The programmatic elite in German health policy: Collective action and sectoral history
| DOI | 10.1177/0952076718798887 |
| Published date | 01 July 2020 |
| Date | 01 July 2020 |
| Author | Nils C Bandelow,Johanna Hornung |
| Subject Matter | Articles |
Public Policy and Administration
2020, Vol. 35(3) 247–265
The programmatic elite
! The Author(s) 2018
in German health policy:
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Collective action and
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DOI: 10.1177/0952076718798887
sectoral history
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Johanna Hornung
and Nils C Bandelow
Comparative Politics and Public Policy, University of
Braunschweig, Germany
Abstract
Do biographies of policy elites make a difference for the policy process and output?
Leading theories of the policy process focus on other explanations that mostly have
been derived from peculiarities of American politics. This article transfers a French
approach to the study of policy processes in German health policy. It emphasizes how
this French perspective presents an added value in the form of the programmatic action
framework. At its core, the programmatic action framework proposes that programmatic
elites in policy sectors form on the basis of shared biographical intersections and connect
to a joint program. Applying the programmatic action framework to the German case of a
programmatic elite in health policy that dominated the last quarter-century of major
reforms, the analysis reveals the explanatory power of the programmatic action frame-
work in other political contexts. A transfer of the programmatic action framework to
other countries and policy issues, however, must respect the specificities of the political
system and policy subsystem. In Germany, the specific role of self-governance enhances
the analytical categories of the programmatic action framework, moving beyond the
traditional conflict between custodians and austerians of state.
Keywords
Health policy, policy change, policy elites, policy studies, programmatic action frame-
work, social identity theory
Introduction
Stemming from French public policy research, the programmatic approach
(Hassenteufel et al., 2010) has the potential to provide valuable insights into the
Corresponding author:
Johanna Hornung, TU Braunschweig, Bienroder Weg 97, Braunschweig 38106, Germany.
Email: j.hornung@tu-braunschweig.de
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Public Policy and Administration 35(3)
study of policy processes, also beyond the French borders. The recent decades
experienced the development of competing frameworks for the explanation of
policy change and stability. In doing so, these frameworks make use of manifold
factors, each of which emerged from specific political systems, policies, and
scholars’ socialization. Originating from the focus on one or few specific explan-
ations, frameworks integrate more and more different factors to be able to explain
as many policies as possible (Weible and Sabatier, 2017). Although most of the
currently used frameworks originate from the Anglo-Saxon perspective on policy
processes, Dudley et al. (2000) already at the turn of the century called for an
increased attention to European perspectives. They advocated an open intercon-
tinental exchange of theories as different lenses on the policy process may enhance
theoretical understanding. What the existing American frameworks do not focus
on is the exact gap that the programmatic actor approach can fill: its central
explanation for policy change and content are shared biographies and experiences
of actors which form the basis for collective action and the pursuit of a joint policy
program. This contribution points out the added value of this approach and intro-
duces the programmatic action framework (PAF), which deviates from previous
strands of the French research traditions on public policy research and adminis-
trative reforms (Smith, 2001). Consequently, this article addresses the question in
what way the PAF provides insights into reform processes that may not be well
explained by other frameworks. It furthermore outlines how to transfer the French
perspective to other contexts.
The PAF originated from the French political system and culture. It supposes
that within policy sectors, competing groups of elites struggle for authority and
financial resources. In France, the approach observed a dual conflict between cus-
todians of state guarding authority and financial resources close to the state, and
austerians, on the other hand, trying to minimize the state’s capacity. In the elites’
struggle, common biographical and personal characteristics form the basis for
successful alliances (Hassenteufel et al., 2010). How can this perspective be trans-
ferred to other political systems? What must be observed when doing so and what
fruitful insights does such a transfer reveal? This article applies the framework to
German health policy, thereby both outlining the specificities of the German
system that must be obeyed when applying the framework and shedding light on
the long-term programmatic elite essentially influencing policy change during
the last two decades. Empirically, major health reforms in Germany serve as
underpinnings of the theoretical argument.
