Case 2: Governance in healthcare policymaking: actors and institutions
Learning goals
1. Who are the main actors in health systems and how would you explain their governance
relationships?
2. What does governance mean and what are the main components of governance according to
the framework by Greer et al. (2016)?
3. What ‘ideal-type’ governance modes exist in the literature?
a. Which actors are involved in each mode and how?
b. What is the institutional context (the formal and informal rules of the game for
coordination) of each mode?
c. What are strengths and weaknesses of each mode?
4. Using the concept of ‘institutional layering’, try to explain how health system governance has
developed over time and what the main challenges are in health systems governance.
Literature
- Bouckaert G, Peters BG, Verhoest K. The coordination of public sector organizations. Basingstoke:
Palgrave McMillan; 2010: Chapter 3: Resources, mechanisms and instruments for coordination
(paragraph 3.1; pg. 34-50).
- Van den Bovenkamp H, De Mul M, Quartz JGU, Weggelaar-Jansen AJWM, Bal R. Institutional
layering in governing healthcare quality. Public Administration, 2014;92(1):208-23.
- Brinkerhoff DW, Bossert TJ. Health governance: principal-agent linkages and health system
strengthening. Health Policy and Planning, 2014;29:685-93.
- Greer SL, Wismar M, Figueras J. Strengthening health system governance: better policies, stronger
performance. Berkshire: Open University Press; 2016: Chapter 2: Governance: a framework (pg. 27-
56)
- Helderman JK, Bevan G, France G. The rise of the regulatory state in health care: a
comparative analysis of the Netherlands, England and Italy. Health Economics, Policy and Law,
2012;7(1):103-124.
1
,1. Who are the main actors in health systems and how would you explain their governance
relationships?
Governance is about steering processes of social and economic interaction among actors.
- The “who-question” – who is coordination and who is being coordinated?
While lead governance responsibility for achieving health system goals lies largely with state
actors, achieving them required the active engagement of other actors as well (Brinkerhoff &
Bossert, 2012).
The model of Brinkerhoff & Bossert (2008) is based on the principal-agent theory: the goals of the
principals (opdrachtgevers) and agents diverge and agents may take advantage of information
asymmetry à Agents are able to maximize their interest at the expense of the principals’ aim in part
because they have better information than principals.
Three main actors
1. State actors
Includes politicians, policy-makers and other government officials.
(E.g., health ministry, health and social insurance agencies and public pharmaceutical
procurement entities, parliamentary health committees and regulatory bodies).
2. Health service providers
Mixes public, private and voluntary providers.
(E.g., hospitals, clinics and laboratories and it also includes organizations that support service
provision such as insurance agencies, health maintenance and equipment manufacturer).
2
, 3. Clients/citizens
Service users, the general public and organized civil society.
(Can be categorized in multiple ways: e.g., income, location, disease, etc.)
Linkage between actors
- From citizens to state actors
Citizens are the principals and state actors the agents. The key feature of the relationship is
the exercise of voice; citizens can express their needs or preferences to e.g., politicians or
policymakers.
- From state actors to citizens
The overriding relationship is responsiveness to the citizen needs, preferences and demands.
This relationship varies in quality and degree and differs per country.
Public policy (principals), they specify objectives, procedures and standards, provide resources and
support, exercise control to providers. The providers (agents): in exchange for what the policy
makers doing, providers carry out the agreed-upon desires and instructions of health policymakers.
- Between state actors and providers
The clearest expression of principal-agent relationship!
- From providers to state actors
The key relationship revolves around reporting: the provision of information for purposes of
monitoring and accountability. This reporting should reduce information asymmetry which is
important if making health governance effective.
- From citizens to providers and from providers to citizens
Providers give services to citizens. On the other hand, citizens have client power: technical
input and oversight.
