Policy Sectors and Professions: The Institutional Foundations of Activist Public Health Policy

Abstract

In many countries, health systems have developed impressive levels of medical care and organizational complexity, providing treatment of a broad range of conditions for the vast majority of citizens and arresting the attention of academic observers, politicians, and the general public. But the health care system has an older step-sister that is much less in the public eye, much poorer both in resources and reputation, and more often concerned with lackluster tasks such as hygiene, immunization, or telling people to clean their teeth or cut back on drinking and smoking. It is to Philipp Trein’s credit that he calls our attention to public health, the older step-sister of clinical medicine and presents this study of the development and relationship between the two, pointing out the significant difference between individualistic, curative health care and collectivist, population-oriented public health. In times of new threats by infectious diseases such as Ebola or the Measles, increasing incidence of multiple drug resistance, and growing prevalence of chronic disease, this is a timely and laudable contribution. Trein’s book is also commendable for its emphasis on the interdependence—coevolution, as Trein calls it—of the two sectors. The book considers this coevolution in an internationally comparative perspective, combining the detailed substantive focus of public policy analysis with the broader generalizations of Historical Institutionalist comparative politics scholarship. Trein is also right in highlighting the great diversity in institutional design of the two health sectors and their relationship across countries—this last point being not so surprising, as this usually emanates from such internationally comparative undertakings. Public health and health care systems, Trein argues, are two policy sectors that evolve in partially interdependent and partially autonomous ways; they coevolve. The form of this coevolution is interesting, because it is consequential for the extent to which activist public health policies are feasible. Coevolution of the two sectors, Trein argues, takes the form of four different institutional and policy-related types, which he calls types of sectoral coupling. The types reflect different kinds of institutionalization of the two sectors, their interaction, and the extent to which there is cooperation and policy integration (i.e., shared policy agendas and jointly developed policies) between the two. Two institutional and behavioral dimensions define the types. First, institutional distinctiveness of the two sectors pertains to the question of whether they are organizationally autonomous or integrated; second, responsiveness pertains to the behavior of professionals in the two sectors and the question of whether they talk to each other and coordinate their work. Tight coupling refers to a situation in which the two sectors are highly responsive and organizationally highly integrated. Under conditions of loose coupling, the two sectors are institutionally distinct but their actors are still responsive and work together. Noncoupling describes organizationally integrated policy sectors in which professionals concerned with the tasks of public health or curative medicine do not work together, and a decoupled setting is one in which we find neither organizational integration nor responsiveness (complete separation). The four types are consequential because only the responsive types are able to produce integrated policies, combining the agendas and resources of both sectors. The book’s explanation of the four types of coevolution draws on the two dimensions of the typology, with sectoral distinctiveness and autonomy being a facet of power sharing in the political system at large, such that integration of the two public health sectors is to be found in countries with unified government. Mutual responsiveness of professions working in the two sectors is a function of the institutionalization and, as the author claims, the strength of those professions. Where professions are strong and politically active and position themselves in competitive, pluralist systems of interest group institutionalization, Trein expects to find responsiveness, whereas “weak” professions in corporatist systems of interest mediation produce situations with little responsiveness between policy sectors. Since unification of government structures and professional interest organization are both institutional variables and, as such, better suited as intervening factors than as independent variables, the author introduces contextual factors such as problem pressure, fiscal strain, and the notion of political environments that are generally amenable to policy integration and responsiveness to account for institutional change and policy development. The case studies examined in the book exemplify the four types, with the three Anglo-Saxon countries (Australia, the United Kingdom, and the United States) representing the responsive types while Switzerland and Germany are constellations with little responsiveness and interaction between professionals of the public health and the health care systems. The book’s empirical chapters present evidence from the histories of health policy over the course of the past 150 years. The case studies trace institutional integration or differentiation as well as responsiveness and cooperation of the professions working in the two policy sectors in four time periods. Trein puts much effort into presenting the historical material very systematically, in each chapter highlighting how it relates to the conceptual framework and in the concluding chapter summarizing the different pathways of coevolution very clearly (cf. p. 240). He is also very explicit about points in which theoretical expectations were not met by the historical record. This analysis demonstrates the author’s strong commitment to reconciling the detailed historiographic work of public policy analysis and policy history