Economic Rationalities and Notions of 'Good Cure and Care'

International journal of health policy and management, 2013

Purpose-This paper aims to employ the concept of subjectivity taken from Lacanian psychoanalysis and Slavoj Ž ižek's idea of the law, enabled via its "inherent transgression", to critique the premises of neolibertarian theory about the market's superior ways of organizing society. Design/methodology/approach-An alternative conceptual framework is being developed and applied to the analysis of the transition from a planned to a market economy in former socialist countries using the example of informal payments in the health system in Russia. The proposed schema builds on the idea of the subject eternally divided between the imaginary conceptions of the self/the other, and the socio-symbolic order, which is offered to theorize on the role of phantasy in this transformation. Findings-The applied (psycho)-analytic schema reveals why the totalizing discourse of the market is no less tyrannical and no less totalitarian in its intent than the socialist ideology it opposes. The central argument is how dominant ideologies are made of, and stand for, an unattainable phantasy, as it was demonstrated in both socialism and the market. Originality/value-By re-engaging psychoanalysis to understand social and political projects and by unearthing the imaginary underpinnings of the symbolic order, the study argues for considering the phantasmatic dimensions of political and organizational transformations in management studies.

Journal of health politics, policy and law, 1997

Enormous changes have recently swept through the organization and delivery of medical care. Scholars and students of the health care system and its politics try to make sense of the shift in power to identify and allocate needed resources away from physicians and toward corporate firms. I suggest that we cannot understand managed care unless we understand its power as at least substantially due to its reliance on a claim to be better science. In this way, managed care needs to be placed within an analytic historical tradition that is concerned with how accounts of scientific objectivity become convincing and support (and are confirmed as scientific by) social and political objectives. In this way, managed care reflects what I call the technocratic wish: an appeal to objective measures to resolve contentious issues and/or clothe their resolution as scientifically logical and natural.

2009

Market-led reform strategies around the world have given rise to fears of a progressive commercialization of hospital care. The aim of this article is to suggest an analytical framework that might explain the ubiquitous market-led reform strategies and to scrutinize widespread claim that commercialization processes impacts negatively on quality and equality of access. In comparing an ideal type model of commercialized health care with institutional and organizational change the article provides an assessment of commercialization processes in German hospital care. Although there is a newly evolving market-led governance structure in German hospital care commercialization processes have, however, been restricted. While there are strong signs that on a regulatory level the German hospital sector has become successively commercialized, there is insufficient data and research to prove the suspected negative impact on quality and equality of care provision.

Health policy (Amsterdam, Netherlands), 2018

Socio-Economic Review

The article scrutinizes the Dutch healthcare market system to provide empirical grounding to the debates around the extent to which rationally constructed markets can develop as originally planned. Focusing on one specific pricing device, we document how the perceived economic ‘rationalities’ embedded in its design are challenged by the unforeseen and unanticipated ‘irrationalities’ of daily practices. We trace how healthcare professionals developed informal ways to adapt to the rules and expectations embedded in that device, resulting in forms of ‘counter performativity’ that threaten the quality and accessibility of Dutch healthcare. The main theoretical contribution of the article is to bridge the gap between ‘Actor Network Theory-based economic sociology’ and its emphasis on (counter-) performativity and the agency of devices with the older European continental inflections building on Weber, Durkheim and Bourdieu, by drawing attention to the distinct epistemologies of different ...

The Linacre Quarterly, 2016

Health care is at a critical stage: doctors and patients, the central protagonists in this field, are less and less satisfied with the outcomes. Much of the debate about health care has focused on the choice between large public or corporate solutions. This creates a false dichotomy and wrongheaded solution. As we evaluate proposed healthcare solutions, we ought to apply the frameworks of Catholic Social Doctrine. We can have a medical system that both meets financial objectives and makes a radical commitment to the person.

Health Economics, Policy and Law, 2015

The governance of medical performance consists of all those mechanisms that together influence the performance of medical work in terms of either diagnosis or treatment, broadly understood". This definition is at the core of Burau's paper from 2007. The paper uses recent contributions to the public administration/governance literature to "explore the coexistence of different forms of governance with the aim of assessing the relative extent and the substantive nature of governance change" (Burau, 2007). The main contribution is thus to apply governance theory concepts within health care (in Germany) and to illustrate this by analyzing development trends in the governance of medical performance using Germany as an example. The analysis of governance changes in Germany convincingly shows the merits of this type of meso-level analysis for understanding the complexities of governance changes and draws out a number of interesting conclusions. In theoretical terms the paper distinguishes between four ideal-typical forms of governance of medical performance. Professional self-governance is based on expert authority and professional control over clinical practice through peer review and professionally defined clinical guidelines and codes of practices. This type of governance was at the core of the historical compromise between the medical profession and the state, whereby professions gained a privileged status in return for their contribution in rationing health services. However, most industrialized countries have a strong public involvement in health care and therefore also rely on hierarchy, which is the second ideal-typical governance form for medical performance in the paper. Hierarchy is based on formal authority within parliamentary chains of command with politicians at the apex and bureaucracy to support decision making and implementation.

sv.ntnu.no

Statistics show that there is a constant scarcity of medical practitioners in Norway. This excessive demand seems to be impossible to solve by an increase of medical students. A qualitative study was performed to develop an understanding of how mechanisms in the health services create the ever-larger demand for doctors. By using interviews of doctors and medical administrators an analytical model of the extensive need for medical doctors was developed. In this paper this qualitative empirical work is presented and the results discussed.

