Health system reforms—Toward a framework for international comparisons

Pergamon 80277-9536(96)00151-7

Soc. Sci, Med. Vol. 43, No. 5, pp. 637-654, 1996 Copyright © 1996 Published by Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

SECTION E HEALTH SYSTEM REFORMS--TOWARD A FRAMEWORK FOR INTERNATIONAL COMPARISONS A N D R E W C. T W A D D L E University of Missouri, Columbia, Department of Sociology, 111 Sociology Building, Columbia, MO 65211, U.S.A. Abstract--Health care reform efforts internationally are focused more on efficiency than on effectiveness or equity. We lack a coherent theoretical framework for understanding those reforms or for engaging in comparative research. This paper presents some theoretical ideas that could contribute to such a framework. A model constructed from expert opinion suggests that hegemonic systems, national systems and medical care systems all contribute, with specific elements identified in each. Three sociological ideas are suggested: a model of trends leading to a fiscal crisis and a crisis of alienation; communities, professions and markets as ideal typical organizational alternatives; global post-Fordist and world systems theories; and hegemonic projects. Together these could explain the timing, speed and direction of health care reform efforts throughout the world. Copyright © 1996 Published by Elsevier Science Ltd Key words--health system reforms, health care reform

countries, to reform medical care systems, not with an eye on improved effectiveness and equity, but Fundamental changes in medical care delivery sys- with the goal of improving efficiency [2-9]. tems seem to be underway throughout the world. In In part, this is a result of the success of medical itself, that is not particularly surprising. There are care. New technologies, specialization, capitalization serious problems in medical and health care deliv- of expensive hospital facilities, and the like have driery. Much of the world is still ravaged by preventa- ven up the cost of medical services wherever the ble water-borne disease. Death rates are still very "state-of-the-art" has been approximated. The high in the Third World and in economically weak Medical Price Index has increased much more populations in parts of the First World. Chronic rapidly than the Consumer Price Index in all develdiseases associated with sedentary lives and over oped countries [5, 10-13]. Third world nations that consumption plague the more developed countries. aspire to state-of-the-art medical care are faced with New types and strains of infectious diseases that enormous capital expenses that often do not meet defy standard means of medical treatment have the needs of the majority of the population, even emerged in recent decades. Clearly, much can be while serving the elites in those countries, who want done to make health and medical care more effec- the technology both for their own care and for the tive and equitable [I]. symbolic value it has politically. Toward this end, the world community has orgaIn the developed world, many countries are nized coordinated efforts through the World Health involved in "market" reforms, which attempt to Organization (WHO), bilateral international aid "make medical care more efficient" by transferring (BIA), and non-governmental organizations responsibilities from the public to the private sector, (NGOs) to set goals, deliver services and promote increasing competition in medical care (both in the environmental changes to improve the health status public and private sectors), and reducing regulation of populations. The eradication of smallpox through of medical care to allow the market to sort out priimmunization, the construction of hospitals and orities, service mixes and the like. From a purely other facilities in most developing countries, the rational standpoint, this is somewhat surprising, efforts to train health workers, the declaration at since the empirical evidence suggests that markets Alma Alta, and numerous other achievements tes- do not provide the expected efficiencies and they undermine equity [14-22]. More surprisingly, the tify to that effort. In the past decade or more, there has been an same kind of reform impetus seems to be at work in increased effort, visible at the national level in many developing countries, where one would think effecINTRODUCTION

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tiveness and equity concerns would have a higher priority than efficiency. Ideologically, these reforms seem to be driven by right-wing political parties, associations of employers, and in some instances professional organizations in the developed world. Intellectually, a form of "neo-liberal" economic theory has come to center stage. Medical economists, while still very much in the debate, have been pushed to the background. Other social scientists, particularly sociologists and political scientists, whose disciplines have spoken to the limitations of classical economic theory, have all but been swept into the wings. This means that alternative theoretical perspectives and an enormous amount of research that speaks directly to the efficiency, effectiveness and equity of medical services is left outside the reform process, making the chances for success more limited than they might otherwise be. The study of these changes is limited by a lack of conceptualization. It is difficult at present to make comparisons across countries, particularly if one wants to compare nations with different levels of socio-economic development. For some groups of developed countries, such as those in the OECD, there are reports in which broadly comparable statistics are given, enabling some important comparisons to be made. Many of these reports highlight variables associated with a limited range of theories and omit data many of us regard as of core importance in making both economic and non-economic comparisons. That is, they are increasingly focused on the question of efficiency and enable only the crudest estimates of effectiveness or equity. For the developing world, the situation is even more difficult, There are articles and books that report on medical care in such countries [26A-B], but none to date have imposed a framework that allows for systematic comparisons of nations on the same parameters. That is, reports, even in the same book, are prepared independently and address different issues and/or use different theoretical frames which highlight different variables. It is our contention that in order to gain a more global picture of health care reforms, even to verify the impressionistic observations above, will require the development of comparable information, and that requires an adequate conceptual framework to guide data collection. A satisfactory understanding and explanation of trends in health care reform must build on existing knowledge. That knowledge must be pooled from a number of disciplines in the social sciences. It is certainly beyond the scope of this paper, to say nothing of the limits of its author, to attempt any such comprehensive statement. However, it is feasible to offer some suggestions of what one discipline, Sociology, might contribute to this project.

SOME PROPOSED THEORETICAL GUIDELINES

I begin by presenting a model developed by a work group in health reform from the 13th International Conference on Social Science and Medicine as a statement of "expert opinion" regarding the social context of the reform movements. That model presents an infrastructure of reform, situating it in larger social contexts. I follow that with a model of changes in medical care organization that have characterized economically advanced countries over this century [11-13, 23-25]. That model shows that attempts to solve a problem of poorly trained practitioners in the early part of the century led to a new set of problems focused on the financing of the system and its ability to relate to patients in a humane way. A third set of ideas has to do with the ways in which medical care can be organized: as a communal responsibility in a democratic context, as a professional endeavor, or as a market commodity. Ideal types of these models will be outlined along with some thoughts about how we might think about changes over time, particularly recent time. A fourth set of ideas has to do with the socioeconomic developments that have varyingly been called "post modern", "post industrial" or "post Fordist." What these refer to, in part, is the internationalization of economies in ways that make economic activity more independent of the state, thus weakening the capacity of the state to manage its own economic and social affairs. A fifth set of ideas has to do with the coalescence of decision makers in key social institutions strategically located so as to dominate the economy. It is their ability to create "hegemonic projects" or policies that set a framework within which decision making will be confined. These statements point to explanations of: (1) strain in the medical care system that poses a crisis in financing; (2) alternative modes of organization for medical care; (3) reasons located in the international economy that set a direction for reform efforts; and (4) guideline for when national interests will support particular types of reform efforts [26].

