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Contents lists available at ScienceDirect
Health Policy
journal homepage: www.elsevier.com/locate/healthpol
An alternative approach to evaluating, measuring, and comparing
domestic and international health institutions: Insights from
social science theories
Eduardo J. Gómez ∗
Department of Public Health & Administration, Rutgers University, 401 Cooper Street, Camden, NJ 08102, United States
a r t i c l e
i n f o
Key words:
Social sciences
Governance
Healthcare systems
Organization and administration
Comparative study
a b s t r a c t
Objectives: This article introduces the benefits of applying social science theories discussing
institutional stasis and change to better measure, explain, and compare elite behavior
within health administration and decentralization processes. A new comparative method
based on these theories is introduced, as well as methods for collecting and analyzing data.
Methods: A literature review of health governance, health system governance, and path
dependency and institutional change theory was conducted to reveal the limitations of
health governance approaches explaining elite behavior. Next, path dependency and institutional change theory was applied to case studies in order to demonstrate their utility in
explaining institutional stasis and change.
Results: Current approaches to analyzing and comparing elite behavior in the health governance frameworks are limited in their ability to accurately explain the willingness of
elites to pursue more efficient institutional and policy designs. Current indicators measuring elite behavior are also too static, failing to account for periodic resistance to change and
the conditions for it.
Conclusions: By applying path dependency and institutional change theory, the policy community can obtain greater insight into the willingness and thus capacity of institutions to
pursue innovations while developing alternative analytic frameworks and databases that
better measure and predict this process.
© 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Never before has the policy community been so interested in the issue of health governance and health
institutions. While health governance [2] entails the participation of elite actors, such as politicians and bureaucrats,
civil society and the private sector in achieving common
health policy goals, an examination of health institutions
[1] restricts its focus to the role of political and bureaucratic
elites in achieving these outcomes through their creation
∗ Corresponding author. Tel.: +1 267 408 3445.
E-mail address: [email protected].
and management of institutions, such as the Ministry of
Health, public health programs, and decentralization processes. Despite their importance as actors in charge of
reforming institutions for greater efficiency in providing
health services, little is known about the behavior and
interests of elites in accomplishing these objectives. To
fill in this lacuna and to contribute to the literature discussing these issues, this article restricts its analysis to elite
behaviors and institutions within the health governance
and health system governance literature [3,10].
In this literature, indicators examining elite behavior and institutional capacity take on a variety of
forms, ranging from political stewardship, strategic vision,
accountability, responsiveness, and bureaucratic capacity
0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2010.08.020
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to decentralization [3,10]. But the questions this article
raises are the following: Do these indicators accurately
define and measure the behavior of elites within institutions and, thus, the willingness and capacity of institutions
to transform for greater efficiency? And to what extent
have these frameworks explored the possibility of applying diverse approaches to social science inquiry [4], such as
political science and sociology, to accurately define, measure, explain, and compare elite behavior and capacity for
institutional change?
Unfortunately, it seems that the practitioner [5] community has not done a good job of addressing these
questions. More specifically, it has failed to explore how
theoretical approaches in social science focusing on the
static and evolutionary nature of institutions, such as path
dependency and institutional change theory [6], respectively, can be used to assess and compare elite behavior
within institutions and, consequently, their capacity to
change.
The purpose of this article is therefore to show that the
practitioner community stands to gain from applying these
theoretical approaches to their analysis of the institutional
aspects of health governance and health system governance. Instead of merely measuring the presence of elite
stewardship, strategic vision, responsiveness, and the like,
this alternative approach suggests that practitioners begin
their analysis by specifying the following issues: political
and bureaucratic elite beliefs, interests, and the supportive
coalitions that motivate elites to become stewards, visionaries, and to pursue institutional change. In contrast to the
existing literature, this approach therefore sees elite interests and coalitions as key independent variables while the
aforementioned health governance and health system governance indictors are treated as outcomes to be explained.
With the usage of brief case studies, I then show how
this approach does a better job of measuring institutional
elite behavior and the capacity for change by filling in
what I call the “grey area” of health institutions, that is,
by establishing direct causal linkages between elite beliefs,
interests, and supportive coalitions with their willingness
to pursue institutional innovations. This is followed by an
explanation about how the practitioner community can use
this approach to establish cross-national, within-case, and
global-level comparisons of health institutions, as well as
developing a new database that more accurately reflects
elite behavior and institutional capacity.
2. Methods
The data used to conduct this study was based on several
sources. First, an extensive literature review of recent publications on the issue of health governance and institutions
was conducted. Next, adopting what Munck [7] defines as
“conceptual reformulation,” I reviewed the literature discussing path dependency and institutional change theory
and used this theory and supportive empirical evidence to
highlight limitations with the existing health governance
and health system governance frameworks. I then used
empirical case studies, obtained from peer-reviewed publications, as illustrations of the potential benefits of my
alternative approach. This is consistent with the method
of analytic narratives [8], which applies formal theoretical
models, such as game theory and rational choice, to explain
the reform of institutions with the intent of not testing theory but rather using detailed case studies to illustrate the
theory’s effectiveness and benefits, while demonstrating
that theory linked to data is more effective than studies
using either data or theory alone [8]. Later, I discuss how
and why analysts should compare diverse nations based on
this approach and the methodological advantages associated with it.
