Market Reforms in Europe: Dynamics
of Policy Fashion
Michael I. Harrison*
Agency for Healthcare Research and Quality
Presented at Academy Health Annual Research Meeting
June 6, 2004, San Diego.
*Email: mharriso@ahrq.gov
EXPLAINING DYNAMICS
OF POLICY FASHION
 Observations:
– Policy makers in Britain, Sweden, and the Netherlands adopted
market reform policies quickly and uncritically.
– Decision makers and their constituencies soon became disenchanted
with market reforms, once the proposed changes proved hard to
implement.
– The health policy agenda shifted quickly, as policy makers explored
new options.
 Research question: Did the rapid rise and decline of political
support for market reforms in health care reflect the
dynamics of policy fashion?
POLICY FASHION DEFINED
The rapid rise and decline in political support for a set of
policy-related beliefs, principles, programs, or techniques is
called policy fashion when these shifts reflect the dynamics
and interactions of fashion setting, policy formation and
adoption, and policy implementation.
+
Demand For Policy
Fashions
Fashion
Setting
Policy
Formation
and
Policy
Implementation
Adoption
Support for Policy Trend
-
DYNAMICS OF POLICY FASHIONS
FASHION SETTING
 Fashion setters --policy gurus, universities, consultants, media
-- actively promote new policies.
 Setters define favorite new policies as progressive and
rational.
 Initial discourse is enthusiastic and uncritical.
FORMATION AND ADOPTION
OF POLICY FASHION
 Advocates in governments and agencies urge adoption of
policies promoted by high-status setters and used by highstatus organizations and sectors.
 Policy makers alter fashions from other sectors to fit target
sector.
 Proponents build supporting coalitions.
FORCES CREATING DEMAND FOR
POLICY FASHIONS
 Norms of progress and rationality
 Budgeting processes and career ladders in public agencies
 Economic cycles
 Organizational and technical contradictions (e.g., public
accountability vs. professional autonomy; disease intervention
vs. wellness)
FORCES AFFECTING SUPPORT FOR
POLICY TRENDS
 Trends in political beliefs and values
 Social and cultural change
 Electoral politics
 Interactions among policy actors
 Organizational and technical conditions
 Policy precedents and institutional commitments
FORCES UNDERMINING SUPPORT FOR
IMPLEMENTED POLICY
 Implementation complications and struggles
 Disappointment with results
– Outcomes below expectations
– Costs beyond estimates
Outcomes of policy fashions always fall below original expectations (and stated
objectives) and costs always exceed estimates, because initial expectations were
unrealistic and overly optimistic.
 Changes in forces affecting demand for policy trend.
 Competition from other policies, including new policy fashions.
IMPLEMENTATION COMPLICATIONS &
STRUGGLES
 Shifts in involvement of main actors bring changes in
implementation needs, views, and priorities.
 Main actors:
– Policy makers
– Implementers
– Recipients
– Nonparticipating stakeholders, e.g., unions, voluntary groups, voters.
 Implementation barriers emerge.
 Policy contradictions surface.
 Conflicts emerge between policy and other strongly held
values.
 Actors learn about policies and implementation.
IMPLEMENTATION BYPRODUCTS
 Discourse becomes critical.
 Supporting coalitions grow weaker or fragment.
 Popular disaffection grows with policies and policy makers.
 Fashion setters and policy makers search for alternative policy
solutions.
CONSEQUENCES OF FASHION
 Challenge taken-for-granted routines and ideas.
 Encourage experimentation.
 Successive waves of fashion can produce significant
changes.
FASHION’S COSTS AND RISKS
 Discourages diagnosis of problems and analysis of program
feasibility
 Blocks improvement during implementation
 Wastes resources
 Fails to attain objectives
 Burdens the implementers
 Creates cynicism
LIVING WITH POLICY FASHION
 Involve those responsible for implementation in policy
formulation and planning.
 Experiment with policy options before full-scale rollout.
 Sponsor research and rapid feedback on implementation.
 Train all levels in diagnostic and critical thinking about policies
and their implementation.
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