Abstract
Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch ‘All About Health…’ (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a ‘most similar cases’ design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English ‘shadow of hierarchy’ and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change ‘Whole-of-Society’ approaches.
Highlights
Alternative types of social coordination between the classical hierarchical state, the market and civil society have emerged since the 1970s
In contrast to the old state-centric theory that focussed merely on unilateral governmental ‘steering’ through regulation, command-and-control and public service provision, which is to an important extent still the default mode in public health policies, modern governance theories take a wider view of the whole repertoire of modes of social coordination for collective action by state and society,[5,7,8] and how these have been institutionalized in governance arrangements.[8,9]
In the Netherlands, this is known as the ‘poldermodel’—a system of consensus-based democracy that allows for longer term relationships between state and society, and the gradual uptake and modification of new ideas over time.[16]. We show how these different institutional contexts and governance arrangements have shaped the developmental trajectories of two apparently similar public health governance programmes: the English Public Health Responsibility Deal (RD) and the Dutch ‘All About Health. . .’ (AaH) programme
Summary
Alternative types of social coordination between the classical hierarchical state, the market and civil society have emerged since the 1970s.1–3 These have been characterized as a move ‘from government to governance’.4–6 In contrast to the old state-centric theory that focussed merely on unilateral governmental ‘steering’ through regulation, command-and-control and public service provision, which is to an important extent still the default mode in public health policies, modern governance theories take a wider view of the whole repertoire of modes of social coordination for collective action by state and society,[5,7,8] and how these have been institutionalized in governance arrangements.[8,9] How public health policies converge or diverge across countries over time can be analyzed and explained using comparative institutional analysis, thereby clarifying under which institutional conditions an alternative governance mode for public health is likely to achieve its goals.[10,11]Due to different institutional starting conditions, welfare states have developed different state-society relations over time, resulting in different governance arrangements. Alternative types of social coordination between the classical hierarchical state, the market and civil society have emerged since the 1970s.1–3. To retain continuity of public administration in such situations, the United Kingdom has a hierarchical and relatively centralized government.[12,13] In contrast, in some continental European countries, governance emerged out of generally devolving public tasks to semi-public or publicly licensed private notfor-profit organisations, thereby setting the foundations for distinct welfare state governance arrangements.[14,15] In the Netherlands, this is known as the ‘poldermodel’—a system of consensus-based democracy that allows for longer term relationships between state and society, and the gradual uptake and modification of new ideas over time.[16]
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