Institutional theories.

2005
The role of political institutions

Lecture 7

Health Politics
Ana Rico
ana.rico@medisin.uio.no
 The old institutionalism
I. Research question
Which is the impact of political institutions and the social structure on
democratic politics and policy change?
II. Main concepts - definitions

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Majority and consensus democracies, plurality and proportional
electoral systems, presidentialism, parliamentarism, federalism
III. Thesis and arguments
Institutions which disperse power across political and sociopol. actors
are more democratic (responsive) & equally effective
III. Anti-thesis: the new institutionalism
Concentrated state power needed for effective policy change
IV. Aplications evidence
Political institutions in Western Europe (Liphart, 1984; 1999)
VI. Policy implications
Power concentration is good for passing controversial policy, but can
have high political and implementation costs
 SOCIAL & POLITICAL THEORIES
L3 L7
1950s/60s: OLD INSTITUTIONALISM
SOCIAL SOCIAL PRESSURES
Formal political institutions
CONTEXT L2, L4
SOCIAL ACTORS L5

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1970s/1980s: (IGs: dependent on POLITICAL ACTORS
ACTOR- social pressures) (STATE: independent
CENTRED of social pressures)
L6
SOCIOP. ACTORS
1990s: L7
(STATE-SOCIETY:
INSTITUT- NEW INSTITUTIONALISM
interdependent)
IONALISM (state institutions &
(+state-society) state/PPs/IGs organization)
L9
L4, L9 L7, L9
2000s: POWER-CENTRED
ACTION THEORIES RATIONAL ACTOR-CENTERED
THEORIES (interactions among CHOICE INSTITUTIONALISM
collective actors & (interactions (interactions among
social structure) among institutions & elites)
individuals
 CONCEPTS (4): The state
SOCIAL CONTEXT: The state as a transmission belt of social pressures

STATE-CENTRIC: The state as a unitary, independent actor with formal

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monopoly of (residual) power over policy-making

STATE-SOCIETY: The state as a set of political representatives and policy

experts with preferences and action partly independent, and partly
determined by a wide range of social actors pressures

INSTITUTIONALIST: The state as a set of political institutions; or as a set of

elites with preferences and actions mainly determined by institutions

ACTION: As a set of political organizations which respond to context,

sociopolitical actors and institutions; and which compete and cooperate
(=interact) to make policy

 ANTECEDENTS (3)

Old political institutionalism (Lijphart)

Formal centralization of decision-making power makes political
regimes, states and organizations more capable & more efficient

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State powers are more centralized when:
Democratic Institutions: Majoritarian (vs proportional)
electoral systems; Unitary (vs federal) states; Executive
dominance (+/- = parliamentarism vs. presidentialism);
Sociopolitical organizations: Biparty/multiparty systems,
majority vs. coalition) government; Corporatism (vs pluralism);
Party discipline and centralized organization
Social groups: Single (=class) vs multiple cleavages in the
soc. struct. seen as causes of institutions
Single/multiple cleavages biparty/multiparty system
single party/coalition gov. centralized democratic institutions
 The old institutionalism
Types of democratic institutions in the EU
MAJORITARIAN CONSENSUS
Unidimensional party systems Multidimensional party systems

Two party systems
Majority(/plurality) elections
Concentration of executive power:
majority government
Executive dominance over parliament
(Presidentialism)
Unicameralism or asymm. bicameralism
Unitary and centralized
Unwritten constitution
Representative democracy, pluralism
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Multiparty systems
Proportional elections
Executive power-sharing: coalition
governements, corporatism
Division of powers (Parliamentarism)
Balanced bicameralism
Federal and devolved
Written constitution and protection of
minorities
Forms of direct (corporatist) democracy

Lijphart, 1984 Later US research shows that Presidentialisms disperses power more
 The old institutionalism
Other arguments and counterarguments (1)
1. LIJPHARTS THESIS
The interplay between social structure, political institutions and sociopolitical

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groups determines policy
Institutions which concentrate power can be more effective, but are less
democratic costs in terms of political support & implementation gaps
Institutions which disperse power across actors are more democratic
(minoritiesrepresentation, direct political participation), and, under some
conditions (cooperation, consensus building), can be equally effective
(minorities protection, economic growth, income inequality)
2. CRITICISMS (anti-thesis)
New institutionalism
Institutions which concentrate state and socioP power are needed for state
capacity/autonomy + effective policy change
Actor-centred institutionalism
Institutions which disperse state power allow more points of acess (veto
points) for IGs to block policy
 The old institutionalism
Arguments and counterarguments (2)
1. LIJPHARTS THESIS (2)

