Policy Learning, Fast and Slow: Market-Oriented Reforms of Czech and Polish Healthcare Policy, 1989-2009 Tamara Popić Thesis submitted for assessment with a view to obtaining the degree of Doctor of Political and Social Sciences of the European University Institute Florence, 24 November 2014 (defence) European University Institute Department of Political and Social Sciences Policy Learning, Fast and Slow: Market-Oriented Reforms of Czech and Polish Healthcare Policy, 1989-2009 Tamara Popić Thesis submitted for assessment with a view to obtaining the degree of Doctor of Political and Social Sciences of the European University Institute Examining Board Prof Sven Steinmo, EUI (Supervisor) Prof László Bruszt, EUI Prof Ana Marta Guillén Rodríguez, University of Oviedo Prof Ellen Immergut, Humboldt University Berlin © Popić, 2014 No part of this thesis may be copied, reproduced or transmitted without prior permission of the author Abstract What determines the pace of policy innovation and change? Why, in other words, do policy makers in some countries innovate faster than in others? This thesis challenges conventional explanations, according to which policy change occurs in response to class conflict, partisan preferences, power of professional groups, or institutional and policy legacies. The thesis instead argues that different paths of policy change can be best explained by the different learning processes by which policy makers develop ideas for new policies in reaction to old policies. The thesis draws upon both ideational and institutional streams of literature on policy change, and develops its argument that policy change, understood as a learning process, is a result of interactions between three different, yet interdependent factors – ideas, interests and institutions. The thesis explores this argument by investigating in detail two radical cases of policy innovation – the introduction of market-oriented elements in Czech and Polish healthcare policy during the first two post-communist decades. The selection of the two cases is based on the methodological rationale of the ‘most similar system design’, given that the healthcare systems of the two countries were both state-dominated under communism, while in the post-communist period the governments of the two countries introduced market-oriented reforms that followed rather divergent policy paths. While Czech reforms were relatively consistent and comprehensive, those in Poland were fragmented, delayed and beset with reversals. The thesis looks at these two cases of healthcare reforms from a long-term historical perspective, covering the inter-war, the communist and, most thoroughly, the post-communist period. It draws upon the official documents, secondary literature and more than 40 interviews with policy making elites, and compares the two policy paths using small-N research design, causal analysis and process tracing techniques. The main finding of the thesis is that the market-oriented ideas that occurred in healthcare policy circles during the 1970s and 1980s were crucial drivers of the post-communist reforms in the two countries. However, the capacity of these ideas to serve as a basis of policy change was dependent on two factors – on the existence of political actors who were willing to promote these ideas, and on the interaction of institutional veto points with the electoral and partisan dynamic. The findings of this thesis contribute to the better integration of the literatures on the role of ideational and institutional factors in policy change, and to the research on the causes and consequences of marketization in healthcare and, more broadly, in social policy. i ii Table of Contents List of Abbreviations ................................................................................................................................ vii List of Tables .............................................................................................................................................. ix List of Figures ............................................................................................................................................. xi Preface ....................................................................................................................................................... xiii Chapter One: Healthcare Marketization .................................................................................................. 1 Introduction ............................................................................................................................................. 1 1. Czech and Polish Post-communist Healthcare Reforms ......................................................... 4 1.1. Systemic change: from ‘Semashko’ to ‘Bismarck’ ............................................................. 5 1.2. Policy change: from state-dominated to market-oriented healthcare ............................. 7 1.3. Czech and Polish Policy Divergence ................................................................................. 11 1.4. Explaining Policy Divergence: Argument in Brief .......................................................... 19 2. Polish and Czech Healthcare Reforms in Context .................................................................. 20 2.1. Transition to capitalism ....................................................................................................... 21 2.2. Transition to democracy ..................................................................................................... 23 2.3. Welfare state transition ........................................................................................................ 24 2.4. Impact of transition on healthcare reforms ..................................................................... 26 3. Markets in Healthcare .................................................................................................................. 27 3.1. Conceptual issues ................................................................................................................. 28 3.2. History ................................................................................................................................... 29 3.3. Theoretical issues ................................................................................................................. 31 3.4. Healthcare markets in practice ........................................................................................... 33 4. Research Design and Methodology ........................................................................................... 34 4.1. Small-N research design ...................................................................................................... 35 4.2. Causal analysis ...................................................................................................................... 35 4.3. Process tracing ...................................................................................................................... 36 4.4. Case studies ........................................................................................................................... 37 4.5. Data collection ...................................................................................................................... 37 5. Summary ........................................................................................................................................ 38 Chapter Two: Theoretical Framework .................................................................................................. 39 Introduction ........................................................................................................................................... 39 1. Ideas, Interests and Institutions ................................................................................................. 41 iii 1.1. Ideas, learning and uncertainty ........................................................................................... 41 1.2. Interests, identities and policy preferences ....................................................................... 47 1.3. Institutions, veto points and policy choices ..................................................................... 51 2. Alternative Explanations ............................................................................................................. 57 2.1. Power Resource Theory ...................................................................................................... 58 2.2. Partisanship Theory ............................................................................................................. 61 2.3. Professional Dominance Theory ....................................................................................... 65 2.4. Legacies .................................................................................................................................. 69 3. Summary ........................................................................................................................................ 72 Chapter Three: Poland ............................................................................................................................. 75 Introduction ........................................................................................................................................... 75 1. Polish Healthcare: Historical Overview ...................................................................................