Expert opinion The expert consensus model consists of three broad categories within each of which there are several more specific dimensions (Fig. 1). I. The most inclusive were the "hegernonic systems" consisting of international organizations that set limits and controls on national development in both developed and developing countries. In the case of the latter, they often set boundaries outside of which development is all but impossible. Among these are: •

Multilateral aid organizations such as the World Bank and International Monetary Fund. These are the main sources of develop-

Health system reforms

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Hegemonic Systems World Bank International Monetary Fund World Health O r l ~ n i z a t i o n E c o n o m i c U n i o n s (e-S-, EU/WTO/NAP'rA) Bilateral Aid P r o g r a m s Non-Governmental Or~antzations

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Reform Pressures, Plans and Programs Professional Model M a r k e t Model C o m m u n i t y / D e m o c r a t i c Model

Fig. 1.

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ment funds. To the extent they are pursuing their own political agenda (strongly suspected) and/or to the extent they are constrained by an impoverished sense of alternatives (also strongly suspected), they may act as much to constrain as to facilitate development in health care. International economic agreements such as WTO, the European Union, and N A F T A set a climate that makes it difficult or impossible for nations to set their own course. They weaken possibilities for a democratic process to guide national development and constrain the kinds of development that are possible. Virtually all of the literature relating such arrangements to medical care has focused exclusively on efficiency, ignoring the dimensions of effectiveness and equity. Even then, the discussions are often theoretical and lack firm empirical grounding. It is not known what impact such developments will have, but they likely will be important. Bilateral international aid. With a large number of bilateral developmental aid programs there are more opportunities for different kinds of development in different countries. With many countries reducing or terminating bilateral aid programs in favor of channeling such aid through international agencies, there may be a loss of diversity that could lead to less appropriate developments and/or the limitation of national autonomy in setting their destinies. Non-governmental agencies, many of them sponsored by church groups and/or private foundations in the developed world, are not

unimportant. They mobilize private resources and target them on specific projects, some of which may be quite useful. It is not known how effective such projects are in general or what differentiates levels of effectiveness. It is not known to what degree such efforts aid or hinder in national development, how they impact equity, how they relate to local needs (for example, where is the planning for specific projects done, who does the planning, how are resources mobilized, and to what degree to NGOs resolve problems as perceived in targeted countries). It is known that the resources involved are substantial. II. At a second level are the national systems. This refers to the particular forms of nation states and the peoples within them. While the features of nation states that might be relevant to understanding their medical and health care systems might be considered almost endless, we thought the following particularly important. •

•

The history and culture of the society. Obviously we do not mean this globally, but with a specific focus on understanding the way in which medical and health care have been formed in that society. Each society, we think, has certain cultural features that place constraints on, or shape, the development of medical care. Those cultural features are the residue of a history that is also to some degree unique. Disease, illness and sickness [27], patterns. It obviously makes a difference if a country is engaged in a battle with water-borne disease or chronic degenerative diseases. It makes a

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•:i'.:!:':-~ morbidity '.2~:':-~';:~-:i',:!:,-~::,',.',,':: ,-'.-:~-:i'.:!:',-'.'::~-~i',:!:',:,',.:~-:','.: :: ,-'.:: :6 ,' :: ,-','::~-/,'/~:",-'.'::~'/,~'~:',~'::.'/,,' :: ,-~:: :/, .' ~:,-'.'::~/,',: ",~':"':',Definition ~.':"'-",f..', Physiological ":','.~":";"",;.',',,"":";'~;~,-¢,',:":":!',;,'G malfunction: ~:.-:: -/ ,,,'.~.%c',-,.- ,,,,:.~...-',-,..,,,':~.. infection, mechanical ;',".'-"~.)~.-'~;',-~.'-'.'~';,~':'~;',-.'-'.'~';.~'.:~.", breakdown, or ~~'.~"-~i"~.:'.:~.;~'2-: !i!:~!!i~ii ".'~:ii! :~"-~, degeneration resulting in reduced capacity and/or life

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difference if the population feels debilitated or healthy. It makes a difference the degree to which people are seen by others as having health problems. Medical and health care systems are designed to respond to such problems and we need a better understanding of differences in what it is such systems are called upon to address. The economy. This is the system for mobilizing resources and one of the institutional frames within which medical care takes place. Particularly important are the size of the economy, grossly and per capita, the means of financing services, and the level of debt in the country (more external in developing countries and internal in some developed countries). We need economic analysis that goes beyond cost accounting and which takes into account the impact of economic decisions on the welfare of people.

•

•

The nature of the welfare system. It makes a difference, we think, if the welfare system is institutional or residual, whether it is broad or narrow in scope, or whether it is a large or small part of the national effort. Medicine is a form of welfare and cannot be understood apart from other forms of social support services (e.g. education, unemployment insurance, family support systems). Interactions among these systems could use more attention. The political system. It makes a difference if the country is democratically run or a totalitarian system. Which elements of a population have a say in political decision-making makes a difference in the kinds of decisions made. If only elites decide on medical care, we would expect a very different system than if working people also have a strong voice in such decisions. Appreciation of this fact needs to

Health system reforms be added to the kinds of economic analysis that are currently in vogue.

unless the delivery system is in imminent danger of breakdown because of a deficiency of revenues or excess costs. The most important criterion is effectiveness, the degree to which the system works to solve the problems in its domain, viz. the health of the people it serves. Most of us would also hold that equity concerns, seeing that all those in need have access to effective services, would come before efficiency. Aside from our own value positions, we hold that different interests in our various countries emphasize each of these values. Those using a rhetoric of efficiency tend to favor market solutions. Those focusing on equity favor democratic control of the system. Those focusing on effectiveness also favor professional control of the system. We were not in agreement as to whether these values are in conflict, or whether that is only the way they have entered political debates. They merit research and discussion. Cost and financing. Everywhere the cost of medical care is growing rapidly, most often more rapidly than the economies of our respective countries. Especially among the more technologically advanced countries, there is an almost universal intent to cap the rise in medical care costs. To do this will require new and different constraints on the shape of medical care in most countries, especially in the rationing of service delivery. In making plans, nations must not rush into ill- considered reforms. The effects considered should not be confined to cost or expenditures, but should include the welfare of the people being served. Equity and effectiveness are at least as important as efficiency in this effort. Comparative research on reforms with an eye on the effects of cost containment on both health outcomes and the distribution of services is essential, and we encourage an expanded effort in this arena [30].

