Co-evolution of Policy Sectors: Health Care and Public Health in five Countries

Cette thèse analyse la co-évolution de deux secteurs dans la politique de la santé: santé publique (public health) et soins aux malades (health care). En d'autres termes, la relation entre les dimensions curative et préventive de la politique de la santé et leur développement dans la durée. Une telle recherche est nécessaire car les problèmes de la santé sont complexes et ont besoin de solutions coordonnées. De plus, les dépenses de la santé ont augmenté sans arrt durant les dernières décennies. Un moyen de réduire une future augmentation des dépenses pourrait consister en davantage d'investissement dans des mesures préventives. En relation avec cette idée, ma recherche analyse les politiques de la santé publique et les soins aux malades de cinq pays: Allemagne, Angleterre, Australie, Etats-Unis et Suisse. En m'appuyant sur la littérature secondaire, des statistiques descriptives et des entretiens avec des experts et des politiciens, j'analyse la relation entre les deux secteurs depuis la fin du dix-neuvième siècle. En particulier, je me focalise sur la relation des deux champs sur trois niveaux: institutions, acteurs et politiques. Mes résultats montrent les similitudes et les différences d'évolution entre les cinq pays. D'un c^oté, lorsque la profession médicale est politiquement active et que le pays consiste en une fédération centralisée ou en un gouvernement unitaire, les deux secteurs sont intégrés au niveau institutionnel, ralliant les professions et groupes d'intérêt des deux secteurs la cause commune dans une activité politique. Par contre, dans tous les pays, les deux secteurs ont co-évolué vers une complémentarité malgré de la politisation des professions et la centralisation du gouvernement. Ces résultats sont intéressants pour la science politique en général car ils soulignent l'importance des professions pour le développement institutionnel et proposent un cadre pour l'analyse de la co-évolution des politiques publiques en général. -- This Ph.D. thesis analyzes the co-evolution of the health care and the public health sectors. In other words, the relation between preventive and curative health policy and its evolution over time. Such research is necessary, because current health problems are complex and might need coordinated solutions. What is more, health expenditures have increased continuously in the last decades. One way to slow down further increase in health spending could be to invest more in preventative health policies. Therefore, I am connecting individual health care and public health into a common analysis, taking Australia, Germany, Switzerland, the UK and the U.S. as examples. Based on secondary literature, descriptive statistics and interviews with experts and policymakers, I am analyzing how the two sectors' relations co-evolved between the late nineteenth and the early twenty-first century. Specifically, I am researching how health care and public health were related on the levels of institutions, actors and policies. My results show that there are differences and similarities in the co-evolution of policy sectors between these countries. On the one hand, when the medical profession was politically active and the country a centralized federation or a unitary state, there was institutional integration and common political advocacy of the sectors' interest groups and professions. On the other hand, in all countries, both sectors co-evolved towards complementarity, irrespectively of the politicization of professions and centralization of government. These findings are interesting for the political science literature at large, because they underline the importance of professions for institutional development and propose an analytical framework for analyzing the co-evolution of policy sectors in general.

Europeanization or Party Politics? Explaining Government Choice for Corporatist Concertation

This article assesses whether changes in government choice for policy concertation with trade unions and employers are better explained by international or domestic factors. We compare patterns of corporatist governance in a strongly Europeanized policy domain (labor migration policy) and in a weakly Europeanized policy domain (welfare state reforms) over the last 20 years in Austria and Switzerland. We show that there is no systematic difference in patterns of concertation between the two policy sectors and that factors linked to party politics play a bigger role in the choice of governments for concertation. If the base of party support for policies is divided, governments are more prone to resort to corporatist concertation as a way to build compromises for potentially controversial or unpopular policies. By contrast, ideologically cohesive majority coalitions are less prone to resort to concertation because they do not need to build compromises outside their base of party support.

High-Speed Rail: lessons for policy makers from experiences abroad

In April 2009, the US government unveiled its blueprint for a national network of high-speed passenger rail (HSR) lines aimed at reducing traffic congestion, cutting national dependence on foreign oil and improving rural and urban environments. In implementing such a program, it is essential to identify the factors that might influence decision making and the eventual success of the HSR project, as well as foreseeing the obstacles that will have to be overcome.

A Pragmatic Intellectual: Dutch Fabians, Boekman, and Cultural Policy in the Netherlands, 1890-1940

Around 1900, the notion of community art (gemeenschapskunst) served to crystallize Dutch social democratic thinking about the role of the arts in society. Drawing on the pragmatism of leading social democrats like Wibaut, and drawing on his formal education in economics and statistics, the self‐made social democrat Emanuel Boekman redressed the utopian meaning of community art to signify the dissemination of "good" culture over all layers of society in his influential 1939 dissertation on the relation of the state to the arts. Being about facts rather than opinions, Boekman set the boundaries of his work to exclude a substantial discussion of the meaning of "good" culture. On the one hand, this pragmatism helped Boekman to gain support for government intervention for the arts over most of the political spectrum. On the other hand, Boekman thus pre‐empted discussions about the tension between "quality" and "accessibility" of the arts that haunts cultural policy in the Netherlands to this day.