2.1. Reevaluating health governance and institutions
In recent years, and as Table 1 illustrates, work by the
WHO, Kaufman et al. (1999) at the World Bank, Brinkerhoff and Bossert (2008) for the USAID, UNDP, PAHO, and
the OECD [3,10] have provided indictors measuring health
governance and its institutional characteristics. These indicators have been helpful for measuring elite commitment
to implementing responsive and equitable health policy as well as the financial, managerial, and technical
resources needed to strengthen institutions for enhanced
policy implementation. Alternatively, other scholars have
emphasized analyzing health governance issues, such as
the collective action and means that society (including governing elites) at the domestic and international level take
to organize themselves in order to promote and safeguard
the health of its members, efforts which are based on formal (e.g., health regulations) and informal (e.g., Hippocratic
oath) rules [9]. Recent work by Siddiqi et al. [10], however, claims that the existing health governance indicators
fail to provide a holistic framework for analyzing health
governance. Advocating an integrative approach to what
they call Health System Governance (HSG), Siddiqi et al.
maintains that analysts need to consider political leaders’
interaction with the rule of law, efficiency and equity, as
well as expanding the unit of analysis to the sub-national
level.
But how do these health governance [11] indicators
explain political and bureaucratic elite beliefs and incentives to become policy stewards as well as accountable
and effective at policy implementation? For even if official government documents clearly indicate the presence
of political stewardship, responsiveness, civic inclusion and
commitment to health policy, with levels of corruption
being relatively low, leaders often behave in an ineffective
and unprofessional manner: at times they fail to consider new bureaucratic and policy innovations, engage in
corrupt practices while avoiding civic inclusion into policymaking processes [12]. What this suggests is that the
aforementioned health governance indicators, which also
resemble key aspects of good governance, have not adequately explained elite behavior within institutions and
their capacity to transform for greater efficiency.
Recent research suggests that this is indeed the case.
In an extensive literature review of 391 articles, of which
164 were selected for their discussion of health policy
reform processes, Gilson and Raphaely [13] found that few
addressed the political aspects of reform, especially from
an analytical perspective (37 in total, 8 of which were analytical) [13]. They also found that there was very little
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Table 1
Frameworks for assessing health system governance.
WHO (2000)—domains ofstewardship [3,10]
Formulating tools for
implementation: powers,
incentives, and sanctions
Building coalitions and
building partnerships
Ensuring a fit between
policy objectives and
organizational structure
and culture
Ensuring accountability
PAHO’s (2002)
essential public health
functions [3,10]
Function and description
OECD (2009) health system
institutional characteristics [3,10]
EPHF1
Monitoring, evaluation, and
analysis of health situation
Health financing and coverage
EPHF2
Public health surveillance,
research, and control of risks
Health promotion
Coverage of basic services
EPHF3
EPHF4
EPHF5
EPHF6
EPHF7
EPHF8
EPFH9
EPFH10
EPFH11
Social Participation in health
Development of policies and
institutional capacity for
planning and management in
public health
Strengthening the institutional
capacity for the regulation and
enforcement of policy
Evaluation and promotion of
equitable access to necessary
health services
Human resource development
and training in public health
Quality assurance in personnel
and population-based health
services
Research in public health
Reducing the impact of
emergencies and disasters on
health
List of low-level indicators
Types of coverage incentives
Degree of user choice
Levers for competition
“Over the basic” coverage;
Types of incentives for users
Patient choice among providers
Gate-keeping
Price signals on users
Types of incentives for healthcare
provision
Degree of private provision
Regulation of workforce and
equipment
Intensity of price and fee regulation
Decentralization and delegation of
decision-making
Resource allocation in healthcare
systems
Priority setting.
Kaufmann et al. (1999) World
Bank Governance Aspects
[3,10]
Process by which those in
authority are selected and
replaced
Voice, accountability,
political instability, and
violence
UNDP’s (1997) 5 principles of
good governance [3,10]
Brinkerhoff and Bossert (2008) USAID
good health governance indicators
[3,10]
Principles
Thematic areas
Legitimacy and voice
Participation
Direction
Strategic vision
Consensus orientation
Ability of the government to
formulate and implement
policy
Government effectiveness
Regulatory burden
Respect of citizens and the
state for institutions which
govern their interaction
Rule of law
Graft (control of corruption)
Responsiveness
Legitimate exercise of beneficiaries
and citizens’ voice
Institutional checks and balances
Effectiveness and efficiency
Clear accountability
Transparency in policy-making,
resource allocation, and performance
Evidence-based policy-making
Performance
Accountability
Government and transparency
Fairness
Responsiveness to public health needs
and beneficiaries’ and citizens’
preferences while managing
divergences between them
Responsible leadership to address
public health priorities
Efficient and effective service provision
arrangements, regulatory frameworks,
and management systems
Equity and rule of law
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Graph 1. Grey area of health institutions.
discussion of institutions as a set of formal rules shaping
how actors implement policy [13]. While studies focusing
on elite actors were mentioned, they did not discuss elite
preferences to sustain or reform institutions, but rather
their awareness of civic inclusion in the policy-making process, how their interests shape policy and their periodic
resistance to it, as well as the impact of culture on elite
policy preferences [13]. Gilson and Raphaely also note that
there was very little discussion of power within institutions
[13].
Because of these shortcomings, the practitioner community has not done a good job of explaining the
connection between elite beliefs, interests, supportive
coalitions, and institutional elite behavior, such as stewardship and strategic vision. As a further consequence, and
as Graph 1 illustrates, practitioners have not addressed
the “grey area” of health institutions, which connects elite
beliefs and interests to their willingness to consider and
pursue new institutional innovations through stewardship,
strategic vision, and responsiveness.
The next step is to measure this grey area. As illustrated
shortly through the usage of brief case studies, this can
be achieved by applying diverse theoretical approaches to
social science inquiry, namely path dependency and institutional change theory, to highlight the causal mechanisms
explaining elite behavior and reform efforts. But before this
is done, it is important to define these theories and their
goals.