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Types of political institutions and degree of concentration of
power
Majoritarian vs. consensus institutions: Functional division of
power DoP- among state organizations and political parties
Unitary vs. federal institutions Territorial DoP between
federal/central and state/local governments)
[Corporatist vs. Pluralist: DoP between state and social
groups)]
2. CRITICISMS
NOTE: Later institutionalists socioP institutions such as party discipline,
or minor constitutional reforms in EU 1950s allowing the Executive to
pass legislation by decree, are critical too to promote power
concentration
 The old institutionalism
The electoral system (translates social support/votes into % of state power)
A. Proportionality = votes/parliam. seats ( access to govern. & parliament)
Main dimensions Maj Prop Maj Prop

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Electoral formula < % Prop > Electoral thresholds > <
District magnitude Small Big Ballot structure 1/2 rounds
Supplementary seats No Yes
C. The social and socioP power structure: Cleavages & pol. parties
NON-PLURAL (2-3 SEMI-PLURAL (3-5 PLURAL (> 5 parties,
parties, 1 cleavage) parties, 1-2 cleav. 2-3 cleav.)
Relig./linguistic UK, Ireland Finland Austria
homogeinity New Zealand France Israel
HIGH Scandinavian Italy Luxemburg

Religious/ling. Australia Germany Belgium

heterogeinity Canada Netherland
LOW United States Switzerland
Lijphart, 1984
 The DoP between Executive & Parliament

PRESIDENTIALISM: PARLIAMENTARISM
President elected by Prime Minister strong,

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citizens, strong Parliament elected by Parliament

MAJORITARIAN United States United Kingdom

The electoral system

(plurality) Philippines Canada

Puerto Rico Australia
Ex-Soviet New Zealand
Asia
Africa

PROPORTIONAL France Most Western Europe

Switzerland
South America

Lijphart, 1994
 Modern institutionalist theory
I. Research questions
Are institutions the main cause of policy? Do they determine actors behaviour?
II. Main concepts - definitions
Types of political institutions; path dependence and institutional inertia.

2005
III. Thesis and arguments
New institutionalism: (1) Institutions determine actors preferences, resources and strategies,
and therefore reinforce and reproduce the status quo
Actor-centred institutionalism (infl. by ECO): (2) Formal political institutions modify (weaken
or strengthen) the degree of autonomy of state actors from IGs
IV. Aplications evidence
Explaining the emergence of different health care systems
V. Policy implications
(1) Institutions do not change, hence big policy turns are unlikely;(2) Changing formal
constitutional rules increases the likelihood of state-led policy change,
VI. Criticisms
Institutions can be changed through political action and policy reform; lack of change is due
to entrenched interest groups and/or reluctant citizens
 Formal & informal institutions
SOCIAL CONTEXT

CULTURE POLICY (SUB-)

SYSTEM
Social organiz. THE POLITICAL SYSTEM
Associations * Ideologies
Churches Sociopol. actors: * Ideas

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Firms IGs, Prof Ass., Unions a State actors: c Policy
Citizens, Mass media STATE-, POL. PARTs (IGs) change
* Org.Struct. Political parties * Policy
paradigms/
* Subcultures legacies
b CONSTITUTION HC
/pol.identities SYSTEM
Social groups Institutions: Interactions:
- Communities
Const. (interorg.) Coalitions/competit.
- Ethnia, gender Leadership/strategy Outputs
- Social classes
Organiz. Struct.
d e
f
Outcomes

POLITY POLITICS POLICY OUTPUTS

INPUTS

a. Demands and supports d. Institutional change

b. Access to the political system e. Impact of policy
c. Decision-making f. Distribution of costs and benefits
 The new institutionalism
Institutions (including public policies, organizations) block new policy
because of their strong resistance to change (inertia) once settled
(path dependence)

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Institutional inertia/path dependence is in turn due to:
A. Technical/cognitive causes (decreasing returns = economies of
scale/scope, learning costs)
ECO + some POL. Sci. (eg Pierson 1998, Wilsford, 1995)
B. Normative causes (cognitive rules are given normative meaning
through the processes of socialization carried out to guarantee the
compliance of individuals to rules; once linked to values, rules
become difficult to change)
Anthropology, Sociology, ORG THEORY, Policy Anallisys

Social embebbedness (Evans)

Policy change happens only as a result of an external shock which

opens a policy window for reform
 Immergut, 1992

ACTOR-CENTRED INSTITUTIONALISM
1. Political institutions which allow for the dispersion of power generate multiple
points of access of interest groups through which they can veto state policies

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DISPERSED CONCENTRATED
Weak executive(US, Switz., Fra 1) Strong executive Weak
Political Strong parliament and courts parliament and courts (EU, Fra 2)

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institutions
Federal (US, Switz., Canada) Unitary (UK, Sweden, France)
PR electoral system (EU) Majority electoral system (US, UK)
Socio-
No party discipline(USA) Party discipline(EU, Canada)
political
institutions Pluralist (USA, UK) Corporatism (EU)

2. Under dispersed formal political power, the chances of policy change (eg WS
expansion) are low Immergut 1992
3. NOTE: Here Presidentialism considered to disperse rather than concentrate
power (evolution from Lijphart based on legislation by decree & party discipline)
 Actor-centred institutionalism
Determinants of National Health Insurance systems
DETERMINANTS SWEDEN FRANCE SWITZERLAND

