Dolsfma Wilfried Institutions, Communication And Values

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ive. Ever-increasing costs because of the rising number of elderly people
among populations, consumerist sentiments expressed by well-informed
and assertive clients, growing medical knowledge and expanding tech-
nical possibilities have created a widening gap between expectations of
and demands on the health-care system and the limited and conditional
nature of its supply. As a result of governments need to control the bud-
get for health-care expenditures, supply of health-care services has lagged
behind people s expectations.
These pressures have led policymakers to instigate novel institutional
settings. Activities that were formerly a responsibility of the system have
been outsourced to the private (market) sphere or redefined as private
responsibilities (Grit and Dolfsma 2002, 2007), as governments leave it
to market players, such as insurance companies, to rearrange the sys-
tem of health-care such that a system with managed competition arises
(Enthoven 1988; Cutler 2002). Moving the financial responsibility for
the use of health-care services to the individual may be needed to pre-
vent free-riding, but it is equally a threat to solidarity as a basis for the
system as has existed for decades. By addressing people as knaves one
thereby undermines their knightly (intrinsic) motives (Le Grand 2003;
Frey 1997).
One example of a new institutional arrangement is the so-called
personal care budget, an institutional arrangment (I ) inspired by market-
like socio-cultural values (V ). Those with a long-term need for care are
given a fixed sum of money each year that they can spend hiring care-
givers. The criteria for eligibility for such a budget, the rules on spending
it, and the rules on accounting for spending are elaborate (Van den
Berg and Hassink 2008). However, informal care-givers, such as grand-
parents, husbands and so on, see that they may as well be hired to
provide the same care that they gave free of charge before, and some
make arrangements accordingly. Such individuals do of course sacrifice
substantial amounts of time, effort and opportunities forgone by provid-
ing care for which others are paid. There is concern among professional
50 Institutions, Communication and Values
care-givers who see this as a potential market that they can move into,
and so they argue that the care they give is of better quality. At the same
time, there is pressure on quality standards as professional care-givers
compete with one another on a cost basis. As a consequence, regulations
have been introduced to ensure the maintenance of standards; one result
of this is that informal care-givers may have to gain some kind of quali-
fications in order to provide the care that was once a matter of affection
or courtesy.
Still others choose to reduce their supply of informal or home care,
believing it is not up to them to suffer the consequences of supplying
informal care while the benefits accrue to unknown others in the system
who may not be concerned about the public good (compare Le Grand
2003). The resulting scarcity puts strains on solidarity as a principle for
structuring health-care. Attempts to save the solidarity-based (V) health-
care system from collapse have induced a gradualist policy of downsizing
and rationing, trying to minimize the dislocation in line with Bush s
(1987) suggestion. Such developments have led to the introduction of
new principles of allocation and distribution in health-care systems.
This is more akin to I, but traditional boundaries between institutional
settings (I as compared to I ) do become blurred. As, increasingly, insti-
tutions of type I , inspired by such socio-cultural values as choice, indi-
vidual responsibility and financial incentives along the lines of V were
introduced, people came to feel the tension between the foundational
value of solidarity still used to legitimize the health-care system and
values embodied in the institutional practice of a market-based system.
The provision of health-care is thus increasingly fragmented into sep-
arate institutional furniture public and private responsibilities, in
the latter between different budgets that have their own rationales
each of which draws on different socio-cultural values (as visualized in
Figure 4.5). Health-care systems have moved from solidarity-based sys-
tems (V I) towards market-oriented systems based on competition and
emphasizing individual interest and responsibility (V I ). Socio-cultural
values underlying one part of the practice as reflected in the institutions
are at odds with those of another part of the practice. Ostensibly, how-
ever, the socio-cultural values on which the system is founded are still
largely those of solidarity, at least for many participants in the system
and not just patients and health-care providers (Grit and Dolfsma 2002).
Consequently, the attempts to introduce market institutions have been
uneven (Grit and Dolfsma 2007). A shift towards an American 10 system
(I ) with the emphasis placed on choice, freedom and accountability
(V ) at some point will be perceived by individuals to have caused a
Structure, Agency and the Role of Values 51
tension of type C. Either a new ground for legitimating institutions of
health-care is sought (in V ), or the institutional setting moves back again
from I to I. Since health-care is a large sector in the economy and cen-
tral to society, the actions by players in dealing with these tensions are
visible in just about any developed country and too numerous to discuss
in full. I do submit, however, that they may be understood in terms of
the framework suggested here.
4.8 Agency, institutional structure and the role of values
We proposed here to focus on the process of institutional change as
a way of avoiding the uncompromising discussion of the structure
agency controversy. Even though individuals cannot escape institutions,
behaviour is more than the mere reproduction of institutional pat-
terns; nor are institutions merely mental constructs that change when
behaviour changes. Because institutions and behaviour are irreducible
to one another, tensions may exist that set off a process of institutional
change. Such tensions can be triggered by changes in constellations of
interests, power and values. Focusing on the role of (socio-cultural) val-
ues in processes of institutional change, I submit that a coherent set of
institutions defining a practice or institutional furniture needs to be per-
ceived by members of a community as being legitimate. The Social Value
Nexus that I introduced explores the ways in which structure, agency and
values interact in processes of institutional change, indicating how (three
types of) tensions as perceived by agents in a given practice may arise. In
the case of tension between extant institutional furniture and the socio-
cultural values referred to for legitimation, individuals can attempt to
change an institutional setting.
5
Silent Trade and the Supposed
1
Continuum between OIE and NIE
The Carthaginians say also this that there is a place in Libya,
and People living in it, beyond the Pillars of Heracles. When
they, the Carthaginians, come there and disembark their cargo,
they range it along the seashore and go back again to their boats
and light a smoke signal. The natives, as soon as they see the [ Pobierz całość w formacie PDF ]

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