III. Both the hegemonic systems and the national systems provide the context for understanding medical care systems. Here there are also a large number of possible topics for investigation. We think some systematic comparison of the following over a large number of countries would be desirable (Fig. 2). •

•

•

•

Public vs private. The relative size of the public and private sectors, both in general and with reference to specific services may have a large effect on the equity of services. We would anticipate this dimension would have less effect on either efficiency or effectiveness. Nevertheless, with regard to efficiency, we think the neo-liberal economists' contention that private services are inherently more efficient should be systematically tested [29]. General vs specialized. Medicine has an inherent bias toward specialized care and high technology. Generalist services are underdeveloped in many economically advanced countries. There is concern about importation of a specialized-high technology model into Third World countries, where they also have appeal as symbols of modernization. Nations need to be assessed on the appropriateness of generalist vs specialist services and low vs high technology interventions to the needs in each country. We need research on the consequences of different profiles under different circumstances. Prevention vs treatment. There is a substantial body of opinion in developed countries that preventive services are underdeveloped, underutilized, and undervalued. In Third World countries, there may be less controversy, since many have overwhelming unmet needs for curative services. There is an opinion that preventive services are more cost effective, but we did not know of much solid evidence to support this position. This is an area in need of research. What are the relative merits of preventive vs curative services under different national conditions? Effectiveness, equity and efficiency. These are values and criteria for assessing the adequacy of medical and health care systems. In most of our nations, the assessment of medical care is done only with reference to efficiency. Efficiency is obviously an important criterion, and we support and encourage studies of the efficiency of medical care systems. Most of us would hold both that it is not the only criterion that should be employed and that efficiency needs to be understood not only from a provider and administrator perspective but also the perspective of the patient. Indeed, it may not be the most important criterion

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Trends in medical care

The provision of a solid scientific basis for medicine in the late 19th Century and the grounding of medical training on that base in the modern medical school unleashed a chain reaction of structural alterations that have resulted in a new set of problems of medical care systems in the developed world (Fig. 3). A model of these changes has been described in some detail elsewhere [13] and is only briefly summarized here. Briefly, the following changes seem of general importance: • •

increased demand for medical care as services become more effective, increased work pressures on health professionals,

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Fig. 3. Trends in medicine: structural changes following the establishment of scientific medidcine.

Health system reforms • • • •

increasingly rapid technological changes in diagnosis and treatment, bureaucratization of services, increasing specialization of personnel and fragmentation of care, and rapidly increasing cost of delivering services to the population.

The result is that almost all dcveloped nations have found it increasingly difficult to finance their medical care systems and have taken, or plan to take, measures to reduce the rate of increase in costs, if not the costs themselves [32]. Another is that the medical care system is more alien to most people in the society, creating problems of legitimacy and increasing the likelihood of conflict between patients and providers. Public expressions of dissatisfaction might be expected to increase over time and "alternatives" to medical care might become more popular. We can think of these as a two-fold "'crisis" [32], fiscal and interpersonal. Thefiscal "crisis". Over the past two decades, the growth of medical care costs has accelerated. Much of that growth has been technologically driven in that new, sophisticated, and expensive methods of treatment have been added to the options within medicine. Much has been a result of the ways in which medical care has been organized, an example of cultural lag. Thc technological development is well known and does not require additional documentation. Suffice it to say that new means were developed at both ends of the life cycle. It was during this period that transplantation technology, which had begun on a small scale earlier, flowered into a standard means of treatment for people in extremis. CAT scanners became commonplace. N M R machines were developed. In vitro fertilization, genetic diagnosis and neonatal intensive care were developed and disseminated. These technologies add to costs in several ways. At the most basic and obvious level, they cost millions of dollars to manufacture and more millions to buy. There has been a marked increase in the direct capital cost of creating and maintaining a medical care facility as a result. Second, these new technologies reinforce the pressures toward bureaucratization and specialization and they increase the labor intensiveness of medical care. Technology thus creates a "feedback loop" that continuously drives up costs. While the strength of this loop has been strongest in countrics with less political control over medical care, as in the US, it is still significant in countries that politically ration the distribution of new and established technologies, as in Sweden. In most countries, physicians have been granted control over clinical decision making. They have either been in complete charge of the purchase and use of technology (as in the U.S.) or they have been a powerful interest group that has had the major

643

voice in selecting and using technology. Since new technology is always more interesting than old established practices, and since it provides new capabilities and might be of use to patients, there is a "technological imperative" in medical care that places a bias toward using the more complex, expensive, and challenging tools in diagnosis and treatment. The result is that there is a tendency to use the more expensive options more often than their effectiveness would warrant and for conditions that could be managed as well or better with cheaper tools. In the U.S., where each unit in the medical care system must meet its own costs and there is no organization at any level that can make allocative decisions for technology, there is a greater use of expensive tools than in countries with regional or national agencies that can enforce rationing. To take one example, in 1979 there were five CAT scanners in Columbia, MO (U.S.A.), with a population of 55,000 and five CAT scanners in Sweden, with a population of 8.3 million. What we have described here might be considered the long-term development of an impending "crisis". During a period of economic expansion, as has characterized most Western economies for most of the post-World War II era, the increases in costs have been manageable. The additional expense has been covered by growth in the economy. During the 1980s, however, most Western economies entered a period of depression (negative growth) or stagnation. The ability of societies to absorb medical care cost increases has been compromised, making it seem mandatory that some way be found to bring the growth of medical care costs under control. The notation in sociological work in the 1960s that medical care threatened to bankrupt the societies they served seems to have come to fruition. In the U.S., where most of the cost of medical care is borne by company sponsored private insurance, corporations have found that health insurance is the fastest rising part of their labor costs. Even more important, the costs of health insurance commitments already made to retired workers will pose threats of bankruptcy in the very near future. In an honored tradition of "lemon socialism" [33A] the corporations have taken an interest in promoting national health insurance, making it appear likely that the U.S. will soon join the rest of the civilized world in providing universal access to medical care for all of its citizens. In those countries where a national system of health insurance already exists or where there is a national health system, it might be expected that there would be renewed interest in cost containment, the more effective use of resources and rationing of care. The nature of those proposals, the identification of interests promoting them, and some assessment of the quality of the various arguments is the core of the present study.

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The "crisis" of alienation. The other "crisis" noted in the model is that of the alienation of the public, particularly as they become patients. Here we use the term, "alienation", in its technical meaning as a loss of control over important resources. It has been argued that the development of the patient-physician relationship (and perhaps all public-professional relationships) has been characterized by a growing autonomy of the professionals in that relationship [34] coupled with a growing alienation of patients, again in that relationship [23, 24, 35]. Further, that autonomy-alienation relationship can be seen as having at least four dimensions: clinical, organizational, economic and interactional. We will describe these briefly and note some implications. Clinical--If we go back to the early part of this century, we encounter a situation in which the knowledge base of medicine was not much more sophisticated than the knowledge of the average patient. In that circumstance, the patient is in a position to make a greater contribution to the mutual understanding of his or her disease and in the selection of treatment. While the physician had more experience with diseases, and hence was a valued advisor, it was not the case that patients were expected to defer to the physician's judgment in every instance. Indeed, several physicians wrote books intended to provide for a lay public the corpus of medical knowledge so that patients could handle their own conditions. As medical knowledge grew, it grew apart from "common sense". The expertise needed for effective diagnosis and treatment became more esoteric and arcane. Physicians became more autonomous in making the decisions that set diagnoses and selected treatments. Patients had to defer more to expert knowledge and hence have become more alienated. Organizational--Early in this century, most contacts with physicians took place in the homes of the patients. Physicians spent most of their time making "house calls". Medical care took place on the "turf" of the patient. What this meant is that physicians were the guests of their patients. They were constrained to follow the rules of the household. As medical care moved out of the patients' homes and into the clinic and hospital, medical care was at the same time shifting to the " t u r f ' of the profession. The imbalance of power in the professional-patient relationship that had earlier been partly redressed by the guest-host relationship was now intensified by that same relationship. In addition to having to defer to the physician's expert knowledge (and monopoly of resources) s/he now had to defer as well to the "house rules" of the medical institution. The increased control of physicians was matched by a loss of control by patients. Economic--Early in the century, medical care was delivered in a communal context wherein the physician provided care "to anyone who needed it" irre-

