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Tamara Popic, lecturer at the School of Politics and International Relations of the Queen Mary University of London, has written a book to study changes in healthcare systems in post-communist Eastern Europe, particularly in the Czech Republic, Slovenia, and Poland. The book identifies the roots of these changes in the socialist period, when market-oriented ideas emerged in response to the anomalies of the socialist healthcare model. Popic also emphasizes how institutions and party relations – in particular the intensity of party divisions – are a factor that can hinder or foster stable policy change.

We interviewed Tamara Popic to find out the main evidence from her book “Health Reforms in Post-Communist Eastern Europe“.

What is the volume about?

The fall of communism in Eastern Europe implied profound changes in the healthcare systems marked by the break-up with the hierarchical, state-centred model of system organisation. The volume takes account of these changes, tracking the main trend and market-oriented healthcare reforms, over the three post-communist decades (from 1989 to 2019).

With respect to drivers of these reforms and their differences across countries, the volume challenges the dominant view of the reforms as essentially shaped by professional interests, external factors, or economic pressures. Instead, it puts forward the argument that reforming post-communist healthcare involved an endogenous process of policy change which originated in the socialist period, when market-oriented ideas emerged in response to the anomalies of the socialist healthcare model.

The volume further stresses the role of politics, arguing that factors such as legacies, institutional structures, and political party competition played a crucial role as they shaped policymakers’ attempts to translate these ideas into policy. The volume provides empirical support for this argument though in-depth case studies based on expert interviews, legal documents, and parliamentary debates.

The volume focuses on three countries: the Czech Republic, Slovenia, and Poland. What are the main characteristics of the three healthcare systems, and how do they differ?

In each of these three countries, post-communist policymakers were keen on market ideas and intensively sought to reform healthcare in market direction. However, they did so with varying degrees of success and, even when they were successful, their reforms did not always stand the test of time. In Slovenia, the reform path was marked by survival, as the policy introduced in the early transition stood the test of time over the three communist decades. The Czech health policy path displayed instability, as market elements were introduced but then partially withdrawn. In Poland, healthcare policy showed radical reversals marked by partial return to state-dominated model of healthcare provision.

The volume analyses these distinctive policy paths and provides account of how they were shaped by different experiences with markets in healthcare under socialism, distinctive institutional configurations of these new democratic states, and the unique patterns of political party divisions over healthcare issues.

The subtitle of the volume is “The Politics of Policy Learning”. What does it mean?

Learning is understood as adaptation of similar policy ideas in different political contexts. The core claim of the volume is that this variation in health policy paths of the three countries was the result of different learning processes. The concept of learning helps accounting for why, in some contexts, the market ideas translated into policy and in others they did not, despite the similar efforts of policymakers. Learning also emphasizes that the process of health policy change was a deeply endogenous process and that the policy making did not involve a simple translation of the policy ideas into policy in each country. Rather, the market-based reforms’ trajectories varied as in some cases they were stable (Slovenia), in others they involved small-scale (Czech Republic) or even large-scale policy reversals (Poland). This underlines that policy learning is not necessarily a linear, progressive process, but a process of adaptation and as such can be discontinuous, interrupted or patchy.

And what are the factors that foster and facilitate the policy learning process in the Czech Republic, Slovenia, and Poland?

In Slovenia, relatively smooth learning process was facilitated by a combination of favourable legacies, which involved experiences with market-oriented reforms in healthcare under communism, relatively weak institutional constraints, and non-divisive politics around healthcare issues. Market ideas, although challenged, displayed remarkable resilience in the development of Slovenian health policy. In the Czech Republic, the learning process was more turbulent. In the early transition, the post-communist health reforms had a difficult start due to lack of experience with non-state instruments in health, demonstrating some text-book examples of market failures. Nevertheless, country’s policymakers demonstrated a remarkable capacity for policy learning, implementing series of adaptations. Yet, moderate political divisions between the left and the right-wing parties in the context of few institutional constraints generated a protracted learning pattern in which policymakers struggled to integrate further elements of market into policy. In Poland, the combination of the state-dominated health policy legacies, sharp political divisions over health reforms and thick setup of institutional vetoes generated a very disrupted pattern of policy learning over the three post-communist decades.

Theoretically, the volume underlines the role of political factors in policy variations. Its focus on party competition underlines that it is not, as usually understood, the partisanship of the parties in the government that explains the policy change. Rather, it is the relations between the parties – the intensity of party divisions over policy – that condition the institutional influence on change and thus influence on the policy learning process. If this intensity is low because the main political parties share similar vision of healthcare policy, and if the institutional context features a small number of vetoes, this can enable a learning process marked by a smooth adaptation of ideas into policy outputs and their preservation over time, like in Slovenia. If these visions are deeply conflictual, and the institutional context is marked by multiple vetoes like in Poland, the adaptation of policy ideas through the learning process is more difficult, generating a protracted process of policy learning marked by reversals. The Czech case stands in the middle, due to its relatively moderate intensity of party divisions and veto points configurations of medium strength.

Considering these three countries, what are the main challenges facing post-communist health systems – and their policy trajectories – in the future?

As also touched upon in the volume, the recent Covid-19 pandemic had significant effect on Eastern European health systems, as it exposed systemic vulnerabilities and put under scrutiny country specific policy choices made in the past.  However, brief analysis of some of the most recent trends suggest that, at least the three countries analysed in the volume, have not dramatically changed their policy paths.

More generally, the countries from the Eastern European region were praised for being exceptionally eager to introduce strict lockdown measures and hence more successfully offset the deadly effects of the pandemic for their populations than countries in Western Europe. Yet, as suggested by recent research, this swift response was due to the government fear that the comparatively weaker health systems in the regions could not withstand the infections. As the pandemic moved on, electoral and economic considerations trumped fears over the vulnerability of health systems, and Eastern European countries took a looser approach.

Given these findings, we should expect region’s health policy trajectories to continue displaying cross-country variation in the future and, in the post-pandemic context, face stronger challenges of the policy trade-offs between health on the one hand and economic and political concerns on the other.

Foto di copertina: Soviet Artifacts, Unsplash.