We are pleased that our recent paper, On Health Policy and Management (HPAM): mind the theorypolicy-practice gap (1), generated lively discussion. Most prominent among the respondents were Professors Jean de Kervasdoué (2) and David Hunter (3).
We reflected on why the field of HPAM has had little impact on the basic arrangements within which most physicians practice. We argued that this failure reflects four dimensions of a theorypolicy-practice gap: 1) The dominance of microeconomic thinking; 2) The lack of learning from comparative case studies in healthcare management; 3) The separation of HPAM from frontline medical providers; and 4) The failure to expose medical students to issues of HPAM with respect to the organizational and regulatory environments in which they will ultimately work.
De Kervasdoué, like many others who commented in articles and web discussions, focused first and foremost on the critique of the role of economics in health policy, especially in the United States (U.S.). He nicely amplifies our point that health policy cycles around financial incentives that fail to capture the special nature of healthcare as a service. “What is the ‘clear’ value of a smile or a thoughtful gesture” he poignantly asks. He supports our plea for more rigorous case studies, but adds, following Rose and McKenzie (4), that “it is necessary to define concepts before engaging in comparison”, and to pay attention to important cultural differences. De Kervasdoué is less convinced that exposing medical professionals to issues of cost and access during their training will increase the probability of health system reform. He reminds us that medical students are educated to focus on the individual patient while issues of cost and low effectiveness should be handled at the political level. He challenges us to “explain what could or should be done to reverse the great stability if not inertia of this American system”.
We accept the challenge, but wish to emphasize that our critique was not leveled at HPAM only in the American context. The fact, pointed to by de Kervasdoué, that systems in which care is free at the point of service cost less, does not exempt such systems from failures to improve the quality and efficiency of care. Costs may come in the form of long queues, poor quality and unresponsive providers. Many European systems are also influenced by many economists’ assumptions about the importance of financial incentives, often recycled in modified forms, aimed at providers who feel alienated by bureaucratic incursions into their profession. With regard to the importance of learning from comparative case studies, de Kervasdoué suggests that we were discussing cross-national comparisons with all the difficulties related to institutional and cultural contexts. However, we were arguing that even withinnational systems there is not enough learning across organizations, including unpacking the concept of culture and accumulating knowledge that can inform improvement; certainly not enough to compete with the one-dimensional, parsimonious, but off target input of microeconomics. As far as exposure of medical profession students to HPAM, we agree that the idea is not to make them the locus of decisionmaking regarding costs, but intended that they should be informed about the institutional lay of the land they will enter as practicing professionals.
David Hunter meets up with de Kervasdoué in his eloquent portrayal of health systems as “complex organizations”. Referring to healthcare reform in the UK, he explains how HPAM is trapped by an industry of healthcare management experts who benefit from reforms, even if they fail, because they maintained their positions of influence, disconnected from front line providers who oppose changes from the top, while “bemused medical and nursing students had little understanding of the changes and their impact on them as they looked to an uncertain future in the NHS”. Hunter praises political science as the discipline that analyzes conflicts among different groups – providers, managers, and communities – that influence the behavior of healthcare organizations. Moreover, he suggests that a political science orientation provides a better understanding of leadership in healthcare systems, and reorients so-called evidence-based management towards learning vertically within local contexts as opposed to seeking generalized solutions imposed from the top by national health policy-makers advised by management consultants.
These two commentaries extend our analysis of HPAM and reinforce the importance of dealing with complex systems that cannot be mechanically manipulated by financial incentives and regulation based on partial measures of quality. We agree that the politics of healthcare has received inadequate attention in HPAM in favor of simplistic “solutions” by managers that Hunter characterizes as “change junkies”. Political science can deepen our understanding of structural interests in the health sector. Moreover, as de Kervasdoué suggests, we need to pay more attention to the multidimensional aspect of medical institutions. We would add that a comparative institutional approach provides the framework in which more sophisticated (politically and organizationally) sensitive approaches (missing in economics) can be linked to policy prescriptions. As Aaron Wildavsky (5) once noted, “The proper comparison for the policy analyst is always among alternative programs, which combine resources and objectives in different ways, but not the one in isolation from the other”.
These alternatives should not ignore institutional arrangements that reflect the values, cultures and politics that our commentators so rightly emphasize. The tradeoffs can never be fully analyzed by one discipline alone. Institutions should be analyzed by multiple disciplines and the choice among them will necessarily reflect the tradeoffs that pervade the field of HPAM. Comparative institutional analysis enables the type of HPAM prescriptions that our commentators have called for, taking into account their demand for culturally and politically sensitive examination of healthcare organizations and their local context. To our mind, these steps go in the direction of responding to important aspects of the theorypolicy-practice gap to which we believe the field of HPAM should pay closer attention.