spective of ability to pay. The patient then "paid" the physician for his services, with money if s/he had it, with goods or services if s/he didn't. The option of bartering for services was common. It is part of the medical tradition that paying patients were charged more to offset the cost of delivering ca,:e to the poor. With the shift into institutional settings with greater cost accounting needs, the bartering option disappeared. Everything had to be based on a cash economy, in which physicians set the fees, determined the number and kinds of services each patient needed and issued a bill. The patient was forced to pay, either out of pocket or through insurance, or do without. Again, as physicians gained autonomy, patients gained alienation. InteraetionaI--One consequence of these developments is that physicians have increasingly lived in a different world from their patients. On the one hand, they have lived more of their lives in a medical culture where the modes of thinking, the kinds of decisions taken, and the assessment of people from "outside", make "common sense" within a culture that is increasingly removed from "common sense" in other cultural contexts. On the other hand, especially in the U.S., physicians have become enormously wealthy as compared with the average patient. In the U.S., the average income of physicians grew from 2.5 times the industrial wage in the 1930s to 40 times the industrial wage in the 1980s. Both these developments have made communication between physicians and patients more problematic. The language used by physicians is remote from the language of their patients. Their assumptions about priorities, their assessments of the abilities of patients to follow advice, either because of their understanding or their command of resources, has become increasingly unrealistic. Medical residents at the University of Missouri, Columbia in the U.S., when asked in 1975 to estimate the average income of their patients, overestimated that income by a factor of 3. In short, physicians and patients have become alienated from each other. Implications--This analysis suggests that public expressions of disaffection with medical care might be expected to increase over time. It has been suggested that the increases in malpractice litigation in the U.S. [12, 37] are such an expression. The growth of complaints to the Medical Responsibility Board in Sweden and the General Medical Council in the U.K. [37A] could be seen in a substantially similar light. One would also expect that there would be increasing complaints of "cold", "impersonal" treatment, or "being a disease and not a person". It would also suggest that alternatives to medical care might become more attractive, particularly as these hold a promise of more "holistic" and "humane" treatment. Groups competing with medi-

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Concentration of economic power; Strenght of professional ideologies; Strength of democracy.

Fig. 4.

and identifying and healing the sick are social activities [41]. Any system is a matter of decision. There is no "natural" way of organizing such that any one form of organization is a priori to be seen as superior to any other; and (2) the ways in which the social response to health problems is organized can be described in terms of different modalities of organization. Toward that end, this section will describe three ideal types [45] and together are thought to encompass the range of organization found in the sphere of Europe [47] and areas under the influence of Europe with respect to health care activity: activity organized by the community [48] as a whole, activity organized by specially chosen experts [49], and activity organized by an economic market (Fig. 4) [501. For each of the three modes we will attempt to provide: (a) a formal definition of the mode of organization in what can be conceived as its' pure form as well as main types of variants; (b) identification of the kinds of actors who will be dominant; (c) identification of the kinds of goals it sets for the population it organizes; and (d) identification of the main modes of social control or regulation [57]. Communal organization. Definition--A communal organized system is an institutionalized means for people collectively to make and administer decisions. In its ideal form, it is a way of decisionmaking in which every member of the community participates: that is, democracy. In all but the smalModels for medical care lest populations units, at least some of the decisionI make two basic assumptions: (1) the activities of making authority is delegated to politicians. To the any society aimed at minimizing disease and illness, extent that politicians are collectively accountable to

cine that had previously been dismissed by professionals as "quacks" may become more popular with the public and exert a claim for official recognition and legitimacy. Chiropractors, faith healers, diet promoters, and the like may not only see greater patronage but even seek recognition as licensed profession [38]. The key point for our purpose is that these changes are a function of the evolving character of modern medicine, not of any particular form of its organization and financing. It seems to describe not only the free market approach of the U.S., but also the more planned and publicly organized systems of Scandinavia and the U.K. The applicability of the model to the Third World has not, to my knowledge, been studied. We may speculate that the modeling of many Third World systems on those of former colonial powers' would suggest a more general applicability. At the very least, the technology of the First World is being exported to developing countries. That technology is increasingly expensive and it's usefulness controversial in solving quite different health problems. In the context of these large-scale trends in medical care organization, there are differences in the ways in which such services can be constructed, each having implications for the operation of the system and its ability to meet public expectations and needs. We turn now to that question.

