Market Reforms in Europe: Dynamics of Policy Fashion Michael I. Harrison* Agency for Healthcare Research and Quality Presented at Academy Health Annual Research Meeting June 6, 2004, San Diego. *

EXPLAINING DYNAMICS OF POLICY FASHION Observations: Observations: – Policy makers in Britain, Sweden, and the Netherlands adopted market reform policies quickly and uncritically. – Decision makers and their constituencies soon became disenchanted with market reforms, once the proposed changes proved hard to implement. – The health policy agenda shifted quickly, as policy makers explored new options. Research question: Did the rapid rise and decline of political support for market reforms in health care reflect the dynamics of policy fashion? Research question: Did the rapid rise and decline of political support for market reforms in health care reflect the dynamics of policy fashion?

POLICY FASHION DEFINED The rapid rise and decline in political support for a set of policy-related beliefs, principles, programs, or techniques is called policy fashion when these shifts reflect the dynamics and interactions of fashion setting, policy formation and adoption, and policy implementation.

DYNAMICS OF POLICY FASHIONS + Fashion Setting Support for Policy Trend Demand For Policy Fashions Policy Formation and Adoption Policy Implementation -

FASHION SETTING Fashion setters --policy gurus, universities, consultants, media -- actively promote new policies. Fashion setters --policy gurus, universities, consultants, media -- actively promote new policies. Setters define favorite new policies as progressive and rational. Setters define favorite new policies as progressive and rational. Initial discourse is enthusiastic and uncritical. Initial discourse is enthusiastic and uncritical.

FORMATION AND ADOPTION OF POLICY FASHION Advocates in governments and agencies urge adoption of policies promoted by high-status setters and used by high- status organizations and sectors. Advocates in governments and agencies urge adoption of policies promoted by high-status setters and used by high- status organizations and sectors. Policy makers alter fashions from other sectors to fit target sector. Policy makers alter fashions from other sectors to fit target sector. Proponents build supporting coalitions. Proponents build supporting coalitions.

FORCES CREATING DEMAND FOR POLICY FASHIONS Norms of progress and rationality Norms of progress and rationality Budgeting processes and career ladders in public agencies Budgeting processes and career ladders in public agencies Economic cycles Economic cycles Organizational and technical contradictions (e.g., public accountability vs. professional autonomy; disease intervention vs. wellness) Organizational and technical contradictions (e.g., public accountability vs. professional autonomy; disease intervention vs. wellness)

FORCES AFFECTING SUPPORT FOR POLICY TRENDS Trends in political beliefs and values Trends in political beliefs and values Social and cultural change Social and cultural change Electoral politics Electoral politics Interactions among policy actors Interactions among policy actors Organizational and technical conditions Organizational and technical conditions Policy precedents and institutional commitments Policy precedents and institutional commitments

FORCES UNDERMINING SUPPORT FOR IMPLEMENTED POLICY Implementation complications and struggles Implementation complications and struggles Disappointment with results Disappointment with results – Outcomes below expectations – Costs beyond estimates Outcomes of policy fashions always fall below original expectations (and stated objectives) and costs always exceed estimates, because initial expectations were unrealistic and overly optimistic. Outcomes of policy fashions always fall below original expectations (and stated objectives) and costs always exceed estimates, because initial expectations were unrealistic and overly optimistic. Changes in forces affecting demand for policy trend. Changes in forces affecting demand for policy trend. Competition from other policies, including new policy fashions. Competition from other policies, including new policy fashions.

IMPLEMENTATION COMPLICATIONS & STRUGGLES Shifts in involvement of main actors bring changes in implementation needs, views, and priorities. Shifts in involvement of main actors bring changes in implementation needs, views, and priorities. Main actors: Main actors: – Policy makers – Implementers – Recipients – Nonparticipating stakeholders, e.g., unions, voluntary groups, voters. Implementation barriers emerge. Implementation barriers emerge. Policy contradictions surface. Policy contradictions surface. Conflicts emerge between policy and other strongly held values. Conflicts emerge between policy and other strongly held values. Actors learn about policies and implementation. Actors learn about policies and implementation.

IMPLEMENTATION BYPRODUCTS IMPLEMENTATION BYPRODUCTS Discourse becomes critical. Discourse becomes critical. Supporting coalitions grow weaker or fragment. Supporting coalitions grow weaker or fragment. Popular disaffection grows with policies and policy makers. Popular disaffection grows with policies and policy makers. Fashion setters and policy makers search for alternative policy solutions. Fashion setters and policy makers search for alternative policy solutions.

CONSEQUENCES OF FASHION Challenge taken-for-granted routines and ideas. Encourage experimentation. Successive waves of fashion can produce significant changes.

FASHIONS COSTS AND RISKS Discourages diagnosis of problems and analysis of program feasibility Discourages diagnosis of problems and analysis of program feasibility Blocks improvement during implementation Blocks improvement during implementation Wastes resources Wastes resources Fails to attain objectives Fails to attain objectives Burdens the implementers Burdens the implementers Creates cynicism Creates cynicism

LIVING WITH POLICY FASHION Involve those responsible for implementation in policy formulation and planning. Experiment with policy options before full-scale rollout. Sponsor research and rapid feedback on implementation. Train all levels in diagnostic and critical thinking about policies and their implementation.