budget rules), and so on. - Deeply rooted perceptions about how policy problems interrelate or how a social health insurance system should be structured are also considered to be substantive rules. - Anyone who violates these 'thinking rules' runs a fair chance of not being taken seriously or being sidelined politically. - This fate likely awaits anyone in the Netherlands who openly advocates for a division in healthcare or for the abolition of income-based and risk solidarity in healthcare insurance. - Of course, there are also thinking rules for the structure of governance and administrative interaction with each other. - Some examples of this are perceptions about democratic decision-making, transparency and legal protection. - The distinction between administrative and substantive rules corresponds to the distinction between institutional and substantive policy made in chapter 3. - Administrative rules and their application in practice are subject to change. - For example, an informal practice often develops in addition to the formal institutional structure, which helps to ensure the smooth running of things like policy development or policy implementation. - Informal rules serve as 'administrative oil' here. - Also, the application of administrative rules is subject to change: a supervisor may decide to act more strictly under external pressure, accountability is more quickly called for in case of failing policy, and appropriate sanctions are demanded, and so on. - Rule-shifting is also a sign of institutional change: certain established rules, such as the informal rule of tolerance, are no longer adhered to. - Sometimes the institutional structure is more or less 'empty'. - (Clear) rules are lacking, so that actors operate in a kind of institutional void (box 5.2). - For example, it is unclear who should be involved in the policy process, what rules govern decision-making, or how to ensure compliance with policy agreements. - Part of the policy process in this type of situation involves 'inventing' workable rules. 3 ## Box 5.2 Institutionele leegte - Over the past 25 years, a lot of energy has been devoted in Dutch healthcare to the development of guidelines for medical practice. - An institutional question in this process was which parties should participate in the development of a guideline (standard). - Other pressing questions concerned, among other things, the ownership of guidelines, their authorization, monitoring and review, and compliance with them. - For a long time, there was no clear answer to these questions. - There was a need for rules. - At a ‘higher’ level of governance, a similar problem occurred. - Who, for example, decided which guidelines to develop? - Who steered this? - How could it be prevented that relevant guidelines were lacking or that their development was stalled due to disagreements? - One of the tasks of the Dutch Healthcare Institute established in 2014 is to fill the 'institutional void' in guideline development. - This institute has the power to enforce this: should the development of guidelines stagnate, the Healthcare Institute can impose a decision. - However, this governance instrument is only used as a last resort. 4 ## 5.3 Institutionele doelmatigheid en legitimiteit - For each institutional structure, the question of institutional efficiency and legitimacy arises. - Institutional efficiency refers to the extent to which the rules ensure an efficient approach to policy problems, and institutional legitimacy refers to the extent to which they meet certain normative principles. - A classic example of an inefficient institutional structure is the Prisoner's Dilemma from game theory, and the Tragedy of the Commons derived from it (box 5.3). - In both cases, the lack of rules, opportunism and mutual distrust results in an outcome that is undesirable for all actors. 5 ## Box 5.3 Prisoner's Dilemma en Tragedy of the Commons - The Prisoner's Dilemma can be described in its simplest form as a game between two rational and distrustful actors, A and B, who each have two options at their disposal: to cooperate or not. - Cooperation (+) produces the best result for both actors together (payoff = 3). - However, if A chooses to cooperate and B does not (-), all the benefits go to B (payoff = 4) and A gets nothing (payoff = 0). - The same applies if B chooses to cooperate and A does not. - In this case, A wins out. - If both A and B choose not to cooperate, they both achieve a suboptimal result (payoff = 2). - A rational player will now opt for non-cooperation. - After all, this strategy always produces full profits in the best-case scenario, and it comes with the risk of exploitation by the other player. - The figure below (based on Scharpf²) visualizes this. - Player A's score is shown in the top right, Player B's in the bottom left. - The dilemma leads to the following paradox: individual rational behaviour (no cooperation) produces a suboptimal result both individually (2) and collectively (2+2=4). - Cooperation would have yielded a better result both individually (3) and collectively (3+3=6)! - The solution to this dilemma is simple. - Actors must choose to cooperate with binding agreements (rules) and penalties for non-compliance, considering their individual and collective interest. - The Tragedy of the Commons refers to an application of this dilemma with more actors and a common good. - Assume, for example, that the common good is the fish in the North Sea. - In the absence of agreements, each fisherman will seek to maximise their catch. - With the advent of modern fishing techniques, this behaviour inevitably leads to no more fish left in the North Sea. - A rational fisherman with only his own interest in mind will opt for the strategy of maximum fishing, as he does not know whether other fishermen will follow the alternative strategy of self-restriction. - The collective outcome is again irrational: a fish-free sea! - Therefore, fishermen need cooperation with binding mutual rules and penalties for non-compliance. - In policy practice, the institutional efficiency of governance often leaves much to be desired. - Governance rules are, for example, not clear or contradictory, obstruct integrated policy-making (the 'compartmentalisation problem'), lead to a scale problem, result in inconsistent conduct, lack sufficient incentives for efficient behaviour, leave it unclear who the problem owner is, or result in high administrative costs. - Shared responsibility can lead to the situation that no one feels responsible. - An institutional structure in which one or more parties can block decision-making (they have what is often referred to as a veto point) easily leads to bureaucratic decision-making. - The institutional legitimacy also sometimes proves problematic, for example, because decision-making is undemocratic or because the requirements of due diligence and legality are not being met. - Institutional efficiency and legitimacy are intertwined. - Legitimacy is needed for efficiency. - If governance rules are not perceived as legitimate, they undermine institutional efficiency. - The converse also holds true: if the development of policy is perceived as legitimate, support for it will grow, which encourages the likelihood of institutional efficiency. - There is also a tension between both possible. - Efficiency requires cooperation between municipalities, for example, in intermunicipal collaboration, which can lead to democratic control over policy at the municipal level being restricted (section 5.6). - Many reforms are based on the assumption that a different organisation of the governance structure will increase the institutional efficiency and/or legitimacy. - Radical institutional reforms often lead to political and ideological conflict, however, (chapter 4). - The old and established governance paradigm (the whole set of assumptions that underlie an institutional structure) is not easily replaced by a new paradigm. - The long-standing struggle over the relationship between government and private initiatives illustrates the prominent role of deeply rooted ideological considerations: private initiatives resisted both for reasons of efficiency and legitimacy against a takeover by the state in the field of healthcare and health insurance (chapter 2). - Similarly, there were serious doubts about the validity of the new governance paradigm underlying recent reforms in the field of healthcare (chapters 11 and 12).