The London School of Economics and Political Science Determining policy priorities in a devolved h ealth s ystem: An a nalytical f ra mework Christina Marie Novinskey A thesis submitted to the Department of Social Policy of the London School of Economics for the degree of Doctor of Philosophy, London, October 2015 1 Authorship Declaration I certify that the thesis I have presented for examination for the MPhil/PhD degree of the London School of Economics and Political Scien ce is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any thi rd party. I declare that my thesis consists of 9 9 , 853 words. Statement of use of third party for editorial help I can confirm that my thesis was copy edited for conventions of language, spelling and grammar by Edit911.com, Inc. 2 Abstract This disse rtation develops an analytical framework for studying the effects of health system devolution on the health policyma king process and policy choices made by subnational governments . It addresses two research questions: (1) H ow does devolution change the st ructure and agency of the health policymaking process? (2) What is the resulting impact on health policy priorities ? A critical literature review covers decentralization , devolution , and interest - based approaches for analy s ing the policymaking process, s tructure and agency. An analytical framework for upper - middle - and high - income countries is constructed by integrating (i) a modified version of Bossert’s decision - space approach for decentralized health systems ; (ii) Blom - Hansen’s combi ned policy network and rational - choice institutionalist approach, which analys e s the intergovernmental relations within the national health policymaking environment; and (iii) a n original conceptual isa tion and analysis of informal intergovernmental policymaking at the subna tional government level . Empirical evaluation uses information on Spain’s 2001 health system devolution reform , focusing on the regional case s of Extremadura and Madrid. Primary data from stakeholder interviews and secondary data are analy s ed primarily u sing qualitative , case study and content analysis methods . The decision space granted to regional governments in Spain is examined before and after the reform , developing a decision - space map for Extrema dura and Madrid and show ing the shifts in the range of choice allowed for each health system function over time . Next, the composition s of the national and subnational health policy networks are determined for before and after devolution, and the policy priorities for each are estimat ed ex ante . Finally, the dissertation analyses t he ex post priorities and results of health polic y decisions made by Spain, Extremadura and Madrid in the period after devolution. Overall results show that the analytical framework is only partially successful in anticipating h ealth policy priorities . S uggestions for improving the framework are proposed, and policy implications and lessons are drawn from the case studies . 3 For Gabriele 4 Contents Tables 7 Figures 10 Acknowledgments 12 Abbreviations 14 1. Introduction 16 1.1. The Research Puzzle and Questions 16 1.2. The Organisation of Ch apters 21 2. Decentralization, Devolution and the Policymaking Process 26 2.1. Decentralization Reform 27 2.2 The Policymaking Process, Structure and Agency 4 1 2.3. A Combined Analytical Approach for the Thesis 77 3. The Analytical Framework 79 3.1. Defining Decision Space for Health System Devolution 82 3.2. In tergovernmental Policy Networks for a Devolved Health System 88 3.3. Policy Directions in a Devolved Health System 103 3.4. Re search Design and Methods 107 4. Defining the Decision Space for Health System Devolution in Spain 121 4.1. Background to the Health System Devolution in Spain 122 4.2. National Health System Functions for the “Slow - Track” Regions, 1996 - 2001 127 4.3. The 2001 Health System Devolution to the “Slow - Track” Regions 152 4.4. National Health System Functions for the “Slow - Track” Regions, 2002 – 2006 154 4.5. Discussion 184 5. Intergovernmental Policy Networks for a Devolved Health System 190 5.1. Intergovernmental Health Policy Networks in Spain 191 5.2. Establishing the Position of the Actor Groups in the National Health Policy Network 203 5.3. Establishing the Position of the Actor Groups in the Subnational Health Policy Network 219 5.4. Discussion 242 6. Examining Health Policy Priorities in a Devolved Health System 246 6.1. Governance and Stewardship Rules: Waiting Time Guarantees 249 5 6.2. Regulation and Planning: Common Health Benefit Package Expansions 258 6.3. Financing: Paying Medical Specialists in H ospital