à These linkages are full with principal-agent problems:
- Power and information asymmetries
- Capacity gaps
- Accountability failures
- Moral hazard
3
Learning goals
1. Who are the main actors in health systems and how would you explain their governance
relationships?
2. What does governance mean and what are the main components of governance according to
the framework by Greer et al. (2016)?
3. What ‘ideal-type’ governance modes exist in the literature?
a. Which actors are involved in each mode and how?
b. What is the institutional context (the formal and informal rules of the game for
coordination) of each mode?
c. What are strengths and weaknesses of each mode?
4. Using the concept of ‘institutional layering’, try to explain how health system governance has
developed over time and what the main challenges are in health systems governance.
Literature
- Bouckaert G, Peters BG, Verhoest K. The coordination of public sector organizations. Basingstoke:
Palgrave McMillan; 2010: Chapter 3: Resources, mechanisms and instruments for coordination
(paragraph 3.1; pg. 34-50).
- Van den Bovenkamp H, De Mul M, Quartz JGU, Weggelaar-Jansen AJWM, Bal R. Institutional
layering in governing healthcare quality. Public Administration, 2014;92(1):208-23.
- Brinkerhoff DW, Bossert TJ. Health governance: principal-agent linkages and health system
strengthening. Health Policy and Planning, 2014;29:685-93.
- Greer SL, Wismar M, Figueras J. Strengthening health system governance: better policies, stronger
performance. Berkshire: Open University Press; 2016: Chapter 2: Governance: a framework (pg. 27-
56)
- Helderman JK, Bevan G, France G. The rise of the regulatory state in health care: a
comparative analysis of the Netherlands, England and Italy. Health Economics, Policy and Law,
2012;7(1):103-124.
1
,1. Who are the main actors in health systems and how would you explain their governance
relationships?
Governance is about steering processes of social and economic interaction among actors.
- The “who-question” – who is coordination and who is being coordinated?
While lead governance responsibility for achieving health system goals lies largely with state
actors, achieving them required the active engagement of other actors as well (Brinkerhoff &
Bossert, 2012).
The model of Brinkerhoff & Bossert (2008) is based on the principal-agent theory: the goals of the
principals (opdrachtgevers) and agents diverge and agents may take advantage of information
asymmetry à Agents are able to maximize their interest at the expense of the principals’ aim in part
because they have better information than principals.
Three main actors
1. State actors
Includes politicians, policy-makers and other government officials.
(E.g., health ministry, health and social insurance agencies and public pharmaceutical
procurement entities, parliamentary health committees and regulatory bodies).
2. Health service providers
Mixes public, private and voluntary providers.
(E.g., hospitals, clinics and laboratories and it also includes organizations that support service
provision such as insurance agencies, health maintenance and equipment manufacturer).
2
, 3. Clients/citizens
Service users, the general public and organized civil society.
(Can be categorized in multiple ways: e.g., income, location, disease, etc.)
Linkage between actors
- From citizens to state actors
Citizens are the principals and state actors the agents. The key feature of the relationship is
the exercise of voice; citizens can express their needs or preferences to e.g., politicians or
policymakers.
- From state actors to citizens
The overriding relationship is responsiveness to the citizen needs, preferences and demands.
This relationship varies in quality and degree and differs per country.
Public policy (principals), they specify objectives, procedures and standards, provide resources and
support, exercise control to providers. The providers (agents): in exchange for what the policy
makers doing, providers carry out the agreed-upon desires and instructions of health policymakers.
- Between state actors and providers
The clearest expression of principal-agent relationship!
- From providers to state actors
The key relationship revolves around reporting: the provision of information for purposes of
monitoring and accountability. This reporting should reduce information asymmetry which is
important if making health governance effective.
- From citizens to providers and from providers to citizens
Providers give services to citizens. On the other hand, citizens have client power: technical
input and oversight.
à These linkages are full with principal-agent problems:
- Power and information asymmetries
- Capacity gaps
- Accountability failures
- Moral hazard
3