Analyzing the paths of the influential programmatic elite of the last 25 years in
German health policy enables the identification of the sectoral programmatic
actors of state, self-governance, and industry in the German health system.
The success of the programmatic elite is specifically visible when regarding major
health reforms passed during its existence. Thus, the contribution will expand on
the Health Care Structure Act (Gesundheitsstrukturgesetz, GSG) in 1992, the
SHI Modernization Act (GKV-Modernisierungsgesetz, GMG) in 2002, the
Act to Enhance Competition in the SHI (GKV-Wettbewerbssta¨rkungsgesetz,
Hornung and Bandelow
249
GKV-WSG) in 2007, and the Pharmaceutical Market Restructuring Act
(Arzneimittelmarktneuordnungsgesetz, AMNOG) in 2011. These explicitly outline
how the constellation of programmatic actors resulted in long-lasting influence of
one programmatic elite despite changing circumstances. During this case study, the
challenge of complex sectoral structures in Germany becomes particularly visible.
Instead of only two competing groups (custodians of state and austerians),
the self-governance plays a third role in this struggle and presents a specificity
in German health policy. A transfer of the PAF to German health policy must
therefore always take into account this triad to appropriately capture the policy
process dynamics.
After the subsequent section provides a first overview on the PAF, its origins,
foundations, elements, and applications, the third section transfers the framework
to German health policy, with explicit attention towards the specificities that
must be observed. We then sketch the research design and methodology before
proceeding with the empirical case study. A conclusion summarizes the challenges
faced by a transnational application of the PAF.
Programmatic action framework
Prominently coined by William Genieys, Patrick Hassenteufel, and Marc Smyrl
(Genieys and Smyrl, 2008a; Hassenteufel et al., 2010), the programmatic approach
provides a new view on policy change and stability informed by French policy
processes. This approach brings in biographies and shared experiences as a central
predisposition for collective action and resulting policy change. By contrast, estab-
lished frameworks follow different assumptions and do not address these explana-
tory factors. The advocacy coalition framework (ACF) (Jenkins-Smith et al., 2017)
assumes that individuals possess beliefs that vary in abstraction and stability, and
that individuals form advocacy coalitions based on shared policy core beliefs,
which are stable for around a decade (Sabatier and Jenkins-Smith, 1993).
Advocacy coalitions finally effect policy change. On the other side, the model of
the individual assumed by the multiple streams framework (MSF) (Herweg et al.,
2017) bases on the idea of several policy alternatives, whereby ambiguity charac-
terizes actors’ preferences and problem definitions. Policy change is the result of a
window of opportunity used by a strategic policy entrepreneur that couples prob-
lem, politics, and policy streams and realizes a policy (Zohlnho¨fer and Ru¨b, 2016).
This strategic element is also inherent in the PAF. Contrary to the view that
policy alternatives just need a policy entrepreneur to realize it (Deruelle, 2016), the
PAF assumes that a policy program is developed within a collective body consist-
ing of programmatic actors that all share the same goals. They strive toward
career enhancement and an increase of their influence within the subsystem.
These programmatic actors have largely ambiguous ideological preferences
before building the joint program. Afterwards, the program is linked to the
social group of the programmatic elite, coining a social identity (Be´land, 2017;
Hogg et al., 2017). Nevertheless, a program is not equal to a stable belief—the
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program is interchangeable and only exists through the programmatic elite that is
bound to it. The actors stick to the program because of their identification with the
programmatic elite as a social group and because of strategic reasons to enhance
their influence and career in the system.
To realize the policy program, programmatic actors combine their power
resources, stemming from the variety of key positions that they occupy.
According to the typology by Scharpf (1997: 57), programmatic actors thus can
be classified as a movement. Connected to the program is the shared wish for
ensuring long-term success and career of each member of the programmatic elite.
Throughout the subsequent years, the...
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