The goal of path dependency and institutional change
theory is to first address the beliefs and interests of elites in
either sustaining inefficient institutional designs or changing them for greater efficiency. For those taking a path
dependency approach, history matters because scholars
examine institutions over a long period of time, using
archival evidence to show how presidents, legislators, and
bureaucrats respond to prior elite decisions to adopt institutions, how they react to and learn from these prior
decisions and why they sustain them [14,16].
As Table 2 illustrates, path dependent processes often
focus on the following causal mechanisms: legitimacy,
learning, increasing returns, power, and coordination. These
mechanisms highlight the fact that elite beliefs in the legitimacy of particular institutional or policy designs [15],
as well as learning from them and passing these beliefs
on to others [16], incentives them to maintain inefficient
institutions. Alternatively, a high level of initial financial
investment within a particular health agency or system
of governance, which is an instance of increasing returns,
such as decentralization, elite control over financial or
administrative resources, i.e., power, and the presence of
neighboring institutions pursuing the same policies, i.e.,
institutional coordination, generates incentives for elites to
refrain from pursuing alternative institutional designs for
greater efficiency [13,14,17].
This path dependent perspective also suggests that
elites are often motivated by irrational decision-making,
failing to engage in cost-benefit analyses based on complete access to information, research, and evidence. When
making decisions, elites may indeed be using what Weyland [18] refers to as cognitive heuristic shortcuts, where
the ready availability of an institution, that is, their close
geographic proximity, as well as their perceived representativeness as a model of excellence motivates elites
to immediately adopt institutions instead of engaging in
timely information gathering and cost-benefit analyses.
Similarly, some argue that elites’ personal values, such as
their moral beliefs, motivate them to refrain from pursuing more efficient institutions whenever they conflict with
these beliefs—e.g., programs encouraging sex education
[19].
Recent case studies provide good examples of path
dependent processes. With regards to institutional legitimacy, work by Vallgarda [20] shows how elite beliefs in
the legitimacy of institutions and policies encouraging the
coercive containment of individuals with HIV/AIDS in Sweden perpetuated these practices despite their inability to
successfully contain the epidemic. Consequently, Sweden’s
government had no interest in pursuing a more effective
approach to curbing the spread of AIDS [20]. This, in turn,
exhibited low levels of elite responsiveness, accountability,
and stewardship. Alternatively, learning constraints have
emerged in Eastern Europe, where elites’ tradition of centralized control over human resource management has
passed on to future bureaucrats and created an unwillingness to pursue a more efficient, decentralized human
resource management process, thus illustrating low levels of elite responsiveness and innovation [21]. Similar
elite responses can be seen in several Eastern European
countries, where increasing returns in the form of early
presidential and legislative investment in particular types
of human resource practices hampered efforts to retrain
agency bureaucrats and encourage decentralization for
greater efficiency through diagonal approaches to health
service provision [22]. And finally, power examples emerge
when elites control the financial resources needed to
expand and strengthen the health bureaucracy [23]. Elites
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Case study of veto and
gate-keeping presence
Case study of budget
history
Case study of budget
history
Case study of policy legitimacy
and support
Process of assigning value
Coordination
Power
Presence of executive
veto power; presence
of legislative veto
override; presence of
gate-keeping power
Initial investment in a
particular institution or
policy
Increasing returns
Learning
Amount of initial
investment in training
and learning
Elite belief that institutions
and/or policies are legitimate
because of their long-term
durability and political support
Legitimacy
Causal mechanisms
Table 2
Causal mechanisms measuring path dependency.
Presence of
neighboring institution
possessing similar
institutions and
policies sustains
institution
Measurement of the
number of neighboring
institutions present
E.J. Gómez / Health Policy xxx (2010) xxx–xxx
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abuse their power for personal gain rather than expressing
any willingness to strive for greater bureaucratic effectiveness [24]—as seen with South Africa’s initial response to
HIV/AIDS [25]. This also accounts for low levels of elite
accountability, commitment, and increased corruption.
As Graph 2 illustrates, the above mentioned path dependent mechanisms nicely capture elite beliefs, interests,
and supportive coalitions, thus leading to preferences to
maintain inefficient institutions. This, in turn, leads to the
absence of any willingness to pursue effective stewardship,
vision, responsiveness, and accountability, elite behaviors
that should lead to institutional adaptation for greater efficiency. Not only does this help to fill in the grey area of
health institutions, but it also provides a more accurate
description of elite behavior and, therefore, institutional
capacity for change.
In contrast to path dependency, institutional change
theory focuses on the international and domestic conditions most conducive for reforming institutions for greater
efficiency. Similar to path dependency, institutional change
theory emphasizes the role of elite actors and their
incentives for reform. As Table 3 illustrates, the causal
mechanisms guiding this approach focus on institutional
conversion, displacement, layering, and de-legitimization.
Institutional conversion emerges when elites strategically reuse the bureaucracy’s established rules, procedures,
and delegated responsibilities for alternative policy goals
[26]. Displacement occurs when elites replace existing institutional structures and policies with new ones [27]. On the
other hand, layering occurs when elites introduce a new law
or policy on top of pre-existing ones, mainly because they
lack the resources needed to reform pre-existing institutions [28]. And finally, de-legitimization occurs when elites
use a change in the international or domestic environment
to de-legitimize the existing institution and introduce a
new one [27].
A good example of institutional conversion can be found
in Brazil. As the work of Gómez [29] highlights, bureaucrats seeking to expand the national HIV/AIDS program
strategically used the simultaneous rise of international
pressures for reform and partnerships with AIDS NGOs to
increase their legitimacy and success in gradually using
the AIDS program for alternative ends: instead of a complete reliance on decentralization, bureaucrats sought to
overcome decentralization’s limitations through a centralized control over municipal AIDS policy via the usage of
discretionary fiscal transfers and informal partnerships
with NGOs. This displays a high level of elite strategic vision, leadership, and innovation. Alternatively, an
instance of institutional displacement is found with the
work of Falleti [30], where in Brazil, she shows how the
gradual infiltration of bureaucrats within the Ministry of
Health led to the transition from an inequitable worker
and employer-based contributory healthcare system to an
entirely decentralized one through increased civic participation and control—i.e., SUS (Sistema Único de Saúde
Publico). This occurred because of the former’s loss of legitimacy and reform bureaucrats’ ability to capitalize on this
and replace it with an alternative system, in turn displaying a high level of elite strategic vision, responsiveness, and
accountability.