with the explanatory and generalizing ambitions of comparative politics scholarship. The reader is never lost in the complexity of historical detail; there is no ambiguity, and the author succeeds in lucidly and transparently identifying distinct cross-national patterns of coevolution as well as explanations for those patterns. It is this very clarity that also exposes limitations of the conceptual framework and some weak spots in the explanation and the historical analysis, however. Here, I would first make some remarks about the conceptualization of the dependent variable, coevolution, and then comment on the explanation of the patterns of coevolution both with regard to its theoretical underpinnings and the historical evidence presented in support of this explanation. The book’s central theoretical claim is that public health and curative medicine coevolve, that is, they are interdependent yet potentially distinct. Coevolution occurs at the intersection of two dimensions, organizational distinctiveness of the two sectors and responsiveness of the professional staff working in the two sectors. This results in the four types of coupling of health care and public health described above. The first of the two dimensions, organizational distinctiveness, is systematically underdeveloped, however. This holds with regard to the empirical case studies, where the author often reports that his findings about the organizational dimension were not in line with his theoretical expectations. It also holds with regard to theoretical underpinnings, where the meaning of “unified government,” conceptually the main explanation of institutional integration of the two policy sectors, remains unclear. Chapter 3 of the book, which discusses the institutionalist underpinnings of the two central hypotheses about responsiveness and distinctiveness, presents a whole bundle of theorizing on government unification or fragmentation, ranging from arguments from the comparative federalism literature to veto player analysis. These arguments are mobilized to motivate the author’s expectation that distinctive and autonomous sectors are to be found in polities with dispersed political power. This is conceptually imprecise, as it does not specify where and in what way political power is dispersed (in legislation, in state structures, in administrative resources, in patterns of political mobilization and interest organization, etc.), and why and how this should have an impact on administrative structures in policy fields. It is not fruitful theoretically, for instance, to use a blanket characterization of German government as “relatively unified” (p. 169) if the intention is to explain details in authority patterns and administrative structures of public health and health care. The German polity may be politically relatively centralized and unified, but public administration is not unified but decentralized. In terms of political power, German corporatism and German federalism are among the core institutions that have been explicitly designed to render the German state “semi-sovereign.” Therefore, while conceiving of sectoral distinctiveness as a facet of power sharing in the political system at large is an interesting approach, it would require more theoretical work specifying precisely how we can establish a connection between dispersed or concentrated executive authority and the organization of tasks in policy sectors. In addition to the fact that the explanation of the distinctiveness dimension is not fully developed, the overall status and significance of that dimension are not entirely clear. It seems of lesser interest than responsiveness, as responsive types of coevolution, whether loosely or tightly coupled, are the constellations in which policy integration, cooperation in public health campaigns, and overall reform activism on public health are more likely. Throughout the book there is an underlying notion of “successful public health activism,” capturing the evolution of public health out of its subordinate status and the “creation of a global public health strategy” (p. 250). This is an interesting and important prospect, and asking when and under what conditions it may occur is certainly a valid and highly significant question. But this question remains implicit and is never accurately formulated as a research question; it is never properly theorized, and it is an entirely different question than what identifying types of coevolution between two policy sectors can answer. Therefore, if successful institutionalization of activist public health is the core commitment, and if cooperation and responsiveness of professionals working in public health and the health care systems is the principal explanation, then the core conceptual tool should reflect this. A typology is probably not the most suitable approach for studying stages of development toward an integrated and activist public health policy because we would then not be talking about a typological distinction but, instead, about an ordinal scale of more or less successful public health efforts. If the underlying core commitment is explaining the success of the public health effort, an outcome of professions’ responsiveness, and responsiveness, in turn, is a function of the “strength” of professionalism, then a few words about that causal connection are in order. In the kind of semantic shorthand-fashion that sometimes makes reading this book more cumbersome than necessary, Trein often refers to the “responsiveness of the two sectors.” As only actors and not sectors can respond or cooperate, he means the extent to which professionals working in the two sectors are willing or able to cooperate across sectoral boundaries or within settings in which sectoral boundaries have become unimportant or nonexistent. Responsiveness, according to Trein, is a function of the political strength of professions. In the case of public health and health care, this includes primarily the strength of the medical profession and its interest organizations. In pluralist systems of interest organization