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Dominant actors--If an activity is to be organized the larger population, we can meaningfully speak of a democratic system in which organizing takes place by experts, professionals will be the dominant as a communal activity. To the extent that some groups. That dominance is typically not generalized; people are excluded from participating in the it is limited to the problems the professional knowldecision-making process, democracy is compromised edge is supposed to solve [66]. Dominant goals--To the degree that professionals and we can no longer speak meaningfully of a comtake seriously their expertise and to the degree that munal mode of organization. Dominant actors--In a democracy, political par- they feel the need to maintain the trust of clients or ties are most often the means for goal setting. potential clients, their goals will include enhancePolitical parties tend to represent constituencies ment of knowledge, improvement of technique and with particular interests, and frame political agendas capacity, and application to problems within the designed to further those interests. The dominant domain of expertise. Aside from that, the goal of actors will be successful politicians: legislators and the professional will be to maintain, enhance and elected executives. Civil servants tend to exercise a defend their domain of dominance. Mode of regulation/social control--Given that restraining force. They set and administer routines for implementing legislation and they resist changes, professional organization is premised on expert thus mediating against sudden alterations in politi- knowledge, a public perception of the usefulness of that knowledge, and client trust, it follows that cal direction or pace. Dominant goals--The dominant goal of any com- there are severe limits on the ability of "outside" munal model of decision-making is the preservation groups to regulate professional activity or to control and extension of democracy. The main issue is con- any but the most obvious and egregious violations trol over the mechanisms for public decision mak- of conduct norms. To a degree not found in other ing; in most societies, the legislative bodies and the forms of organization or with reference to other units that give political direction to administrative kinds of occupational groups, one element of public units. In a democratic system, these decisions are trust is that the professionals will regulate themgenerally made to distribute resources in a manner selves. so as to meet conditions communally defined as Market activity. Definition--A perfect market "fair " [58]. The communal mode promotes univer- must meet three conditions: (1) the largest unit in sal access to those resources defined as basic and the arena must have a trifling amount of the total places limits on inequity in the distribution of economic activity. There must be a large number of units; (2) each unit must act independently. Econothers. Mode of regulation/social control--In any but the omic competition must be impersonal. "The essence smallest societies, there is a diversity of interests, of perfect competition, therefore, is not strong rivmaking it likely that any group of politicians will alry, but rather the utter dispersion of power to inrepresent, not the whole community, but the por- fluence market behavior" ( [67], p, 181); and (3) tion that was able to mobilize a majority (or plural- participants in the market have perfect knowledge ity, depending on the system) in the last election. of (proposed) transactions. In the empirical case, Elections and opposition parties, then, are the main perfect markets are an abstraction, in Weber's terms, an "ideal type". They do not exist, but under means of social control in a democracy. Professional organization. Definition--The pro- rare circumstances may be approximated [66]. fessional bases a claim to an exclusive right to In a market, activity is organized around people decide on organization on his or her formal training who see needs that might be filled by providing in a field that requires abstract knowledge that is goods and services for others to purchase. The only useful to others and which requires that those with- requirement for participation as a provider is that s/ out such training defer to the professional. As he have something to put up for sale. The only requirement for a purchaser is to have the means to expressed by Brante ( [59], cf. [60]) execute a transaction (i.e. money or some equivalent Professions are carriers of abstract expert systems, enabling medium of exchange). Dominant actors--Business interests dominate them to perform acts that are perceived as valuable (skilled, informative, helpful, profitable) and trustworthy by clients markets. The image of the entrepreneur is ideologi[61]. In this regard, medicine is a prototypical profession. cally at the core of the actor in the market. The conception of an individual who by his or her own To organize around professional activity means creative efforts takes personal financial risks and that only experts will define the content of that ac- builds a new enterprise is internalized by every tivity. They have a mandate to develop requisite business person and is put forth in debate to suggest skills and to apply those skills solely in the interests that the market generates creativity and energy [69]. Dominant goals--Actors in the marketplace are of people in need of them. They will be given the exclusive right to set and maintain standards of motivated by the potential for profits. Unlike the practice on the condition that they enforce perform- professional expert who limits his or her occupational activity to a particular body of knowledge ance ethically.

Health system reforms

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Global Post-Fordism

Fordism N a t u r e o f "Regime"

Nature of "Regime"

National economies based on domestic mass production and consumption regulated by welfare states • National and multinational corporations • "Rigidity"

International economic relations based on flexible accumulation [decentralization of production, "informalization"of labor], global sourcing, and transformation of the nation state • "Flexibility"

Goals

Goals

• Growth of national internal market • Extraction of low cost resources and labor from third world by firstworld multinational corporations. • Matching domestic production with domestic consumption. * Development of international trade

• Avoid higher cost of doing business in first world states • Bypass regulations (e,g. environmental) and welfare state arrangements • Deindustrialized first world • Deregulation of global finance; Capita] flight to newly industrialized and third world states

M o d e of R e g u l a t i o n

Mode of Regulation

• Strong local, regional, and national controls • Breton Woods Agreement • Stable, neo-corperatist labor-capital arrangements medicated and enforced by welfare state (social security, unemployment) • Keynesian economic policies, State as bearer of monetary constraint, consumer credit • National relations • Collective bargaining, corporatist ~class

• Absence of local, regional and national controls. • GA'I'r, EC/EU, NAFTA, IMF, World Bank * Internationalizationof Capital • Transnational corporations • Globalization of economy

compromise" • International relations

Characteristics

Characteristics

Centralized production, strong unions Full time employees with job security, benefits, step increases on ladder • Corporations identified with nations • Financial and research capacity located in first world • Development of welfare state

* Decentralized production, weak unions • Part tim and temporary employees with no secutiry, benefits or career ladders • Corportions independent of nation state • Financial and research capacity remains in fast world • Rollback of welfare state

•

•

Fig. 5. A comparison of Fordism and global post-Fordism. and set of skills, they are indifferent to the nature of the product being marketed. Indeed, it is considered not only permissible, but "smart" to change product lines with shifts in demand. Mode of regulation/social control--Competition among a myriad of units with approximately equal power in the economy will force each of them to provide goods and services on equivalent terms if the quality of information to consumers is good. A market is thus self- regulating as firms will be forced to lower prices if their product is provided more $$H 43:5-F

cheaply by another firm. Any other form of internal social control is seen as irrelevant. Indeed, the ideology of those who work in markets is one that sees external regulation, particularly communal, as not only unnecessary, but harmful, creating artificial imbalances between supply and demand and/or reducing the connection between supply, demand, and price [70, 71]. The state has a limited function of creating the climate for market activity, most importantly by enforcing private agreements as expressed in contracts.

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One caveat is critical. There is no empirical system that can be characterized by any one of the above models. The models are ideal types that serve as benchmarks for analysis. Real societies are almost always some mix of these types, although most approximate one model more than the others. Democratic--Communal models tend to emphasize equity as a value. Professional models emphasize effectiveness, and market models emphasize efficiency. That said, the degree to which those values are realized is an empirical question. Further, emphasis placed on one value to the exclusion of others produces a seriously unbalanced view of the needs of both social systems and human beings. The only meaningful policy issue is where the balance should be struck.

Internationalization of economies A third set of ideas has to do with developments in the macro-socioeconomic sphere, specifically with respect to the internationalization of the economy and, by implication, of society as well. It is no longer the case that nation states can be the arena in which macroeconomic decisions can be made and implemented. Indeed, there is much speculation about whether the economic models that have been credited with successful management of national economies in this century are any longer relevant. Work on transnational social organization, however, is new to the social sciences and we do not yet have models that provide a fully satisfactory basis for analysis. As expressed by Gosta Esping Andersen [56], Ours is an epoch in which it is almost universally agreed that a profound realignment, if not revolution, is underway in our economy and society. The proliferation of labels.., often substitutes for analysis. But it mirrors the recognition that we are leaving behind us a social order that was pretty much understood, and entering another the contours of which can be only dimly recognized. Most analysts would agree that there has been a large and important change in the organization of economic activity [14, 33, 72-92]. Fig. 5 identifies some of the main characteristics of the change as identified by "global post-Fordist" theorists [93] (Fig. 5). In the industrial, modern or Fordist era, mass production economies were organized around firms that were geographically based in a single country, even when they had substantial international activity. Production was organized in plants which centralized labor activity. Labor unions were organized and legitimated. A welfare state provided support for workers who were subjected to new pressures of cyclical unemployment. In the post-industrial, post-modern or global post-Fordist era, a more "flexible" and "decentralized" economy is organized around the firms that have no national "home". Production is decentralized with workers scattered in different

