Exploring Theory for Citizens’ Preferences in Health Policy: The Contribution of Health Policy Cultures to Understanding the Roles of Public and Private Health Service Providers

Introduction

Over the last few decades there has been growing interest among health policy makers in citizens’ preferences¹ regarding allocation rules for public and private health service delivery (Allen & Jones, 2011; Magnussen, Vrangbæck, & Saltman, 2009). Throughout the world, citizens have become increasingly interested in the welfare and health services they receive and pay for, both as tax-payers and users. At the same time in nations at all levels of political and economic development, health policy makers seek to determine whether goods and health services are best provided by government, markets, communities, some set of hybrid forms, or how much should citizens take more responsibility their welfare and health care. They ask, “Under what arrangements are the public health needs and welfare best served?” and “How and by whom should health services be provided, and why?”

Increasingly, the questions about allocation of goods and health services receive market answers. In recent health policy reforms consumerism as a form of individualism has been a taken for granted solution and as a manifestation of “new public management” and “value for tax-payers money” (Battaglio, 2009). However, the consumerist model may weaken accountability and values such as fairness and social justice, as Brewer (2007) argues. Medical paternalism produced by hierarchism on the other hand demonstrates traditional and authoritarian doctor-patient relationships as a key basis of service delivery (McLaughlin, 2009). But the rationale behind health service systems is very different, as social value is much more than the aggregation of consumer or patient centered benefits. For the purposes of health policy, a wider conception of health² and welfare is inevitably required. There are at least three competing and forgotten institutionally informed health policy cultures that mediate different preferences in health policy making: egalitarianism, fatalism and autonomy. These health policy cultures may provide unexplored opportunities for organizing health services in more pluralistic way, beyond the public and the private sectors.

Public interest in health policy is often restricted to governmental organizations or market intervention, rather than asking what citizens prefer in public and private health services, we ask in this paper what makes a health service organization more likely to provide for public and private outcomes in relation to citizens’ preferences. In contrast to a dichotomous view of public and private health service organizations based entirely on ownership or funding (Rainey, Backoff & Levine, 1976), the institutionally and culturally informed view of publicness and privateness presented in this paper recognizes varying degrees of political authority (public influence) and economic authority (private influence) over all forms of health service organizations (Bozeman, 1987; Dahl & Lindblom, 1953; Rainey, 2009; Wamsley & Zald, 1973). Correspondingly, in contrast to dichotomous view of consumers and patients, it recognizes citizens’ political and economic authority that manifests itself in their preferences and choices in ordinary life. Furthermore, some citizens may have well-formed preferences that trump default rules produced by the dichotomous view of public and private values. Therefore, sensible health policy planners make multiple choices available when citizens’ preferences vary most (Sunstein & Thaler, 2006). For this reason, we should know how much preferences vary across individuals and health policy cultures.