THE POLITICS OF HEALTH CARE REFORM IN CENTRAL & EASTERN EUROPE

This project is a part of my doctoral work carried out in the Department of Social Policy and Social Work at Oxford University under the supervision of Dr Martin Seeleib-Kaiser

Background

Throughout the period of transition - which for the purpose of this study is limited to 1989-2004 - the Czech Republic and Hungary replaced a centralised integrated state model of health service with a decentralised model of contracted social health insurance. However, these reforms did not result in any substantial efficiency or quality gains in the health sector. Rather, they soared administration costs, fragmented the health care systems, and contributed towards a growing inequality in access to health services. This took place in the context of unprecedented political, administrative, economic, and social reforms: the two nations attempted transition from one-party rule, a highly centralised politico-administrative system, and a planned economy to democracy, decentralised government, and a market economy.

During this transition, the old divisions of interests in the health sector have been changed and new political and economic cleavages have been created. Subsequently, the content of health care reform has been influenced by conflicts of interests between doctors, trade unions, employers, medical and pharmaceutical industries, political parties, different levels of government and its agencies, as well as other health policy actors. It is therefore imperative to examine the changing nature of health politics in Eastern Europe in order to find how the transitional changes have affected the system of health policy-making and its capacity to provide effective solutions to health policy problems.

Health care is one of the most important forms of welfare in modern European societies. The health sector is a leading consumer of public funds, and one of the major employers. The present study attempts to provide limited historical insights into the evolution of the national health services as part of development and reform of the socialist "welfare state". Was it just a "premature welfare state" (Kornai 1997) or is it fundamentally problematic to conceptualise socialist social services as a welfare state? Do the origins of the Eastern European welfare state lie in the sporadic pre-socialist social security, in comprehensive socialist social services, or in the transitional attempts to restructure the latter? I shall use insights into these questions in order to set the scene for a broader discussion of the development of the linkages between welfare programmes and emerging capitalism and democracy during the transitional period.

Research questions

Across the two nations, there is an intriguing variation in the dynamics of policy change. Whereas health care financing and primary health care were overhauled, there is surprising continuity in secondary and tertiary health care arrangements . Although at the dawn of transition, politicians in Hungary and the Czech Republic proposed similar reforms, the timing and outcomes of political struggles over these reforms varied substantially from nation to nation. As a result, health care systems in these two countries started to diverge. Later, however, many of the enacted reforms have been revised to the effect that the early trend of divergence took the opposite direction. My research project attempts to compare the politics of reforms in each country with a view to explaining continuity and change in health care policy. It is imperative to know what factors influence policy debates, how policy issues are formulated, and why some of these become policies and others not.

Research design and methodology

There two major aspects to my research project. The first one focuses on the politics of health care reform policy process in Hungary and the Czech Republic. The second aspect of the project uses insights into the health policy process in these two nations in order to discuss the politics of the welfare state in Eastern Europe more broadly. Given that Eastern European literature on both aspects of my research is scarce, I shall draw substantially on the relevant Western European and North American literature. Although theoretical concepts and related explanatory factors developed in the context of Western Europe and North America may not always fully apply to the context of Eastern Europe, when treated as "sensitising concepts", they can help to reduce the complexity of the phenomena under investigation by setting parameters to the data collection and organisation of evidence (Ragin 1994, pp.87-89). In the course of research, I shall clarify and even abandon some of these concepts and factors. At the same time, when they are significantly altered, there will be a possibility to come back to the data initially discarded as irrelevant and to propose new concepts and factors.

Theoretical-methodological approach

Because currently there is no theory on the subject of my project, in order to investigate its both aspects, I shall use an analytical framework. The value of employing an analytical framework is threefold.

1. An analytical framework allows case studies to be comparable and cumulative (Marmor 1970).

2. An analytical framework substitutes the role of theory in guiding research (Scharpf 1997).

3. An analytical framework helps to focus research on elements of a framework which are of particular importance to the research (Immergut 1992).

Because the framework will be used to collect data, it should be as inclusive as possible, in order not to miss any data relevant to my research questions. This can be achieved by incorporating in the framework elements that have proven to have an explanatory power in previous studies. On the basis of literature review, I have identified the following broad elements of the framework to be analysed in the socio-economic context of each country:

• policy actors
• institutions
• policy ideas

This framework will be employed within the wider "analytic narratives" approach (Bates 1998) which relies on the tools and assumptions of rational choice theory, new institutionalism, and basic game-theory modelling. This approach allows one to tell a story and provide explanations that can ultimately be evaluated. It requires the construction of a model that explicates key decision-making points and options, the logic of explanation, and allows evaluation of the model through comparative studies and the implications that this model has (Levi 2002; 2003). The strength of this approach is that it allows the formulation and evaluation of parsimonious causal mechanisms, whereas its weakness is that it does not generate any strict theory.

Country studies

In comparative social science, there are five strategies for case selection: 1) the most similar or most different cases, 2) focused and structured case studies, 3) statistically sampled case studies, 4) cases to test certain theories, 5) area centered-studies (Levi 2002). My project combines the rationales of the fourth and fifth strategies: it draws on the assumptions of rational choice theory in order to explain health policy change in the area of particular interest, central-East Europe. The countries in focus are Hungary and the Czech Republic. They feature a number of striking differences and similarities.