Policy idea + + +

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Governments support
Interest groups - - -
Left vote & unions + - -
Territ. DoP (state capacity) Unit. Dev. (-) Unit. Centr. (+) Federal (--)
Veto points/(DoP E/P/C) Few (+) * 1st : Multiple (-) Multiple (--)
* 2nd : Few (+)
Party system (& discipline) Concentr (+) Dispersed (-) Highly disp. (--)
* Influenced by electoral system

POLICY CHANGE NHS (++) SHI (+) PI (-)

* 1st : -
Immergut, 1992 * 2nd : +
 Veto points
SOCIAL CONTEXT

POLICY CONTEXT

Social organiz. THE POLITICAL SYSTEM

ASSOCIATIONS
CHURCHES

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FIRMS Sociopol. actors: Policy actors:
NEW SOCIAL MOV.
MASS MEDIA a STATE ACTORS
IG & PROF ASS
IG & PROF ASS POLITCAL PARTIES c
POLITCAL PARTIES Policy
Implemen-
change tation
Social groups b
COMMUNITIES Institutional HC
services
ETHNIA, GENDER
SOCIAL CLASSES
framework
Interactions Outputs
d e
f
Outcomes

POLITY POLITICS POLICY OUTPUTS

INPUTS

a. Demands and supports d. Institutional change

b. Access to the political system e. Impact of policy
c. Decision-making f. Distribution of costs and benefits
 Actor-centred institutionalism
(State) actors and political parties are the main determinant of policy
Institutions increase or decrease their opportunities to influence policy

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EVIDENCE: Canada (NHI) vs the US (no NHI) in the 1960s
In the US as in Canada, the main advocate of NHI were small
socialdemocratic parties territorially concentrated
In the US as in Canada, the majority of citizens strongly supported NHI in
these states/provinces
In Canada, due to open political acess & strong federalism in HC, a tiny
socialdemocratic party ruling in one province introduces NHI,
demonstrating that can work with good effects outside Europe this
helps them convince the reluctant democratic party & public opinion to
support it at national level
In the US, weak federalism impedes pro-WS minority parties to govern
no demonstration effects possible

Maioni, 1997
 CAUSES OF NHI: CANADA vs USA
VARIABLES CANADA 1960S: NHI USA 1960s: NO NHI

CONTEXT.
Social values, culture Individualism Individualism

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INSTITUTIONS (RULES)
1. Executive dominance Medium/weak Weak
2. Federalism Strong Weak
3. Party discipline Yes No

ACTORS (PLAYERS)
1. State authorities Weak Weak
2. Pro-WS Pol. Parties + IGs Access to governm. No access

PAST POLICY
1. Past WS policies in HC (a Underdeveloped Underdeveloped
cause of state auton. & capacity)

Maioni, 1997
 FEDERALISM IN EU HC
NORDIC COUNTRIES

POLITICAL DEVOLUTION FISCAL FED. CENTRAL COORD.

2005
ITALY /SPAIN

POL. DEVOLUTION FISCAL FED. CENTR??

UK / GREECE / (PORTUGAL) POL. DEV.?

60s 70s 80s 90s 00s

 FEDERALISM & impact of DoPower

CENTRAL SHARED LOCAL

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RESPONSIVENESS
Interests represented
Decision costs - ++ +
- ++ +?
ACCOUNTABILITY
Visibility (citizens) ++ - -- ?
Control (central state) ++ + - ?

Political OUTCOMES (for democratic representation)

 POLICY IMPLICATIONS

New institutionalism, path sependence:

Institutions do not change, hence once they are established big

2005
policy turns are unlikely

Historical determinism: countries are prisioners of history (and

individuals of their early socialization experiences/the prevailing social
norms)

Actor-centred institutionalism (old-institutionalism): debate on

Immergut: Changing formal political institutions towards further

concentration of power increases the likelihood of policy change, even
if powerful opposed interests

Maioni (with Lijphart): Institutions which disperse power increase

access of minority political parties in government and hence the
likelihood of policy change
 CRITICISMS
Old-institutionalism
Presidentialism implies dispersion of power across state organizations (President and
Parliament), while Parliamentarism implies dispersion of power across political parties and Igs
New institutionalism, path dependence:

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Political actors can modify some of the rules of the game or ignore them
Part of the causes included under institutions are rather culture, actors or past policy + state
performance
Low explanatory power: it only explains policy inmobility or small changes in policy instrument,
but not big policy reforms or instances of path reversal
Actor-centred institutionalism, :
Veto points do not only allow private IGs (anti-WS, capture) to block policy, but also public (eg
citizens) IGs to support government policies (pro-WS, democratic participation).
The degree of concentration of political power not only depends on formal institutions, but also
on the social structure (eg active cleavages) and actors strategies (coalitions, internal
cohesion collective action socioP power resources)