Living Under Austerity, 2018

Healthcare is one of the world's largest industries. In 2011, the world spent a total of 6.9 trillion US dollars 1 on health. Healthcare accounted for 10 percent of global gross domestic product (GDP) in 2013, 2 of which 59.6 percent was public expenditure. The economic, political, social and ethical stakes are high. Depending on the purpose ascribed to healthcare, two opposite conceptions emerge: healthcare as a fundamental human right, or as a marketable and tradable commodity. The first defines health not merely as the absence of disease but as a state of general physical, mental and social wellbeing. It views healthcare systems as a public good, as core social institutions that should be universally accessible to all on the basis of clinical need, not ability to pay. Enshrined in the Declaration of Alma Alta (1978) that identified primary health care (PHC) as the key to achieving health for all, this view was also the essence of the postwar Western European social security and national health systems, and served as a landmark for the belated construction in the 1980s of the post-dictatorship Greek, Spanish and Portuguese Welfare States. The second approach, healthcare as an economic transaction, became increasingly prominent in the 1990s and 2000s, along with the deepening hegemony of neoliberal social and economic doctrines. It was transmitted by institutions of international economic governance such as the World Bank, which successfully networked at global level to impose a conceptualization of healthcare based on investorfriendly principles of health economics and cost-effectiveness analysis, and the international Monetary Fund (IMF), which prescribed relatively standard policy prescriptions focusing on maximizing private provision, imposing user fees and prioritizing markets and competition as part of its Structural Adjustment Programs. The ostensible design was to "increase value for money" in health systems and create the conditions for sustainable economic development. A growing body of critical research, however, disputes the validity of these arguments. Indeed, market-style devices have failed to save money or to generate proven efficiencies, let alone produce more equitable patterns of service delivery; quite to the contrary, they increased bureaucratic and overhead costs while deepening health inequalities and undermining existing public health services and research (Lister 2008; Sachs 2005; CSDH 2008). Even market-friendly OECD researchers have recognized the complications, contradictions and increased costs incurred by the implementation of standard healthcare restructuring packages (Lister 2008: 25, 77). Western Europe has not been immune from the trend toward commodification of healthcare. Since the 1980s governments have to varying degrees espoused a market fundamentalist ("neoliberal") political rationality that "casts the political and social spheres both as appropriately dominated by market concerns and as themselves organized by market rationality," and promotes "policies that figure and produce citizens as individual entrepreneurs and consumers whose moral autonomy is measured by their capacity for "self-care"-their ability to provide for their own needs and service their own ambitions, whether as welfare recipients, medical patients, consumers of pharmaceuticals, university students, or workers in ephemeral occupations" (Brown 2006: 694; Foucault 2004). Accordingly, most Western European governments introduced measures borrowed from the "one size fits all" package advocated by the elite community of policy-shapers and rule-makers to restructure their health and social protection systems. However, the pace of transformation was variable and was spread over several decades. European governments for the most part deliberately chose an incremental implementation method in order to contain social contention and control the transformation process. Being rich enough and relatively (albeit unequally) autonomous, the core countries among the twelve first EU members (EU12) were and are in a position to direct the process and control the pace of change. In fact, until recently, none had experienced situations comparable to highly dependent "Third World" countries or the countries "in transition" from Eastern and Central Europe that experienced the severe, indeed coercive, conditions of structural adjustment programs. Today, however, that situation has changed: Greece has been submitted to a particularly harsh austerity regime since 2010, akin to the structural adjustment programs applied in vulnerable countries of the Global South. Greece thus constitutes a particularly good analytical terrain to assess the validity of the two above-mentioned approaches. This chapter analyzes the principal measures implemented in the Greek public health sector since 2010 and their social and ethical consequences. It brings to light the difficulties and contradictions that emerged in the "reform" process in which World Bank/IMF "one size fits all" recipes-e.g. cost sharing, the purchaser/provider split, activity based systems of payment, privatization of support and private insurance schemes-have been arbitrarily and coercively imposed on the Greek healthcare system with the primary aims of cutting costs, extracting resources from the public health sector in order to repay a crushing debt load, 3 and reorienting behaviors toward the "consumption" of private insurance and health services. As in other key sectors for the future of the country such as higher education (Athanasiades, Vareas and Souvlis, Chapter 7 in this volume), prescriptions dictated by the Troika have been introduced precipitously, in total disregard and even in denial of their sanitary and social effects. In the end, the problems of the Greek National Health System (ESY) have been amplified rather than solved. The first section presents a synthetic description of the ESY on the eve of the first 2010 Memorandum of Understanding (MoU). It is followed by a reminder of the comprehensiveness of health, which depends not only on primary and secondary care institutions, but also on key social determinants of health such as social security, housing, education, food security, or decent work. The chapter also discusses the main restructuring devices that were introduced in the primary, secondary, and pharmaceutical healthcare sectors. The argument, based on a growing body of evidence, is that the quasi-liquidation of the weak Greek Welfare State has amplified the life-threatening effects of the adjustment programs' market-style approach: the hope of living a decent and good life (Sen 1999) has receded and people have been made vulnerable, exposed to illness and premature slow or rapid death.