places around the globe, and "globally sourced", in that each component can be gotten from any of a variety of places. Non-union and part time labor replace full time union workers. Collective bargaining is de legitimated and labor unions weakened or abolished. The state loses power to regulate environmental impacts and welfare state provisions are scaled back and weakened to reduce taxes and the costs of benefits. To underline the facts that seem to have particular importance, the nation state becomes incapable of economic or social regulation and the working class, including most of what was earlier the middle class, is pushed into a new condition of powerlessness in the absence of any internationally organized labor movement. Until international law with regulatory powers can be created, it seems likely that we will experience growing unregulated capitalist development and growing social anarchy. Trade agreements, such as WTO, N A F T A and EU, designed, supported and managed by economic elites in the international sectors of the affiliated countries, and designed to maximize profits at the expense of social development are increasingly dominant. Measured by the percentage of gross national product devoted to welfare services, the era of the growth of the welfare state seems to have come to an end. The issues now under discussion are the extent to which the achievements of the past several decades can be protected, the means for protecting them, and the best structure of services that can be attained versus the extent to which the whole idea of a welfare state was a mistake and the welfare of the country requires that it be dismantled as quickly as possible. In the balance may hang democracy itself. Wallerstein [33, 91, 92] has long contended that there is a world economic system, on historical form of which has been a world capitalist system that has been identifiable for some 200+ years. That system has had a core that originated in Europe and expanded to North America. Within the capitalist world system, the core seems to be shifting toward Asia. The point for us is that Fordism marks one historical compromise or adjustment in the global organization of capitalism. It was a compromise that provided for redistribution toward the working class and the strengthening of the nation state as an economic arena. It is that compromise that is now being unraveled. Indeed, there is reason to believe that the internal contradictions of capitalism have reached a point of crisis as defined [45]. One core concept in Wallerestein's work has been a distinction between "core" and "periphery". The core countries are those who engage in production and where the accumulation of wealth is concentrated. The peripheral countries are those that supply resources to the core, but are prevented from engaging in meaningful wealth producing activity.

Health system reforms The economics of households, has been shown to differ markedly between the core and periphery in the mix of income that comes from wages, market activity, rent, transfer payments and subsistence. Core country households rely more on wages and transfer payments, periphery country households rely more on subsistence [94]. The central activity of medicine has been both more international and more local than other welfare activities. Medicine as a body of knowledge and practices has been international since at least the 18th century [95]. The content of medicine and the standards for medical care have been shared throughout the developed world and widely diffused to the less developed world in this century. Medical care organizations and the nature of medical work are easily recognizable from one country to another. Medical training is grossly similar in all medical schools, regardless of location, as are standards for treatment. On the other hand, medicine is a local activity. Except for the most esoteric treatments, people do not tend to travel long distances to get medical care. Indeed, unless unavailable locally, people seldom leave town for primary care. What this means is that trends toward internationalization of economies will probably have little special significance for medicine. That is, one would expect the pressures on medical care activity to be grossly similar to those on the welfare system in general. It would be under pressure to privatize, introduce competition into the public sector. The main caveat is that medicine may be in a stronger position to resist change than are other welfare activities. It is, as seen above, treated as a special category of service that requires a licensed monopoly to maintain standards. In its core activities, it has been relatively immune to external controls. Indeed, that is at the core of what it means for medicine to be a profession [62, 60, 96--98]. To the degree that physicians see the preservation of their organization as a profession as important and threatened by pressures to behave more as a market mode of organization, they may be able to withstand pressures to become more like a business. When looking at international differences, it may be important to carefully consider the implications of Wallerstein's core and periphery distinction, particularly in its application to the economics of households. That study would suggest a strong possibility that an analysis of types of income used to obtain health care would yield insights into the limitations placed on developing countries when it comes to improving medical care. It suggests we may find that culture and poverty are insufficient explanations. The very structure of the world economic system denies opportunity entirely aside from the policies of hegemonic organizations.

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Hegemonic projects As discussed by Jessop [99], hegemonic projects are broadly based agendas designed to promote a particular kind of accumulation regime. The project must "resolve the abstract problem of conflicts between particular interests and the general interest" (p. 208). Both at the international and national levels, Jessop contends that particular classes exercise hegemony by creating such projects thereby ensuring that they will be favored by the accumulation regime. One has to untangle the concept from a thicket of nested ideas. The place to start would seem to be the concept of an accumulation regime. This is defined as "a specific economic growth model" complete with its various extra-economic preconditions a n d . . . "a general strategy appropriate to its realization" (p. 198). Establishment of a regime is a means by which a class exercises economic hegemony [100] which is "won through general acceptance of an accumulation regime". "Fordism" and Keynesian political-economic policy are offered as examples of accumulation strategies found within a regime founded on markets. Presumably neo-liberal political-economic policy would be another. The hegemonic project is a means of (re)creating an accumulation strategy and hence a means of legitimating and undergirding an accumulation regime. As described by Jessop, ... this involves the mobilization of support behind a concrete, national-popular program or action which asserts a general interest in the pursuit of objectives that explicitly or implicitly advance the long-term interests of the hegemonic class (fraction) and which also privileges particular "economic--corporate" interests compatible with the program. Conversely, those particular interests which are inconsistent with the project are deemed immoral and/or irrational and, in so far as they are still pursued by groups outside the consensus, they are also liable to sanction. Normally, hegemony also involves the sacrifice of certain short term interests of the hegemonic class (fraction), and a flow of material concessions for other social forces mobilized behind the project. It is thereby conditioned and limited by the accumulation process (p. 208). A "project" to promote equality, solidarity, and security for all by extending democracy might constitute a hegemonic project for interests mobilized by social democratic forces, as in the middle half of the 20th century in Scandinavia. A project to make the state more efficient, reduce government and trim welfare expenditures might constitute another for forces mobilized around right wing political parties as in the U.K. of the Thatcher years and the U.S.A. of the Carter, Reagan, Bush and Clinton years, most aggressively in the Republican congress elected in 1994 [101].

