WHY NONE OF HEALTH REFORM ATTEMPTS SUCCEEDED ? THE CASE OF THE CZECH REPUBLIC Marek Pavlík Objective: Although there have been many attempts to start the health reform during past ten years in the Czech Republic; none of these attempts were successfully implemented. The exception is the partial success of the last health reform proposal (2007). The aim of the paper is to analyze two key conditions of initiation of the health reform in the Czech Republic. In other word, the paper will try to answer the question of why the last reform attempt seems to be more successful than previous ones. Considering the complexity of the health reform process the research is narrow down to examination only two of necessary conditions of successful health reform implementation. Author sets two conditions which are examined during the period 1998-2008. The first one is that the cabinet has to have majority in all important representative bodies (i.e. Chamber of deputies, Senate, Regions). This condition is based on assumption that each reform is inevitably tight with accepting new legislation. The second condition is that the Cabinet (fomated by more than one politicla party) has to reach at least 50% agreement on basic health reform principles. There is an assumption that the reform would be postponed in the case of disagreement. Design and settings: The Czech political system and health policy situation are mentioned at the beginning of the paper. Consequences of the cabinet inner heterogenity are also mentioned. The second part of the paper introduces the methods of analysis, which are suggested by the author. The third part of the paper discovers the results of both examined conditions. The results are counted from the cabinet point of view aside from the fact if the cabinet was a coalition type or not. Data and methods: The analysis is based on already published data: results of elections to the Chamber of Deputies, the Senate, regionals’ legislatures; data about members of the Cabinets and theirs members’ political affiliation; pre-election programs of the Cabinet political parties. Author suggested the method which allows displaying the cabinet position in the all lawmaking bodies. The analysis of the second condition – the agreement inside the cabinet coalition is done through analysis of the pre- election programs each of cabinet’s party. Using simple mathematic model was formed “the curve of the coalition cabinet’s concordance rate”. Both results are displayed in chart. Results and conclusion: The main result of analysis is that all Cabinets had minority in all lawmaking bodies except close majority in the Chamber of Deputies since 2002b; and except the second Cabinet formed after the election in 2006 which gained more that 50% in all lawmaking bodies. The curve of the coalition cabinet’s concordance rate shows that all cabinets before the last one (since 2007) reached inner agreement about 25%. The second condition was also fulfilled only by the last Cabinet. There is no doubt of existence more than these conditions and therefore this paper is only part of complex analysis of the Czech health policy. However the extension of nonfulfilment these conditions is surprising and could be explanatory of previous hopeless health reform attempts. Key words: health reform, government, health policy JEL classification : I 1, H 7 1 INTRODUCTION According to the theory of the policy cycle; the cabinet is seen as the key actor for the policy formulation and implementation (e.g. HOWLETT , RAMESH 2003). According to top-down approaches (HOWLETT , RAMESH 2003) or synthesizers accented top-down approach (BERGEN AND WHILE 2005), the cabinet is assumed as the key actor in the process of policy formulation and implementation. Considering Czech inability to realize a coherent vision of health policy (HOL ČÍK 2004), we should search for the roots of such failure 1. Regardless of explanation of past failures we have to seek answers which would improve a chance for future success. Although there have been many attempts to reform the health care system during past ten years in the Czech Republic; none of these reform proposals were successfully implemented (DRBAL 2005, MALÝ , DARMOPILOVÁ 2005). The exception is partial success of the last health reform proposal (success in 2007, interruption of the reform process in 2008). The reasons of these failures would be rooted in the phase of the policy formulation and implementation (see NEMEC 2006). The aim of the paper is to find out if the cabinet was strong enough to enforce the policy implementation. This aim will be examined through analysis of cabinet support in representative bodies; and through analysis of cabinet’s inner agreement on health care reform principles. Therefore the paper analyzes two key conditions of initiation of the health reform in the Czech Republic 2. Consequently the paper will try to answer the question of why the last reform attempt seems to be more successful than previous ones. Considering the complexity of the health reform process the research is narrow down to examination only two of necessary conditions of successful health reform implementation. Author set two conditions which are examined during the period 1997-2008. The first one is that the cabinet has to have majority in all important lawmaking bodies (i.e. Chamber of deputies, Senate, regional legislatures). This condition is based on assumption that each reform is inevitably tight with accepting new legislature. The second condition is that the Cabinet (in the case of coalition) has to reach at least 50% agreement on basic health reform principles. There is an assumption 3 that the reform would be postponed in the case of disagreement between politicial parties in the coalition. 