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Graph 2. Illustration of connecting path dependency’s mechanisms with institutional elite behavior.
Brazil submits yet another example of institutional layering, where recently the national AIDS program has supplemented the inefficient, decentralized implementation
of AIDS policy through SUS with new legislation providing
the AIDS program with discretionary, performance-based
fiscal transfers to municipalities. Because of AIDS officials’
inability to reform SUS to support the AIDS program’s
specific needs, fiscal transfers and policy conditionalities
have been used to ensure that municipalities have the
resources and the incentives needed to implement the
AIDS program’s policy vision [31]. This, in turn, displays
a high level of elite strategic vision, responsiveness and
accountability to the needs of AIDS victims. And finally,
an instance of institutional de-legitimization can be found
in China, where the work of Huang [32] shows how the
SARS epidemic in 2003 highlighted the government’s inefficient healthcare system. The international community’s
de-legitimization of China’s system in turn motivated its
leadership to strengthen the AIDS program and its policies, thus displaying elite stewardship and strategic vision
in pursuit of innovation [32].
2.2. Broadening our comparative horizons
In addition to better explaining institutional elite behavior, my approach also provides a new way of broadening
our comparison of health institutions. This can be achieved
at the cross-national, within-case, and global-level. It is
important to note, however, that conducting comparisons
between nations with different historical, cultural, and
political contexts can be challenging. In fact some caution against this, as these differences lead to unique elite
interests and reform strategies, making it nearly impossible
to establish generalizable theoretical claims [33]. Others,
as well as this article, disagree, claiming that when one
focuses on specific kinds of elite actors, such as health
bureaucrats, who are often isolated from various political
and cultural interests, there may be more commonalities
than differences between nations with different contexts
[34]. Indeed, scholars believe that these types of comparisons are ideal for testing and developing generalizable
claims [34]. Moreover, conducting comparisons between
seemingly different nations, such as the US and Brazil
(given their differences in industrialization and resources),
not only facilitates the illustration and creation of generalizable claims, but it also underscores the limitations that
governing elites in advanced industrialized nations have in
their willingness to pursue institutional innovations, with
lesser developed nations at times outpacing them in this
regard [29].
When comparing nations, a fruitful strategy is establishing variation in health institutional outcomes, as well
as discovering unique and innovative cases of institutional
sustainability. To achieve this, I propose a multi-stage,
sequential comparative case study design. As Graph 3
illustrates, during Stage 1, analysts can select and compare nations known for their similar pre-existing path
dependent nature (PD), controlling for instances of elite
learning, legitimacy, and increasing returns. Analysts can
then establish variations in causality and outcomes based
on elite decisions to eventually change health institutions
for greater efficiency, either through conversion, displacement, or any of the other mechanisms discussed earlier.
This, in turn, accounts for differences in health institutional
outcomes.
During Stage 2, analysts can then switch to selecting
and comparing nations based on their similar pre-existing
institutional change processes (IC). To achieve this, first
control for prior instances of institutional conversion, displacement, or de-legitimization. Analysts can then establish
variation in causality and outcomes based on institutional
sustainability, where elites periodically strengthen institutions through the passage of new policies that support
it—e.g., layering.
Consider the following example. During Stage 1, the
analyst can compare the US and Brazil based on their a priori awareness of both governments’ early commitment to
decentralized approaches to controlling disease and how
this, in turn, leads to institutional and policy inefficiencies
(i.e., through increasing returns and legitimacy). The analyst then discovers, however, that Brazil’s health officials
eventually engaged in a process of institutional conversion by using the emergence of new international pressures
for a more aggressive, centralized bureaucratic response to
disease containment, such as HIV/AIDS. This type of institutional conversion was absent in the US.
Next, during Stage 2, analysts can compare Brazil to
other nations exhibiting prior instances of institutional
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Process of assigning value
De-legitimization
Layering
Addition of new laws and
policies on top of existing
institutions
Measurement of the
number of new
amendments to an existing
law or policy
Replacement of existing
laws and policies with new
ones
Measurement of the
number of new legislative
policies passed that are
similar to existing policies
and institutions
Displacement
Conversion
Usage of existing
institutional rules for new
policy goals
Case study of the
interaction between
political, bureaucratic
actors, international and
civic organizations
Causal mechanisms
Table 3
Causal mechanisms measuring institutional change.
International and domestic
criticism and opposition to
existing policy or law
Measurement of the
number of new bills
introduced in reaction to
existing policy
E.J. Gómez / Health Policy xxx (2010) xxx–xxx
7
change processes, such as conversion. India and Uganda, for
example, are often described as nations where politicians
and bureaucrats positively responded to international
pressures and worked closely with NGOs for an expansion of their AIDS bureaucracy and policies [35]. Analysts
can therefore control for prior instances of institutional
conversion. After doing this, analysts may find that, in an
effort to sustain an effective decentralized system and
AIDS program, Brazil periodically supplements the devolution of healthcare financing with other fiscal policies
that further strengthen the national AIDS program’s control
over municipal AIDS policy, such as through the creation
of performance-based fiscal transfers. This represents an
instance of institutional layering. Thus, through this comparison of institutional conversion, analysts can discover an
instance of institutional sustainability, which they can learn
from. This represents the final Stage 3 of the comparative
sequential analysis.