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Jessop noted first that many states experience a "crisis of hegemony" where there is a lack of consensus on a project. In this regard he distinguished two kinds of projects: "one nation" and "two nations." One nation strategies aim at an expansive hegemony in which the support of the entire population is mobilized through material concessions and symbolic rewards (as in "social imperialism" and "Keynesian welfare state" projects). In contrast, "two nations" projects aim at a more limited hegemony concerned to mobilize the support of strategically significant sectors of the population and to pass the costs of the project to other sectors (as in fascism and Thatcherism) (p. 211) . . . . two nations projects require containment and even repression of the "other nation" at the same time as they involve selective access and concessions for the more favored "nation" (p. 212). The important point for our purposes is that reform of medical care systems can be a hegemonic project in itself (although I suspect that would be rare) or, more likely, can become a part of a larger hegemonic project. We have little empirical work to draw upon for guidance, but it would seem worth exploring in each nation the degree to which there is a hegemonic project involving health care reform as an aspect. If located, it would be of interest to know what interests have organized it, what interests have been mobilized in support of it, and what interests are excluded from it. Impressionistically, I would hazard a guess that we have seen a shift from "one nation" to "two nation" strategies' in most of Europe and North America, with projects more closely tied to the interests of international corporate interests. One unexplored area is the degree to which the "Global Post-Fordist" regimes in the international sphere are dependent upon nationally based hegemonic projects. Perhaps the two are but two perspectives on the same phenomenon. To the degree that some independence can be established, there may be an interesting dynamic that could provide a much more nuanced understanding of international trends.

SUMMARY AND CONCLUSION

In this paper I have not presented a fully articulated argument on health care reforms. Instead, I have presented a set of ideas that could serve to provide a theoretical framework for the comparative study of such reforms. I started with a model that represents a consensus of expert opinion on the factors underlying reform efforts in countries in both the developed and developing world. That consensus was arrived at by participants in a Health Reform work group at the 13th International Conference on Social Science and

Medicine. It set forth ideas from an interdisciplinary group. To further that work, some concepts taken from sociological theories were offered as a possible framework for understanding the reform effort. Four theoretical ideas are advanced in this paper. First, there are common trends in the nature of the professional-patient relationship in the developed world that have shaped and been shaped by changes in the organization of the medical care systems in those countries. These define trends in the development of medical care activities. Second, there are three ideal typical models that characterize the possible modalities for the organization of medical services. They can be organized as professional activities, as democratic-communal activities, or as market activities. For each type, primary goals, principle actors, and main modes of regulation or control can be identified. Together, these define the possibilities for organization as well as benchmarks for detecting changes. Third, the character of the internationalization of economies, especially the development of new transnational economic units and trade associations set up constraints on economic decision making at the national level and create pressures for changes in one direction, toward market forms of organization. Finally, the propensity of economic elites at the national level, led by those in the internationally exposed sector, to form hegemonic projects may either create pressures at the national level for market reforms in medical care or be the manifestation of the market bias of the transnational corporate interests cut loose from any national interests. Taken together, these ideas, if further developed, suggest a potential for a theoretical statement that can account for the timing, speed and direction of medical care reform efforts throughout the world. In that hope, I place offer them for our further discussion.

CONSEQUENCES

• • • • • • • • • •

•

•

National soverignty Social norm of consumption Growth of service sector Homogenization Strong worker bargaining power Improved working conditions, wages and job security Political decision making in democratic process Steady or reduced class differences Growth of middle class Facilitation of worker association, communication and organization; worker identify with job and class Separation of sphere of influence of the state from sphere of influence of capital State fiscal crises

Health system reforms • • • • • • •

Segmentation Weak w o r k e r bargaining p o w e r P o o r e r working conditions, lower wages and loss o f j o b security Political decision removed f r o m democratic process Increased class polarization Decline o f middle class F r a g m e n t a t i o n o f work force; workers identify with residence, ethnic, nationality and cons u m p t i o n patterns

[28, 29A, 31, 36, 39, 40, 42--44, 46, 51-55, 63-65, 67, 68].

Acknowledgements--Some content of this paper was previously circulated among those who attended the International Conference on Social Science and Medicine in 1994. This version has benefited from critical responses from David Hughes and Gabriel Gyarmati, I am especially grateful for critiques by my colleagues Ibitola Pearce, James Campbell, Jack Glasier and Richard Hessler, graduate students Soo-Yeon Cho and Yvonne Villanueva, and undegraduate students Amy Cassoff, Dewayne Dungan, Sarah Kreitner, Gwen Marberry and Jamie Zurheide. Needless to say, remaining defects in this paper are attributable to the author.

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47. Including North America.

48. By community, we m e a n any geographically based collectivity that constitutes a population. People in any area can function at some level as a collectivity. Discussion of decision making in such a context is, of course, more complex the larger the population under consideration. M u c h of what is here referred

49. 50.

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58.

59.

to as community, is called the state in other literature. While I intend community to encompass the state, I do not wish to limit the definition to units that meet conditions of sovereignty and I do want to include smaller units of organization such as provinces, cities, villages, etc. There is another deftnition of community as a natural order based on tradition and including family, neighborhood, and kinship, what Habermaus called the life sphere [8]. That is not the meaning intended here. In this type, I have been much influenced by discussions with Thomas Brante. In different ways, each of the ideal types has already been discussed with reference to medical care organization. In the discussion of medical care, for example, Talcott Parsons [51, cf. 52-54] argued that the market was unsuitable for medical care organization. Given the importance of medicine for individuals and the vulnerability of the sick to exploitation, only a professional mode of organization that makes the patient's needs central would be appropriate. Other observers have discussed medicine as a market activity, with special emphasis on its putative superiority to communal modes of organization in providing a more efficient and costeffective service [2-4, 6-9, 15, 17, 21]. Several observers have framed discussion of medical care changes in terms of a conflict between professional and market modes of organization, seeing the growing strengths of market modes of organization as a threat to professional modes [19, 20, 36, 55, 56]. Parsons T. (1968) Professions, International Encyclopedia of the Social Sciences, Vol. 12, p. 536. Parsons T. (1951) The Social System. Free Press, Glencoe, IL. Parsons T. (1964) Social Structure and Personality. Free Press, Glencoe, IL. Parsons T. (1975) The sick role and the role of the physician reconsidered. Milbank Memorial Fund Quarterly 53(3), 257-278. Esping-Anderson G. (19850 Politics Against Markers. Princeton University Press, Princeton, NJ. Esping-Anderson G. (1990) The Three Worlds of Welfare Capitalism. Princeton University Press, Princeton, NJ. We omit, to accommodate space limitations, (e) identification of factors that enhance and diminish that mode vis-d-vis others (that is, that enhance or undermine its dominance). It is to be expected that neither the concept of fairness nor the criteria for judging what is fair in any instance will be uniform throughout any but the smallest and most homogeneous communities. Indeed, different standards in this regard are characteristic of different social classes and ethnic groups. Brante T. (1992) Expert society: the origins and development of professions in Sweden. Studies in

Higher Education 2. 60. Brante T. (1988) Sociological approaches to the professions. Acta Sociologica 31(2), 119-142. 61. Emphasis in original. Brante was attempting a definition that avoided the naive definitions of the functionalist or the cynical definitions of the conflict theorists. He was also seeking a definition that would work as well in the European tradition of state employment for professionals as in the

