Public health policy at the frontline - a comparative perspective

This cumulative dissertation, titled ‘Public health policy at the frontline – a comparative perspective’, encompasses three independent research projects in terms of their theoretical and empirical content. However, they all focus on public health policy implementation and innovative qualitative comparative research methods.

Aims

The implementation of public policies remains a poorly understood phase of the policy cycle. Materialized, ‘real’ policies are seldom if ever fully congruent with the politically agreed upon, ‘theoretical’ policy decisions. As an implication, it is crucial to analyze implementation processes in order to understand whether, how and under what circumstances policies have the (un)intended effects – ultimately, whether policies adequately address the important problems they are designed to resolve.

The concept of discretion, defined as the freedom to act, is crucial for the study of implementation. Top-down and bottom-up implementation perspectives differ in their views of the role and effects of discretion. Top-down perspectives tend to view discretion as a control problem. Conversely, bottom-up implementation perspectives emphasize the environment in which implementing agents act and how the latter problem solve to adjust to policies. The dissertation combines and confronts top-down and bottom-up views on discretion, and illuminates the latter’s use and effects.

One major reason why implementation research remains a ‘missing link’ lies in the lacking availability and the highly complex and context-dependent nature of the empirical data at hand. Recent years have witnessed a host of innovations in qualitative comparative research methodology, which provide researchers with useful and exciting tools to tackle these empirical challenges. The studies presented here intend to illustrate the potential of these techniques, and how their diligent application can generate valuable insights with a high relevance for both practitioners and researchers.

Thomann, E (2015). Customizing Europe: Transposition as bottom-up implementation. Journal of European Public Policy. DOI: 10.1080/13501763.2015.10085.

The first study of this collection focuses on implementation as legislative output in a multi-level system. European Union (EU) implementation research has neglected situations when member states go beyond the minimum requirements prescribed in EU directives (gold-plating). The top-down focus on compliance insufficiently accounts for the fact that positive integration actually allows member states to transcend the EU’s requirements to facilitate context-sensitive problem-solving. Adopting a bottom-up perspective, the study asks how four European Union (EU) member states use their discretion to adapt EU veterinary drugs directives to domestic contexts during transposition. Moving beyond compliance, it introduces the concept of ‘customization’ to depict how transposition results in tailor-made solutions in a multi-level system. The study analyzes the hitherto unexplored veterinary drug regulations of four member states. Using Fuzzy-set Qualitative Comparative Analysis and formal theory evaluation, this paper assesses how policy and country-level factors interact. The combination of QCA with formal theory evaluation has long been suggested by methodologists, but this is arguably the first published empirical application of this technique.  Results reveal the countries’ different customization styles. The latter simultaneously reflect the interplay of domestic politics with institutions, and the ‘fit’ of EU regulatory modes with domestic, sectoral interventionist styles. Customization is an often neglected but real aspect of the European experience and has at least partly different explanations than compliance. The EU aims at combining integration with legitimate diversity in terms of national preferences. Beyond the question of compliance, this diversity should be further explored to understand how shared policy problems are jointly resolved in the EU.
 

Thomann, E. (2015). Is output performance all about the resources? A fuzzy-set Qualitative Comparative Analysis of street-level bureaucrats in Switzerland. Public Administration 93(1): 177-194.

The second study moves further down the implementation chain. It applies a bottom-up focus on the use of discretion by street-level bureaucrats who implement policies at the frontline in daily interaction with the target groups. The article refines Lipsky’s (1980) assertion that lacking resources negatively affect output performance. It uses fuzzy-set Qualitative Comparative Analysis to analyse the nuanced interplay of contextual and individual determinants of the output performance of veterinary inspectors as street-level bureaucrats in Switzerland. Moving ‘beyond Lipsky’, the study builds on recent theoretical contributions and a systematic comparison across organizational contexts. Against a widespread assumption, output performance is not all about the resources. The impact of perceived available resources hinges on caseloads, which prove to be more decisive. These contextual factors interact with individual attitudes emerging from diverse public accountabilities. The results contextualize the often-emphasized importance of worker-client interaction. In a setting where clients cannot escape the interaction, street-level bureaucrats are not primarily held accountable by them. Studies of output performance should thus sensibly consider gaps between what is being demanded of and offered to street-level bureaucrats, and the latter’s multiple embeddedness. The study moves research on street-level bureaucracy forward in two ways. First, it adopts a systematic comparative approach across organizational contexts, taking advantage of the Swiss federal system as an ideal ‘laboratory’ to hold many systemic factors constant. Second, the article contributes to cumulativeness in the field by synthesizing and testing recently developed core concepts such as policy alienation and the public service gap. By combining fsQCA with a targeted analysis of typical and deviant cases, the study illustrates how in-depth case knowledge can be systematically integrated in QCA analyses.

Thomann, E. and A. Manatschal (under review). Disentangling contextual effects in small-N settings - A Comparative Multilevel Analysis of refusal rates to organ donation in Switzerland and Spain.

The third study, co-authored with Anita Manatschal, adopts a more top-down policy design perspective and explores the link between outputs and outcomes. Qualitative small-N comparisons face the challenge to disentangle contextual effects under conditions of limited empirical diversity. Context is typically treated as another causal factor at a different analytical level. However, sometimes context only affects the operation of a causal mechanism, without being a cause itself. The novel method of Comparative Multilevel Analysis (CMA) (Denk 2010) assesses the role of context as a contingent necessary condition that enables causes to produce an effect. This paper is the first critical application of CMA to a small-N setting exhibiting multiple contextual levels, exploring the role of policy instruments for relatives’ refusal rates to organ donation. The article addresses the question of how context influences the policies’ capacity to resolve the underlying policy problem. Why are relatives’ refusal rates to organ donation low in Spain and in certain Swiss hospitals, while they are high in other Swiss hospitals? The results illustrate that while incentives work independently of context, voluntary information measures only unfold the desired effect in the context of a ‘credible’ state, which comprehensively and actively supports the goal of organ donation. The study identifies weaknesses and suggests several practical refinements of CMA, addresses recent critiques, and highlights the method’s analytical usefulness when QCA cannot be applied. Although it does have limitations, CMA can fruitfully be combined with other techniques to tackle contextual effects and limited empirical diversity in small-N comparisons.

This dissertation was written by Eva Thomann under the supervision of Prof. Dr. Fritz Sager (secondary advisor: Prof. Dr. Benoît Rihoux, Belgium). It was awarded “summa cum laude” by the Faculty of Business, Economics and Social Sciences at the University of Bern, Switzerland on February 18, 2015.