At the beginning of the 1990s, they both started moving away from a centralised integrated state model of health service to a decentralised and contracted social health insurance model. While Hungary introduced compulsory social health insurance in 1990, the Czech Republic did so in 1993. Unlike Hungary, who opted for one national health insurance fund, the Czech Republic envisaged competition between various independent health insurance funds. Of the two countries, the Czech Republic was the first to introduce privatisation of the primary health care providers in 1993. In Hungary, GPs became owners of their practices as late as the year 2000. Reformers in all two nations have tried repeatedly to implement privatisation of the secondary health care providers, but their attempts have continuously failed. In tertiary health care, privatisation or any other form of restructuring has never become an agenda. What is more, many of the enacted health care financing reforms have been revised. In 1997, competition between insurance funds in the Czech Republic was abolished. A year later, Hungary returned to governmental control the formerly independent National Health Insurance Fund.

I shall draw the data for these two case studies from both published sources and interviews. There already exists a body of publications from which it is possible to reconstruct the dynamics of health policy change in both nations as well as policy options available to policy makers when major health care reforms were implemented. These are publications by international organizations (such as the World Health Organisation, World Bank, OECD), academic journals, professional publications and newspapers. At the same time, none of these has fully captured the different rationales for selecting particular policies that different policy actors had as well as their influence on the policy process with the aim to adopt certain policies. To fill in this gap, I plan to undertake a series of explanatory and in-depth interviews with policy makers themselves, experts, journalists, non-governmental organisations, and representatives of different interest groups. They posses information which is unavailable in the printed sources, or they can refer to grey literature, official documents, and other publications which are time-consuming to trace. I have already made 10 exploratory interviews in the Czech Republic. These serve as a solid base to identify key policy makers and the conditions under which health policy was made. In further approximately 20 interviews with mainly policy makers, I plan to clarify their interests and other factors which affected policy making. An actual number of interviews will depend on how many of them is sufficient to construct a full picture of the policy making process, but also it will be constrained by the resources that I have in my disposal. The same format of fieldwork (i.e. approximately 10 exploratory and 20 in-depth interviews) is envisaged to be applied to the case of Hungary. Given the fact that I do not speak Hungarian, an actual number of interviews may need to be increased. However, I can draw on my previous research on Hungary and on the data that I collected but not have used fully.

To support my research, I have been learning the Czech language for six months and have already acquired a modest working knowledge of it. The reason for my fast progress in Czech is that it is not very distant from my first language Belarusian. Unlike Czech, Hungarian is not a Slavic language, therefore, it is not feasible for me to master it quickly. As such, I will work with the Hungarian sources published in English, and conduct interviews with Hungarians in English directly or with help of my Hungarian colleagues acting as interpreters. As my research experience in Hungary shows (Ovseiko 2004), it will slow down data collection but will not create a major obstacle to gathering valuable research evidence. As a rule, Hungarian policy makers speak English. Also, I have a grasp of key health policy concepts in Hungarian. It helps me identify relevant literature and discuss it during interviews with Hungarian health policy experts, or to ask my Hungarian colleagues for help with translation.

Comparative analysis

Although my research project does not attempt to create general theory of health policy change in Eastern Europe, it attempts to find causal mechanisms and institutional structures behind health policy change in the two selected nations. The aim is to arrive at a parsimonious model of health policy change that would be extendable to other cases under certain specifiable conditions. Therefore, I shall use the cases of the Czech Republic and Hungary in order to formulate this model to explore by means of comparison between the two cases the conditions under which the model holds true. Another important aspect of comparative analysis will deal with directions and drivers of health policy change as an instance of welfare state development. This comparative analysis will aim to draw generalisations from the two cases that could be potentially extended to other Eastern European countries under certain specifiable conditions. In overall, my study attempts to draw from comparative analysis "limited generalisations" (Ragin 1987) in the form of causal mechanisms of policy action and interaction in the health policy arena, rather than definitively test a certain theory or build a grounded theory of my own.

References

BATES, R. H. (1998). Analytic narratives. Princeton, N.J.; Chichester, Princeton University Press.

IMMERGUT, E. M. (1992). Health politics: interests and institutions in Western Europe. Cambridge [England]; New York, NY, USA, Cambridge University Press.

KORNAI, J. (1997). Paying the bill for goulash communism: Hungarian development and macro-stabilisation in a political economy perspective. Struggle and hope: essays on stabilization and reform in a post-socialist economy. Cheltenham, E. Elgar: xiv, 290.

LEVI, M. (2002). Modeling complex historical processes with analytic narratives. Akteure-Mechanismen-Modelle: Zur Theoriefahigkeit makro-sozialer Analysen. R. Mayntz. Frankfurt/Main, Campus Verlag: 108-127.

LEVI, M. (2003). An analytic narrative approach to puzzles and problems.

MARMOR, T. R. (1970). The politics of medicare. London, Routledge & K. Paul.

OVSEIKO, P. V. (2004). Challenge for effective health sector governance in Hungary: Cooperation between the medical profession and government. Proceedings of the 11th Annual Confrerence of the Network of Institutes and Schools of Public Administration in Central and Eastern Europe "Enhancing Capacities to Govern: Challenges Facing the CEE Countries", Bucharest, April 10-12, 2003. B. Michael, R. Kattel and W. Drechsler. Bratislava, NISPAcee: 224-242.

RAGIN, C. C. (1987). The comparative method: moving beyond qualitative and quantitative strategies. Berkeley; London, University of California Press.

RAGIN, C. C. (1994). Constructing social research: the unity and diversity of method. Thousand Oaks, Calif; London, Pine Forge Press.

SCHARPF, F. W. (1997). Games real actors play: actor-centered institutionalism in policy research. Boulder, Colo.; Oxford, Westview Press.