Alternatively, analysts can take a similar approach to
conducting within-case analysis. That is, analysts can better
describe and predict institutional performance by applying the concepts and mechanisms of path dependency,
institutional change, and sustainability to the national,
sub-national, and even community-level, thus providing
further observations of the implications of their theories
[36].
For instance, although path dependent processes may
lock-in certain types of policy responses at the nationallevel, analysts may see instances of institutional change
occurring at the sub-national level, i.e., among state and
community health departments. Next, analysts can further
broaden their within-case comparisons by comparing similar types of institutional change processes at the stateand community-level (Stage 2), while highlighting differences in sustainability among health institutions at these
levels (Stage 3). I can only surmise that this kind of response
is more likely to occur in federations where the central
government has devolved a great deal of financial and
policy-making authority.
And finally, my approach provides insight into how
analysts can conduct comparisons at the global-level. An
application of path dependency theory to multi-lateral
institutions shows, for example, why elites are unwilling to pursue changes in existing lending policies while
neglecting to work closely with domestic governments.
Mechanisms of increasing returns and legitimacy, for example, can highlight the fact that institutions investing a
lot of money, time and training in establishing certain
types of financial lending criteria may not desire to switch
to a newer one even if studies suggest that alternative
approaches are more effective. Governing boards may also
assign a high degree of legitimacy to existing lending criteria, given that the criteria was initially very popular and
had a lot of support.
A good example of this dilemma is the work of Eichler and Glassman [37]. Looking at the case of the Global
Fund to Fight AIDS, TB, and Malaria, as well as GAVI (The
Global Alliance for Vaccines and Immunization), they show
that these donors are faced with the constraint of proving incapable of clarifying and updating their rules linking
payments to health systems results. These organizations
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Graph 3. A comparative sequential analysis of path dependency, institutional change, and the sustainability of health institutions.
need to overcome these constraints in order to play a
more effective role in donor assistance [37]. By applying
the mechanisms of increasing returns and learning, analysts
may be able to explain why these organizations have not
been able to achieve these goals. This approach also has the
potential of revealing the sources of power within donor
institutions.
In addition, analysts may also employ theories of institutional change to examine reform within multi-lateral
institutions. Conversion, for example, may emerge when
international pressures or changes in the international
environment (e.g., increased poverty, war, and famine)
prompt donors to reevaluate their interests and policies for donor assistance. Furthermore, this may lead to
instances of de-legitimization, as actors within multi-lateral
institutions believe that lending procedures and policy suggestions are no longer applicable and effective in meeting
health goals.
Some scholars believe that the World Bank provides
a good example of institutional change processes [38]. In
contrast to its original mandate of providing loan assistance for economic restructuring, by the late-1980s some
claim that the Bank was able to quickly adapt to a changing international environment, such as the need for more
investment in poverty and education, as well as worsening global inequalities and pressures for health systems
change [38]. While some may argue that this change
in Bank vision occurred during the 1960s [39], others
maintain that it was in the 1990s that the Bank finally
displayed significant changes, especially with regards to
its lending programs in healthcare and poverty alleviation
[38].
2.3. Measurement and data
And finally, my approach can also be used to find better ways of measuring and obtaining data on elite behavior
within institutions. With regards to path dependent arguments that are more qualitative in nature, the first step
is to clearly specify the causal mechanism of interest—see
Table 2. Next, the analyst can use online news databases,
such as World News Connection, Access World News, Lexis
Nexis, and Google, which not only translate foreign language newspapers but also allows for the use of key word
search terms capturing the mechanisms of interest. With
regards to institutional legitimacy; for example; the analyst can either type in the terms “policy legitimacy,” “policy
durability,” “political support for policy,” or use these terms
separately to broaden the search results of articles discussing these issues. Articles will also highlight the search
terms found in the text; which will then require the analyst
to make sure they are being used in the appropriate context
and that the theoretical argument is present.
Analysts will then need to assign values to the presence
of institutional legitimacy. A nation can receive a dichotomous value of “1” or “0.” Alternatively, the analyst may
employ Fuzzy Set theory [40] and assign values based on
the degree of policy legitimacy present—e.g., elites considered the legitimacy of a policy and were somewhat, not
entirely, influenced by it, thus receiving a score of “0.5.”
For example, I used Access World News to search for the
presence of institutional legitimacy in Brazil. The following
search terms were used: “Brazil,” “health,” and “political
support.” This search provided an article by the newspaper Toronto Star [41], which was listed as #5 in a search
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result of 276 possible articles. This article discussed political elites’ long commitment to providing universal access to
medicine, culminating with the decentralized provision of
HIV/AIDS treatment by 1996. Although other researchers
have found the decentralized distribution of drugs to be
ineffective [29], this provided evidence of enduring elite
beliefs in the universal distribution of medicine, suggesting a tentative score of “1” for the presence of institutional
legitimacy.
Alternatively, I considered the case of Uganda. After
using Google for the search terms “Uganda,” “HIV/AIDS,”
and “political support,” I found a peer-reviewed article [42]
(#3 out of 8620) indicating that since the late-1980s, the
government was not entirely supportive of a decentralized
approach to AIDS policy. Instead, elites viewed decentralization as a means to achieve the government’s pre-existing
ideological commitment to community involvement and
empowerment. This merits a tentative score of “0.5” for
the presence of institutional legitimacy.
The same process can be done for the causal mechanisms associated with institutional change. For example,
with regards to institutional de-legitimization, the search
terms “China,” “criticism,” and “HIV/AIDS” were used in
Access World News. The #1 search result (out of 873) was
an article written by a Chinese newspaper [43] discussing
how international criticisms of China’s pre-existing AIDS
policies created incentives for elites to strengthen them.