The Institutional, Economic and Social Determinants of Local Government Transparency

Interest in public accountability and government transparency is increasing worldwide. The literature on the determinants of transparency is evolving but is still in its early stages. So far, it has typically focused on national or regional governments while neglecting the local government level. This paper builds on the scarce knowledge available in order to examine the economic, social, and institutional determinants of local government transparency in Spain. We draw on a 2010 survey and the transparency indexes constructed by the NGO Transparency International (Spain) in order to move beyond the fiscal transparency addressed in previous work. In so doing, we broaden the analysis of transparency to the corporate, social, fiscal, contracting, and planning activities of governments. Our results on overall transparency indicate that large municipalities and left-wing local government leaders are associated with better transparency indexes; while the worst results are presented by provincial capitals, cities where tourist activity is particularly important and local governments that enjoy an absolute majority. The analysis of other transparency categories generally shows the consistent impact of these determinants and the need to consider a wider set of variables to capture their effect.

The role of the tourism sector in economic development. Lessons from the Spanish experience

Tourism is one of the most important sectors in the global economy and is considered an efficient tool with which to promote economic growth. The case of Spain¿s economy is well known in this respect; in fact, widespread consensus exists on the part played by tourism in enhancing the industrialisation process in Spain and the part played by foreign currency receipts from tourism in financing the imports of capital goods, which made the expansion of manufacturing possible. This paper aims to assess the real role of foreign currency receipts from tourism in Spain¿s economy from 1960 to the present. The results of Spain¿s experience may well help to guide policy decisions in developing countries in similar circumstances.

The role of the tourism sector in economic development. Lessons from the Spanish experience

Tourism is one of the most important sectors in the global economy and is considered an efficient tool with which to promote economic growth. The case of Spain¿s economy is well known in this respect; in fact, widespread consensus exists on the part played by tourism in enhancing the industrialisation process in Spain and the part played by foreign currency receipts from tourism in financing the imports of capital goods, which made the expansion of manufacturing possible. This paper aims to assess the real role of foreign currency receipts from tourism in Spain¿s economy from 1960 to the present. The results of Spain¿s experience may well help to guide policy decisions in developing countries in similar circumstances.

The First Privatization Policy in a Democracy: Selling State-Owned Enterprises in 1948-1950, Puerto Rico

In the 1940s, when the Governor of Puerto Rico was appointed by the US President and the Puerto Rican government was answerable only to the US Federal government, a large state-owned enterprise (SOE) sector was established on the island. Public services such as water, transportation and energy were nationalized, and several new manufacturing SOEs were created to produce cement, glass, shoes, paper and chalkboard, and clay products. These enterprises were created and managed by government-owned corporations. Later on, between 1948 and 1950, under the island’s first elected Governor, the government sold these SOEs to private groups. This paper documents both the creation and the privatization of the SOE sector in Puerto Rico, and analyzes the role played by ideology, political interests, and economic concerns in the decision to privatize them. Whereas ideological factors might have played a significant role in the building of the SOE sector, we find that privatization was driven basically by economic factors, such as the superior efficiency of private firms in the sectors where the SOEs operated, and by the desire to attract private industrial investment to the Puerto Rican economy.

Structuration and branding of a religious tourism product: Catalonia sacra

This article aims to provide an overview of the products Catalonia has to offer in terms of religious tourism. The growing interest in this kind of tourism worldwide, and in Catalonia itself, along with the region's wealth of religious heritage (particularly connected to the Christian Church) contrast with the lack of religion-based tourism products available, which results in its absence from the region's image as a tourism destination. In view of this, the Faculty of Tourism (University of Girona), the Vic Bishopric's Albergueria-Centre for Cultural Dissemination and the Tarraconense Episcopal Conference's Interdiocese Secretariat for the Custody and Promotion of Holy Art (SICPAS) decided to address the situation with the help of funding from the Autonomous Government of Catalonia. In order to re-position Christian religious heritage in the image of Catalonia as a tourist destination, the aforementioned parties embarked upon a project to set up a series of routes throughout the region, branded under the name Catalonia Sacra

Empowering local democracy in Catalonia: tools and policy domains to implement a top-down solution

This article is the result of an ongoing research into a variety of features of Spanish local government. It aims, in particular, at providing a profile of the tools implemented by local authorities to improve local democracy in Catalonia. The main hypothesis of the work is that, even though the Spanish local model is constrained by a shared and unique set of legal regulations, local institutions in Catalonia have developed their own model of local participation. And the range of instruments like these is still now increasing. More specifically, the scope of this research is twofold. On the one hand, different types of instruments for public deliberation in the Catalan local administration system are identified and presented, based on the place they take in the policy cycle. On the other hand, we focus on policy domains and the quality of the decision-making processes. Researching the stability of the participation tools or whether local democracy prefers more 'ad hoc' processes allows us to analyze the boundaries/limits of local democracy in Catalonia. The main idea underlying this paper is that, despite the existence of a single legal model regulating municipalities in Catalonia, local authorities tend to use their legally granted selfmanagement capacities to design their own instruments which end up presenting perceivable distinct features, stressing democracy in different policy domains, and in diverse policy cycles. Therefore, this paper is intended to identify such models and to provide factors (variables) so that an explanatory model can be built.