Ambulatory Settings 263 6.4. Financing: Sources of Revenue 267 6.5. Discussion 271 7. Conclusion 276 Appendix A. The Potential Governance and Political Effects of Decentralization 286 A.1. Responsiveness, Accountability and Liberty 286 A.2. Policy Diversity and Innovation 290 A.3. Political Stabili ty 291 A.4. Policy Stability or Change 293 Appendix B. Structure - based and Classical and New Institutionalism Approaches to P olicymaking 297 B.1. Structure - based Approaches to Policymaking 297 B.2. Institutional - based Approaches to Policymaking 299 Appendix C. An Example Interview Guide (Spanish Only) 316 C.1. Guía de la Entrevista para Actores Clave en las Regiones 316 Appendix D. List of Key Stakeholders Interviewed 321 Appendix E. Interview Information Sheet and Written Consent Form 325 Appendix F. Excerpt from the Codebook for the Thesis, in Nvivo 9 329 Appendix G. Health Expenditure and Population Coverage Data 336 Appendix H. Relevant Human Resource Regulation 338 Appendix I. Accountability and Public Participation Regulation 343 Appendix J. Author’s Implementation of von Hagen’s Structural Index 345 Appendix K. Indices for Topocrat Strength and Health - Sector Ken trocrat Stewardship 353 Appendix L. Principle Health Regulations, 2001 – 2006 355 Appendix M. Waiting Time Legislation and Regul ation 356 Appendix N. Legislation on Health Benefit Package Expansions, Extremadura 357 References 359 6 Tables 2. Decentralization, Devolution and the Policymaking Process Table 2.1. The Main Dimensions of Decentralization 3 7 3. The Analytical Framework Table 3.1. Bossert’s Original Health System Decision - Space Map 83 Table 3.2. Health S ystem Decision - Space Map for This Thesis 8 4 Table 3.3. Key Health System Functions and Indicators for Comparative Mapping of Decision Space 86 Table 3.4. Intergovernmental Policy Networks as Institutions 89 Table 3.5. The National Budget Process in S pain 98 Table 3.6 . Index for Topoc r at Strength in the National Policymaking Env ironment 99 Table 3.7 I ndex of Stewardsh ip Functions for Health - Sector Kentrocrats 102 Table 3. 8 . Intergovernmental Health Policy Networks for Subnational Government s 103 Table 3. 9 . Characteristics of Spain’s Autonomous Communities 111 4. Defining the Decision Space for Health System Devolution in Spain Table 4.1. Areas o f the MOH´s Joint Responsibility with other Government Entities, 1996 – 2006 129 Table 4.2. Resource Allocation Formulas for the Ordinary Financing Regime 139 Table 4.3. Health System Decision - Space Map for Extremadura and Madrid, as of 2001 150 Table 4 .4. Principal Health Regulation of t he Spanish Central Government, 2002 – 2006 16 6 Table 4.5. The 2006 NHS Quality Plan, Areas and Strategies for Action 168 Table 4.6. Development of Plans for Specific Health and Disease Prevention Areas in Extremadura , 2006 1 70 Table 4.7. Active Health Plans for Madrid, 2005 – 2006 1 70 Table 4. 8 . Health System Decision - Space Map for Madrid and Extremadura, as of 2006 1 82 Table 4. 9 . Decision - Space Map Illustrating the Effects of the 2001 Health System Devolution Reform for Extremadura and Madrid 1 85 5. I ntergovernmental Policy Networks for a Devolved Health System Table 5.1. Intergovernmental Policy Networks as Institutions 1 93 Table 5.2 . Matrix of Institutional Architecture of Intergovernmental Health Policymaking in Spain for 2001 – 2003, and Measure s to Assess the Power of the Topocrats and Kentrocrats for 2004 – 2006 202 7 Table 5. 3 . The National Budget Proces s in Spain, with Comparisons to Scandinavia , during the 1990s 20 7 Table 5.4 . The National Budget Process in Spain 212 Table 5. 5 . Plenary Session s and Agreements of the CISNS, 1996 – 2006 214 Table 5. 6 . CISNS Agreements by Thematic Area , 2002 – 2006 216 Table 5.7. Topocrat Strength in Sp a in for before 2 001 and 200 4 – 2006 2 17 Table 5.8 . National Health Policy Networks in Spain , with Comparison to Scandinavia 21 8 Table 5.9. The Regional Budget Process in Extremadura and Madrid, with Comparison to Spain , 2004 – 2006 2 22 Table 5.10. In dex for Stewardship Func tions of Healt h - Sector Kentrocrats in Spain, 2004 – 2006 24 0 Table 5.1 1 . Subnational Health P olicy Networks for Extrema dura and Madrid, 2004 – 2006 241 6. Examining Health Policy Priorities in a Devolved Health System Table 6. 1 . Extremadura Waiting Time Guaran tees, 2003 – 2006 2 5 4 Table 6. 2 . Madrid Waiting Time Guarantees, 2003 – 2006 2 5 6 Table 6. 3 . Gross Monthly Salaries (in Euros) of Medical Specialists in Hospi tal Ambulatory Settings by Level of Dedication and Type of Contract, and Regional Gross Monthly Salary by Region for 2004 2 6 5 Appendix G .