2 BACKGROUND Searching roots of implementation failures in Czech health care system there is necessary to consider many factors. Following analysis should be taken as a part of complex analysis of health policy implementation in the Czech Republic. Considering the cabinet as the key actor for the policy formulation and implementation conduce to necessity of investigation of cabinet’s relations with other “state” actors and also its inner relations; especially in the case of coalition cabinets. The first step is discussion the terms “state” and “cabinet” and its consequences for the policy formulation and implementation. Second step formulation of examined conditions and criteria of evaluation. Although terms as „state“, “government” or „cabinet“ are often used; understanding of theirs meaning could be different from the economist and politics point of view. Generally we suppose that the cabinet has to have a support of parliament under Parliamentary democracy conditions. It’s just that the cabinet formulates the policy and the parliament implements (through changes in legislature) the policy. Therefore we could simply assume that the cabinet is homogenous actor i.e. “state” which stands against other actors. Such stance is more close to scientist focused of public economy (see e.g. JACKSON , BROWN (2003), STIGLITZ (1997)). The problem of optimal allocation and effectiveness is studied on background of behavior of “state” and “other actors”. 1 The result of implementation can be either fulfilling the aims or implementation failure. LINDER AND PETERS (1987) consider implementation failure to be one of three policy failures: Implementation failure; Policy design (crippled at birth); Policy results (aims can be achieved; however it creates too many “side effects”, the situation could be worse than before). 2 Czech health care system is based on co-financing principle. Main sources are: National and local budget; Public health insurance (i.e. solidarity principle, payment to the system depends on income. Health insurance is provided by nine health insurance companies); Co-payment from patients; Foundation and sponsoring. The basic principle is shown in appendix 1. Total expenditures for health is around 7,1% of GDP and about 90% of total expenditures come from public sources. 3 The assumption is based on MARTIN (2004) which proves that agendas more attractive for the cabinet are preferred more than other, simultaneously is valid that political parties in coalition achieve more easily the agreement to these “favorite” agendas. On the other hand most of polimetricians and public policy scientist see difference between the state and the cabinet (see e.g. HEYWOOD (2004)). Polimetricians systematically examined relations between the cabinet and parliament as one of possible important factor for policy formulation and implementation 4. The problem of homogeneity could be seen not only as the problem of relation between the cabinet and parliament but also as a problem of relations inside the cabinet. Results of election to the Chamber of Deputies in the Czech Republic (see appendix 3) often faces the necessity of coalition cabinet formation. It is advisable to put stress on this factor. E.g. CARMIGNAMI (2001) examined 13 countries and conclude that delay in the policy formulation depend on the level of heterogeneity of opinions inside the cabinet. The cabinet cannot be considered as a homogeneous actor from the implementation theory point of view. The cabinet is heterogeneous actor which interacts with other state or non-state actors. The level of cabinet’s heterogeneity depends for example on: • Relation between Prime Minister and other ministers (the level of authority control). • The type of cabinet (the one party type or coalition type). • Diversification of opinions inside the coalition cabinet. • Personal relations between ministers. We consider the cabinet as heterogeneous actor which acts as one against other actors for the purpose of analysis. Therefore we examined both the cabinet’s inner homogeneity and cabinet’s relations to key representative bodies. The cabinet’s homogeneity is investigated through one of possible methods – analysis of political parties’ pre-election programs. We assume that it is necessary to enforce the cabinet’s will in the Parliament (or other actors) for implementation of the reform policy.