This suggests a tentative score of “1” for the presence of
institutional de-legitimization.
With regards to mechanisms involving quantitative
arguments, the analyst will need to use alternative sources
of data. For example, if one is measuring elite power, one
can use primary and secondary literature. One can scan
the literature and count those nations that have presidents
with executive veto authority; the presence of legislative
veto override; and the presence of gate-keeping power
[44]. Shugart and Carey’s [44] analysis of executive decree
authority provides a database of these measurements. In
their index of executive decree authority, they assign a
dichotomous value of “0” or “1” for the absence or presence of executive veto power, legislative override and
gate-keeping authority. Alternatively, the analyst can read
primary literature, such as published case studies, to assign
values.
Once the data is collected, nations can then be listed in
a spreadsheet along with their respective values based on
the presence of path dependent and institutional change
mechanisms. Next, analysts can use this data as independent variables while the aforementioned World Bank,
WHO, PAHO, and OECD health governance indicators can
be used as dependent variables. This can eventually provide
the data needed to conduct statistical analyses of how the
behavioral characteristics of health institutions account for
variations in health governance, which to my knowledge is
an approach not yet taken in the literature.
3. Conclusion
Studies of health governance and institutions are justifiably on the rise. However, this article has argued that the
approach taken by practitioners to measure and explain
9
elite institutional behavior and resource capacity within
health governance frameworks is inadequate. One cannot understand the stasis of health institutions and their
eventual change by simply analyzing static measurements
of elite stewardship, accountability, responsiveness, corruption, financing, and the like. In addition to failing to
account for contradictory and unexpected elite behavior,
these indicators only explain policy direction and resource
levels. They do not explain elite beliefs, interests, and the
supportive coalitions determining the rise of these governance indicators, and thus the willingness and capacity of
institutions to transform for greater efficiency. This failure underscores the fact that most practitioners lack formal
training in social science—especially political science.
In contrast, this article has argued that practitioners
should consider using diverse approaches to social science
inquiry, specifically path dependency and institutional
change theory, to guide their questions and analyses of
institutional elite behavior. In so doing, analysts can ask
questions that are more specific about elite beliefs, interests, coalitions, and their willingness to pursue innovations.
For example, how have early financial investments in institutional designs, pre-existing elite support for them, and
the concentration of power created incentives for elites
to consistently refrain from creating new coalitions seeking institutional innovation? Alternatively, how do changes
in the international and domestic environment create
incentives for elites to gradually build international and
domestic coalitions seeking to either convert, displace, or
add on top of existing institutional rules and procedures for
greater efficiency? These are brief examples of a myriad of
questions that can be proposed through the usage of path
dependency and institutional change theory.
In addition to proposing new questions, these theories can also be used to highlight and measure the causal
mechanisms filling in the “grey area” of health institutions. In so doing, analysts can better describe and predict
institutional behavior and capacity, while discovering institutional problems that may have been overlooked.
The approach offered here also helps to broaden our
comparative analysis of health institutions. Analysts can
use path dependency and institutional change theory to
select and compare diverse nations while ultimately highlighting variation in institutional sustainability, which is
an area in need of further research. The next step will
be to understand the international and domestic political
conditions sustaining investments in Ministries of Health
or introducing new fiscal policies that supplement poorly
designed decentralization policies—i.e., layering. In addition, these theories can help to explain institutional and
policy stasis within multi-lateral institutions. This is an
uncharted area of research. Future work needs to explore
the sources of power and resistance within multi-lateral
institutions, such as the Global Fund and GAVI, while highlighting the successful conditions for institutional change,
as seen with the World Bank. As private philanthropies,
such as the Bill & Melinda Gates foundation, rise as important agenda-setters in global health, it behaves us to also
assess power issues within these institutions and their
capacity to learn and adapt to changing domestic environments.
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And finally, my approach can help to create new
databases that bi-lateral and multi-lateral institutions can
use to better assess, measure, and predict the behavior of elites and their willingness to pursue institutional
innovations. Recently, bi-lateral and multi-lateral donors,
such as PEPFAR and the Global Fund, respectively, have
expressed interest in discovering alternative ways of
measuring institutional capacity and sustainability [45].
The theoretical and methodological approach offered
in this article may provide some useful insights and
suggestions.
We are now at the crossroads where diverse approaches
to social science inquiry meet health institutions. The time
has come to think seriously about how social scientists
can work with the practitioner community to reevaluate
how practitioners define, measure, and assess health institutions. I hope that this article brings us a step closer in
achieving this goal while posing new questions for future
research and collaboration.
References
[1] I define “institutions” as the political and bureaucratic organizational
structures responsible for implementing policy, such as the Ministry
of Health and public health programs, as well as the design of health
systems distributing policy responsibilities to sub-national governments, such as decentralization. My definition of institutions also
entails the presence of political and bureaucratic elites that control
these structures and systems and whose interests, preferences, and
motivations are shaped by informal and formal organizational rules,
which in turn delegate responsibilities and expectations of behavior.
My decision to focus on elites is guided by the application of institutional change and path dependency theory, which, as explained in
more detail shortly, underscores the importance of elite actors when
reforming institutions.
[2] In this article, I refer to “governance” as the strategies that society (including government) takes to work in a collective manner,
both formally and informally, in order to achieve common goals. I
also interpret governance to mean the process of decision-making
and the formal and informal processes of how decisions are made;
moreover, this is a process that incorporates the participation of civil
society as well as international institutions. However, it is important
to note that the term “governance” is distinct from “good governance.” Rather than focusing on decision-making processes, good
governance emphasizes government responsiveness, accountability, transparency, adherence to the rule of law, efficiency, equity,
and anti-corruption. While not the focus of this article, this closely
resembles my discussion of institutional elite behavior.