Fiscal policy and interest rates: the role of financial and economic integration

It is commonly believed that a fiscal expansion raises interest rates. However, these crowding out effects of deficits have been found to be small or non-existent. One explanation is that financial integration offsets interest rate differentials on globalised bond markets. This paper measures the degree of integration of government bond markets, using spatial modelling techniques to take this spillover on financial markets into account. Our main finding is that the crowding out effect on domestic interest rates is significant, but is reduced by spillover across borders. This spillover is important in major crises or in periods of coordinated policy actions. This result is generally robust to various measures of cross-country linkages. We find spillover to be much stronger among EU countries.

Testing the FTPL across government tiers

Control on regional government budgets is important in a monetary union as lower tiers of government have fewer incentives to consolidate debt. According to the Fiscal Theory of the Price Level; unsustainable non-Ricardian fiscal policies eventually force monetary policy to adjust. Hence, uncoordinated and non-regulated regional fiscal policies would therefore threaten price stability for the monetary union as a whole. However, the union central bank is not without defense. A federal government that internalises the spillover effect of non-Ricardian fiscal policies on the price level can offset non-Ricardian regional fiscal policies. A federal government, which taxes and transfers resources between regions, may compensate for unsustainable regional fiscal policies so as to keep fiscal policy Ricardian on aggregate. Following Canzoneri et al. (2001), we test the validity of the Fiscal Theory of the Price Level for both federal and regional governments in Germany. We find evidence of a spillover effect of unsustainable policies on the price level for other Länder. However, the German federal government offsets this effect on the price level by running Ricardian policies. These results have implications for the regulation of fiscal policies in the EMU.

Estimating the effects of fiscal policy under the budget constraint

I reconsider the short-term effects of fiscal policy when both government spending and taxes are allowed to respond to the level of public debt. I embed the long-term government budget constraint in a VAR, and apply this common trends model to US quarterly data. The results overturn some widely held beliefs on fiscal policy effects. The main finding is that expansionary fiscal policy has contractionary effects on output and inflation. Ricardian effects may dominate when fiscal expansions are expected to be adjusted by future tax rises or spending cuts. The evidence supports RBC models with distortionary taxation. We can discard some alternative interpretations that are based on monetary policy reactions or supply-side effects.

Fiscal sustainability across government tiers: an assessment of soft budget constraints

This paper analyses how fiscal adjustment comes about when both central and sub-national governments are involved in consolidation. We test sustainability of public debt with a fiscal rule for both the federal and regional government. Results for the German Länder show that lower tier governments bear a relatively smaller part of the burden of debt consolidation, if they consolidate at all. Most of the fiscal adjustment occurs via central government debt. In contrast, both the US federal and state levels contribute to consolidation of public finances.

Impact of maternity care policy in Catalonia: a retrospective cross-sectional study of service delivery in public and private hospitals

Background: As a result of the growing number of interventions that are now performed in the context of maternity care, health authorities have begun to examine the possible repercussions for service provision and for maternal and neonatal health. In Spain the Strategy Paper on Normal Childbirth was published in 2008, and since then the authorities in Catalonia have sought to implement its recommendations. This paper reviews the current provision of maternity care in Catalonia. Methods: This was a descriptive study. Hospitals were grouped according to their source of funding (public or private) and were stratified (across four strata) on the basis of the annual number of births recorded within their respective maternity service. Data regarding the distribution of obstetric professionals were taken from an official government survey of hospitals published in 2010. The data on obstetric interventions (caesarean, use of forceps, vacuum or non-specified instruments) performed in 2007, 2010 and 2012 were obtained by consulting discharge records of 44 public and 20 private hospitals, which together provide care in 98% of all births in Catalonia. Proportions and confidence intervals were calculated for each intervention performed in all full-term (3742 weeks) singleton births. Results: Analysis of staff profiles according to the stratification of hospitals showed that almost all the hospitals had more obstetricians than midwives among their maternity care staff. Public hospitals performed fewer caesareans [range between 19.20% (CI 18.84-19.55) and 28.14% (CI 27.73-28.54)] than did private hospitals [range between 32.21% (CI 31.78-32.63) and 39.43% (CI 38.98-39.87)]. The use of forceps has decreased in public hospitals. The use of a vacuum extractor has increased and is more common in private hospitals. Conclusions: Caesarean section is the most common obstetric intervention performed during full-term singleton births in Catalonia. The observed trend is stable in the group of public hospitals, but shows signs of a rise among private institutions. The number of caesareans performed in accredited public hospitals covers a limited range with a stable trend. Among public hospitals the highest rate of caesareans is found in non-accredited hospitals with a lower annual number of births.