Health system reforms American tradition of the self-employed professional. Some theorists (e.g. Freidson [62, cf. 12] have added that professionals are people who have been granted autonomy in the conduct of their occupational activities [63, p. 261]. Others have contended that the professional has formal technical training that has been validated with some provision to assure that the knowledge and skills are put to socially responsible uses [51, 64]. As Denzin [65] observed, it is not enough for individuals to have these characteristics. To be a profession, they must organize on that basis to have a claim to license and mandate for the exclusive practice of the occupation. 62. Freidson E. (1970) Profession of Medicine. DoddMead, New York. 63. Simpson R. L. (1971) Imperative control associationalism, and the moral order. In Turk H. and Simpson R. (eds) Institutions and Exchange: The

Sociologies of Talcott Parsons and George Homans. Bobbs-Merrill, Indianapolis. 64. Freidson E. and Lorber J. (eds) (1972) Medical Men and the Work, p. 1. Aldine, Chicago. 65. Denzin N. (1968) Incomplete professionalization: the case of pharmacy. Social Forces 46, 375-382. 66. There is another dominance issue, that of the authority of different experts in the professional arena. There may be different disciplines with different bodies of expert knowledge and some real ambiguity regarding which might be most beneficial at a given time and place under given circumstances. It is the former, and not the latter, that most concerns us in this instance. 67. Stigler G. (1968) Competition. International Encyclopedia of the Social Sciences, Vol. 3, pp. 181-186. MacMillan, New York. 68. Economic theory, however, is predicted on the model of the perfect market. Very little attention has been paid to the organization and effects of an imperfect market. This is not to say that economists have not studied imperfect markets, only that a theory of imperfect markets is still awaited. Among business interests, markets are often assumed, even when all of the stipulated conditions have been violated. 69. With the advent of the limited liability corporation owned by stockholders and controlled by a board of directors, the reality became quite different for most people in business. The major actors work for a salary. In the sense that managers sell their labor and do not control the means of production, management can be thought of as proletarianized. To the extent that they take financial risks, it is with other people's money, for which they are not personally responsible. Such people act as representatives of the organization, and to that extent might be considered professionals. Neither of these images should be pushed too far, but they do suggest that the actor as entrepreneur is not characteristic of firms in the market. 70. Carniero R. L. (ed) (1967) The Evolution of Society: Selections from Herbert Spencer. University of Chicago Press. 71. Sumner W. G. (1983) What Social Classes Owe to Each Other. Harper & Row, New York (Reprinted 1961 by Caldwell, Idaho, Caxton, 1883). 72. Antonio R., Kellner D. (1992) Communication, modernity, and democracy in Havermas and Dewey. Symbolic Interaction 15(3), 277-297. 73. Bonanno A. et al. (eds) (1995) From Columbus to

AonAgra: The Globalization of Agriculture and Food. University of Kansas Press, Lawrence.

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74. Bonanno A. and Constance D. (1995) Caught in

the Net: The Global Tuna Industry, Environmentalism, and the State. University of Kansas Press, Lawrence. 75. Borrego J. (1981) Metanational capitalist accumulation and the emerging paradigm of revolutionist accumulation. Review 4(4), 713-777. 76. Clarke S. (1990) The crisis of fordism or the crisis of social democracy. Telos 83, 71-98. 77. Constance D. (1994) Global post-Fordism: the case of the tuna-dolphin controversy. Unpublished Ph.D. dissertation, Department of Rural Sociology, University of Missouri, Columbia. 78. Constance D., Heffeman W. (1991) The global poultry agro/food complex. International Journal of Sociology of Agriculture and Food 1, 126-142. 79. Friedland W. (1991) The transnationalization of agricultural production: palimpsest of the transnational state. International Journal of Sociology of Agriculture and Food 1, 48-58. 80. Gramsci A. (1971) Selection from Prison Notebooks. International Publishers, New York. 81. Harrison B. and Bluestone B. (1988) The Great U-

turn." Corporate Restructuring and the Polarization of America. Basic Books, New York. 82. Harvy D. (1990) The Condition of Postmodernity. Blackwell, Oxford. 83. Hicks A., Misra J. (1993) Political resources and the growth of welfare in affluent capitalist democracies, 1960-1982. American Journal of Sociology 99(3), 668-710. 84. Huber E., Ragin C., Stephens J.D. (1993) Social democracy, Christian democracy, constitutional structure, and the welfare state. American Journal of Sociology 99(3), 711-749. 85. Jameson F. (1991) Postmodernism, or the Cultural Logic of Late Capitalism. Duke University Press, Durham. 86. Lambert J. (1991) Europe: the nation state dies hard. Capital and Class 43(2), 9-23. 87. Lipietz A. (1992) Towards a New Economic Order," Postfordism, Ecology and Democracy. Oxford University Press, New York. 88. Picciotto S. (1991) The internationalization of the state. Capital and Class 43, 43-63. 89. Pitelis C. (1991) Beyond the nation state: the transnational firm and the nation state. Capital and Class 43, 131-152. 90. Sassen S. (1993) The Global City. New York, London, Tokyo. Princeton University Press. 91. Wallerstein I. (1979) The Capitalist Worm Economy. Essays. Cambridge University Press. 92. Wallerstein I. (1992) Creating and Transforming

Households The Constraints of the World-Economy. Cambridge University Press, Paris. 93. Particularly good summaries can be found in [14, 74]. 94. Smith J. and Wallerstein I. (1992) Creating and

Transforming Households: The Constraints of the Worm Economy. Cambridge University Press, Paris. 95. Wallerstein would presumably contend that medicine, based on scientific principles, is an aspect of world capitalism in this regard. See his essay, Typology of Crises in the World System in Ref. [33], pp. 104-22. 96. Stevens R. (1966) Medical Practice in Modern England. Yale, New Haven, CT. 97. Stevens R. (1966) American Medicine and the Public Interest. Yale, New Haven, CT. 98. Twaddle A., Hessler R. (1986) Power and change: the case of the Swedish Commission of Inquiry on Health and Sickness Care. Journal of Health Politics, Policy and Law 11(I), 19-40.

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99. Jessop B. (1990) State Theory: Putting Capitalist States in their Place. Penn State Press, State College. 100. Jessop differentiates economic hegemony from economic domination and economic determination. T h e former occurs when one one fraction is able to impose its own particular economic-corporate interests on the other fractions regardless of their wishes and/or at their expense (p. 199). It is an exercise in power. T h e latter is not formally defined in Jessop's book. Economic hegemony, by contrast, derives from economic leadership won through gen-

eral acceptance of an accumulation regime (p. 199). 101. While one could argue that the accumulation regime supported by the US examples is the same, there are important differences in the degree to which Carter and Clinton, on the one hand, and Reagan and Gingrich on the other proposed to shift the costs of the project to the underclasses of the society. One could, of course, elaborate the examples to include the Swedish Social Democrats since 1982 and the more rapacious Bildt government of 1991-94 among others.