[3] World Health Organization. Health systems: improving performance. Geneva: World Health Organization; 2000;
Pan American Health Organization. Essential public health functions.
In: Public health in the Americas; 2002. Scientific and technical publication no. 589;
Brinkerhoff D, Bossert T. Health governance: concepts, experiences,
and programming options. Washington, DC: United States Agency
for International Development; 2008;
Kaufmann D, Kraay A, Zoido-Lobaton P. Governance matters. Washington, DC: World Bank Policy Research Working Paper no. 2196;
1999;
United Nations Development Program. Governance for sustainable
human development: a UNDP policy document. New York: UNDP;
1997;
Organization for Economic Co-operation and Development. Health
systems institutional characteristics. Paris: Organization for Economic Co-operation and Development; 2009.
[4] Diverse approaches to social science inquiry reflect the fact that political science and sociology often apply different types of theoretical
and methodological approaches.
[5] The term “practitioner community” refers to those analysts, medical doctors, public health experts and policymakers working in
international organizations, think tanks, foundations, and domestic
governments.
[6] It is important to note that institutional change theory is a diverse
field of social science inquiry, often encompassing elements of path
dependency. For example, some argue that institutional change
first requires shifts in the endogenous path dependent mechanisms
reproducing inefficient institutions, such as legitimacy (leading to
de-legitimacy) and changes in levels of resource power; Deeg R.
Change from within: German and Italian finance in the 1990s.
In: Streeck W, Thelen K, editors. Beyond continuity: institutional
change in advanced political economies. New York: Oxford University Press; 2005. p. 169–02; Schneiberg M, Clemens E. The
typical tools for the job: research strategies in institutional analysis. Sociological Theory 2006;24:195–227. Alternatively, some view
institutional change processes as distinct from changes in endogenous reproductive mechanisms, emphasizing instead elite strategies
and interests in gradually transforming institutions; Thelen K. How
institutions evolve: insights from comparative historical analysis.
In: Mahoney J, Rueschemeyer D, editors. Comparative historical
analysis in the social sciences. New York: Cambridge University
Press; 2003. p. 208–40. Similar to Thelen, my emphasis on institutional conversion, displacement, and layering entail processes that
have different causal mechanisms, elite intentions, and strategies
when compared to reproductive path dependent processes. With
regards to conversion, displacement, and layering, elites are trying to use changes in the international environment while devising
domestic coalitions seeking to transform institutions for greater efficiency. Conversely, path dependent processes entail elite interests
and strategies for sustaining inefficient institutional designs. While
processes of elite power and legitimacy are certainly present in both
theoretical approaches, these differences in elite intentions, strategies, and causal mechanisms are why I view institutional change and
path dependency as distinct theoretical approaches.
[7] Munck G. Tools for qualitative research. In: Brady H, Collier D, editors.
Rethinking social inquiry: diverse tools, shared standards. New York:
Rowman & Littlefield Press; 2004. p. 105–22.
[8] Bates R, Greif A, Levi M, Rosenthal JL, Weingast B. Analytic narratives.
Princeton: Princeton University Press; 1998.
[9] Dodgson R, Lee K, Dragger N. Discussion paper no. 1: global health
governance; a conceptual review. Centre on Global Change & Health,
Department of Health & Development, London School of Hygiene and
Tropical Medicine and World Health Organization; 2002.
[10] Siddiqi S, Masud T, Nishtar D, Peters B, Sabri K, Jama M. Framework
for assessing governance of the health system in developing nations:
gateway to good governance. Health Policy 2008;90:13–25.
[11] Henceforth, the term “health governance” will be used when referring to the literature on health governance and health system
governance.
[12] For instance, consider those governments that the Global Fund
decided not to renew for subsequent funding rounds. This was based
on governments’ repeated failure to adequately include civil society
into the policy-making process (e.g., CCMs), while engaging in corrupt practices; Copson R, Salaam T. The global fund to fight AIDS,
TB, and malaria: background and current issues. Washington, DC:
Congressional Research Service; 2005.
[13] Gilson L, Raphaely N. The terrain of health policy analysis in low
and middle income countries: a review of published literature
1994–2007. Health Policy & Planning 2008;23:294–337.
[14] Mahoney J. Path dependency in historical sociology. Theory and Society 2000;29:507–48.
[15] Mahoney J. Revisiting general theory in historical sociology. Social
Forces 2000;83:459–89;
Clemens E, Cook J. Politics and institutionalism: explaining durability
and change. Annual Review of Sociology 1999;25:441–66.
[16] Heclo H. Modern social policies in Britain and Sweden. New Haven:
Yale University Press; 1974;
Rose R. Inheritance before choice in public policy. Journal of Theoretical Politics 1990;2:263–91;
Pierson P. Increasing returns, path dependency, and the study of
politics. American Political Science Review 2000;9:251–67.
[17] Pierson P. Increasing returns, path dependency, and the study of politics. American Political Science Review 2000;9:251–67;
David P. Clio and the economics of QWERTY. American Economic
Review 1985;75:332–7;
Knight J. Institutions and social conflict. New York: Cambridge University Press; 1992;
Hartsock N. Money, sex, and power: toward a feminist materialism.
New York: Longman Press; 1983;
Morris P. Power: a philosophical analysis. Manchester: Manchester
University Press; 2002;
North DC. Institutions, institutional change, and economic perfor-
Please cite this article in press as: Gómez EJ. An alternative approach to evaluating, measuring, and comparing domestic and international health institutions: Insights from social science theories. Health Policy (2010),
doi:10.1016/j.healthpol.2010.08.020
G Model
HEAP-2585;
No. of Pages 11
ARTICLE IN PRESS
E.J. Gómez / Health Policy xxx (2010) xxx–xxx
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
mance. New York: Cambridge University Press; 1990;
Hall P, Soskice D. An introduction to varieties of capitalism. Harvard
University, Unpublished manuscript; 2000.
