Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999
Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999
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DOI：
10.1093/heapol/czh033
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发表时间：
2004-09-01
影响因子：
3.2
通讯作者：
Gilson, L
中科院分区：
文献类型：
--
作者：
Thomas, S;Gilson, L
医疗改革本质上是政治性的。健全的技术分析永远不足以保证政策的通过。旨在促进公平的融资改革尤其可能挑战既得利益并引起反对。本文回顾了 1994 年至 1999 年间南非健康保险政策的发展。尽管经过了 10 多年的辩论、分析和设计，但到 1999 年，没有一套社会健康保险 (SHI) 提案获得足够的支持，成为实施计划的基础。相比之下，重新监管健康保险行业的提案在这一时期末迅速制定并实施。针对政策目标和设计细节的行动者参与和管理过程是这一经验的核心。本文采用扎根的方法来分析主要访谈数据和一系列文献材料，探讨了参与指导政策变革的改革推动者与一系列其他行动者之间的动态。它描述了参与者参与健康保险政策制定的过程、他们相互参与的细节，并确定了参与者管理策略的尝试以及改革过程的结果。这一进程的主要推动者是卫生部长和国家卫生部卫生财政和经济司负责卫生财政和经济的单位，并得到了南非学术界成员的支持。这些行为者在一系列四个特设政策咨询委员会内并通过这些委员会开展工作，这些委员会是健康保险政策制定和私人健康保险监管的主要论坛。通过演员管理的视角对每个委员会的不同经历进行审查和对比。尽管监管提案获得了足够的支持并在立法中得到实施，但这些驱动因素之间的差异和其他参与者的反对最终阻碍了为任何形式的 SHI 提供充分支持的努力。作者借鉴南非的经验和一个简单的分析框架，强调了五种潜在的战略，任何政策进程的改革推动者都可以通过这些战略建立足以克服对拟议政策变革的潜在反对的支持联盟。由于目前对如何管理让参与者参与改革进程的过程知之甚少，因此这些发现为进一步分析该问题奠定了基础。
Health reform is inherently political. Sound technical analysis is never enough to guarantee the adoption of policy. Financing reforms aimed at promoting equity are especially likely to challenge vested interests and produce opposition. This article reviews the Health Insurance policy development in South Africa between 1994 and 1999. Despite more than 10 years of debate, analysis and design, no set of social health insurance (SHI) proposals had, by 1999, secured adequate support to become the basis for an implementation plan. In contrast, proposals to re-regulate the health insurance industry were speedily developed and implemented at the end of this period. The processes of actor engagement and management, set against policy goals and design details, were central to this experience.Adopting a grounded approach to analysis of primary interview data and a range of documentary material, this paper explores the dynamics between reform drivers engaged in directing policy change and a range of other actors. It describes the processes by which actors were drawn into health insurance policy development, the details of their engagement with each other, and it identifies where deliberate strategies of actor management were attempted and the results for the reform process. The primary drivers of this process were the Minister of Health and the unit responsible for health financing and economics in the national Department of Health Directorate of Health Financing and Economics, with support from members of the South African academic community. These actors worked within and through a series of four ad hoc policy advisory committees which were the main fora for health insurance policy development and the regulation of private health insurance. The different experiences in each committee are reviewed and contrasted through the lens of actor management. Differences between these drivers and opposition from other actors ultimately derailed efforts to establish adequate support for any form of SHI, even as regulatory proposals received sufficient support to be enacted in legislation. Drawing on this South African experience together with a simple analytical framework, the authors highlight five potential strategies by which reform drivers of any policy process could create alliances of support sufficient to overcome potential opposition to proposed policy changes. As little is currently known on how to manage the process of engaging actors in reform processes, these findings provide a foundation for further analysis of this issue.