in which interest groups and professions compete based on their political appeals, professional organizations mobilize on a broader substantive agenda; they are willing to respond to the commitments and agendas of adjacent policy fields, such as public health. In corporatist social insurance systems, by contrast, there is no need for broader political mobilization; professional representation accords public status to organized interests, and professions focus on their narrow material interests. Therefore, weak professionalism renders policy sectors nonresponsive and, as a result, less able to produce integrated policy solutions. The first difficulty of this argument is that we learn a lot about the political strength or weakness of the medical profession, but the image of the public health profession (or professions?) remains pale. So, it is a one-legged cooperation, responsiveness to an unknown interlocutor. The argument’s main problem, though, is rooted in the theoretical underpinnings of the notion of “weak professionalism” as core building block of the explanation of coevolution types. As in the case of organizational distinctiveness and unified government, this notion is based on a somewhat selective and skewed reading of large theoretical literatures on systems of interest mediation. In the central point, namely the assessment of a profession’s (or an interest group’s—Trein never decides which) strength, it runs flatly against core findings of these relevant literatures, especially when it comes to assessments of corporatism. While there is no divine verdict against disagreement with core claims of a literature, some discussion would have been required. This is what is often lacking here—there is no recognition and discussion of Mancur Olson’s seminal argument that interest groups under pluralist conditions may be more prone to defending narrow interests and more powerful in doing so but are especially ill-suited for taking on more encompassing views, which are more likely in corporatist systems of interest organization with their broad peak organizations (Olson 1982: 47–50). The book includes no acknowledgement of Peter Katzenstein’s groundbreaking argument about a state (Germany’s state), rendered semisovereign, precisely because of this political system’s entrenched corporatist structures in which a strong and centralized civil society organizes policy sectors such as health with some degree of autonomy, thus constraining the central government’s interventionist prowess (Katzenstein 1987, especially pp. 23–34). This idea may explain sectoral distinctiveness, but Trein does not use this opportunity and instead sets out to contend that organized medicine is politically weak in corporatism. There is no appreciation of scores of writings about veto-group politics in health policy making, in which the strength of organized medicine may have made cost-containment a cumbersome task in many health systems but has not per se undermined the activist policy making or quality of health services in either the health care or the public health domain. Finally, not much actual evidence is provided for the claim that lesser amounts of actual interaction, cooperation, and responsiveness amount to lesser efforts and success in sanitation, vaccination campaigns, health surveillance, health education, or however one might circumscribe the substantive scope of activist public health policy. The conceptual weakness, again, spills over into the cogency of the empirical narratives. For instance, it is a bold assertion (to put it mildly) to call organized medicine in Germany politically weak. This profession has been able to determine prices for medical services (i.e., their income) practically unilaterally for decades, which is not much of a sign of political weakness. To write a 30-page policy history of public health in Germany, a narrative that amounts to an image of institutional underdevelopment of that sector because of the putative political weakness of health professions, without ever mentioning the names of Robert Koch, Emil Bering, Paul Ehrlich, Rudolf Virchow, all of whom are towering figures in the history of public health, amounts to a bold assertion, to say the least. It is also testimony to the difficulties of a style of argument as predominantly institutional and structural as this one. Organizational distinctiveness is a function of government fragmentation, an institutional variable. Responsiveness is a function of professions’ political strength and status, likewise primarily a function of the professions’ institutionalization. Schematically applied, this leaves little room for understanding the actual policy histories, and that, in turn, leaves us wondering how much explanatory power this account of coevolution has at the end of the day. This book is full of interesting ideas and observations. The way in which they are put together into a conceptual argument, however, is not fully convincing. There are (too many) weak spots on the conceptual and theoretical level, and readings of underlying theoretical literatures are somewhat thin and skewed at times. As a result, some of the empirical narratives—likewise often lacking the historical and policy field-related depth and detail that would be necessary to sustain this argument—do not capture key developments in the countries and in the time periods under review. As such, the five-way comparison does not successfully substantiate this book’s explanation of coevolving policy sectors. It is the very commitment to clear-cut hypotheses and systematic inquiry that has brought forth the limitations of the argument. But then, social science is a collective undertaking, one might say, and much can be said in favor of putting an interesting and novel set of observations and possible relationships on the table, leaving much room for improvement. We read our colleagues’ work as much in search of inspiration and creative disagreement as we look for instruction and conclusive results. In that spirit I can say, do read this book! But do not believe what you read.