Weyland K. Bounded rationality and policy diffusion: social sector
reform in Latin America. Princeton: Princeton University Press; 2007.
Morone J. Hellfire nation: the politics of sin in American history. New
Haven: Yale University Press; 2005.
Vallgarda S. Problematizations and path dependency: HIV/AIDS policies in Denmark and Sweden. Medical History 2007;51:99–112.
Djibuti M, Gotsadze G, Mataradze G, Menabde G. Human resources
for health challenges of public health system reform in Georgia.
Human Resources for Health 2008;6:1–7.
Balabanova D, McKee M, Mills A, Walt G, Haines A. What can global
health institutions do to help strengthen health systems in low
income countries? Health Research Policy and System 2010;8:1–11.
Mills A, Rasheed F, Tollman S. Strengthening health systems. In: Jamison D, Breman A, Measham G, Alleyne G, Claeson M, Evans D, Jha P,
Mills A, Musgrove P, editors. Disease control and priorities in developing nations. Washington, DC: The World Bank Group Press; 2007.
p. 87–102.
However, it is important to note that elites may eventually change
their mind and use their concentrated sources of power to suddenly
change health institutions for greater efficiency.
Schneider H, Stein J. Implementing AIDS policy in post-apartheid
Africa. Social Science & Medicine 2001;52:723–31.
Thelen K. Historical institutionalism in comparative politics. American Political Science Review 1999;2:369–404;
Thelen K. How institutions evolve: insights from comparative historical analysis. In: Mahoney J, Rueschemeyer D, editors. Comparative
historical analysis in the social sciences. New York: Cambridge University Press; 2003. p. 208–40;
Eisenstadt SN. Institutionalization and change. American Sociological Review 1964;29:235–47.
Mahoney J, Thelen K, editors. Explaining institutional change: ambiguity, agency, and power. New York: Cambridge University Press;
2010;
True J, Jones B, Baumgartner F. Punctuated-equilibrium theory:
explaining stability and change in public policy-making. In: Sabatier
P, editor. Theories of the policy process. Boulder: Westview Press;
2007. p. 152–87.
Schickler E. Disjointed pluralism: institutional innovation and the
development of the US congress. Princeton: Princeton University
Press; 2001;
Mahoney J, Thelen K, editors. Explaining institutional change: ambiguity, agency, and power. New York: Cambridge University Press;
2010.
Gómez E. How Brazil eventually outpaced the United States when it
came to HIV/AIDS: the politics of civic infiltration and strategic internationalization. Journal of Health Politics, Policy and Law 2011;36.
Falleti T. Infiltrating the state: the evolution of healthcare reforms
in Brazil, 1964–1988. In: Mahoney J, Thelen K, editors. Explaining
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
11
institutional change: ambiguity, agency, and power. New York: Cambridge University Press; 2010. p. 38–62.
Pires D. Alguns apontamentos sobre o processo de descentralizacão
do programa de Aids. Masters thesis, Universidade de Estado do Rio
de Janeiro-Instituto de Medicina Social; 2006.
Huang Y. The politics of government response to HIV/AIDS in China.
Asian Perspective 2006;30:95–125.
Katznelson I. Structure and configuration in comparative politics. In:
Lichbach M, Zuckerman A, editors. Comparative politics: rationality,
culture, and structure. New York: Cambridge University Press; 1997.
p. 81–112.
Przeworski A, Tuene H. The logic of comparative social inquiry. New
Jersey: Wiley-Interscience Press; 1970.
Putzel J. The politics of AIDS in Uganda. Public Administration &
Development 2005;24:19–30;
Sridhar D, Gómez E. Health financing in Brazil, Russia, and India: what
role does the international community play? Health Policy & Planning 2010:1–13; available online at: http://heapol.oxfordjournals.
org/cgi/reprint/czq016v1.
King G, Keohane R, Verba S. Designing social inquiry: scientific inferences in social science research. Princeton: Princeton University
Press; 1993.
Eichler R, Glassman A. Health systems strengthening via
performance-based aid: creating incentives to perform and to
measure results. Washington, DC: The Brookings Institution Press;
2008.
Mattos R, Terto V, Parker R. World Bank strategies and the response
to AIDS in Brazil. Divulgacão em Saúde para Debate 2003;27:215–
27.
Prah Krueger J. The changing role of the World Bank in global health.
American Journal of Public Health 2005;95:60–70.
Ragin C. Fuzzy set social science. Chicago: University of Chicago
Press; 2000.
Teotonio I. World looking to Brazil for answers. Toronto Star, August
5, 2006.
Youde J. Ideology’s role in AIDS policies in Uganda and South Africa.
Global Health Governance 2007;1:1–16.
China Daily (Beijing). HIV battle enters new phase. October 27,
2005.
As Shugart and Carey (1998) explain, gate-keeping authority occurs
when policy must be initiated by the Prime Minister or President.
While legislatures may propose a policy idea, they must first rely
on the former to initiate the idea. If the Prime Minister or President
fails to do so, the idea does not pass on to the legislature for a vote;
Shugart M, Carey J, editors. Executive decree authority. New York:
Cambridge University Press; 1998.
PEPFAR, United States Agency for International Development. The US
President’s emergency plan for AIDS relief: 5 year strategy. Washington, DC; 2009; The Global Fund to Fight AIDS, TB, and Malaria. CCM
performance indicators. Geneva; 2010.
Please cite this article in press as: Gómez EJ. An alternative approach to evaluating, measuring, and comparing domestic and international health institutions: Insights from social science theories. Health Policy (2010),
doi:10.1016/j.healthpol.2010.08.020