THEME PAPERS
The concept of stewardship in health policy
La notion d'administration générale dans les politiques de santé
El concepto de rectoría en las políticas de salud
Richard B. SaltmanI; Odile Ferroussier-DavisII
IProfessor of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, CA 30322 Atlanta, USA
IIRollins School of Public Health, Emory University, Atlanta, Georgia, USA
ABSTRACT
There is widespread agreement that both the configuration and the application of state authority in the health sector should be realigned in the interest of achieving agreed policy objectives. The desired outcome is frequently characterized as a search for good governance serving the public interest. The present paper examines the proposal in The World Health Report 2000 that the concept of stewardship offers the appropriate basis for reconfiguration. We trace the development of stewardship from its initial religious formulation to more recent ecological and sociological permutations. Consideration is given to the potential of stewardship for encouraging state decision-making that is both normatively based and economically efficient. Various dilemmas that could impede or preclude such a shift in state behaviour are examined. We conclude that the concept of stewardship holds substantial promise if adequately developed and effectively implemented.
Keywords: public health administration; government; health care rationing; health policy; ethics, institutional; social responsibility.
RÉSUMÉ
Au cours de la dernière décennie, une attention considérable a été portée au rôle de l'Etat dans le secteur de la santé. Presque tous les observateurs pensent qu'il faut réaligner la manière dont est configurée et appliquée l'autorité de l'Etat dans ce secteur de façon à atteindre les objectifs politiques souhaités. Le présent article analyse la proposition avancée dans le Rapport sur la santé dans le monde, 2000, selon laquelle l'administration générale offre une base appropriée à partir de laquelle s'atteler à ces questions.
Les racines de la notion occidentale d'administration générale sont religieuses et on les retrouve dans l'Ancien et le Nouveau Testaments. Dans l'Islam, l'institution de l'Hisba organise les fonctions d'administration publique aussi bien sur le plan moral et normatif qu'administratif et technique. La notion de bonne gestion de l'environnement qui est apparue en Europe du Nord et en Amérique du Nord est directement issue de la tradition religieuse. Toutefois, dans cette version écologique, la notion de responsabilité devant Dieu a été largement remplacée par celle de responsabilité intergénérationnelle.
Le terme d'«administration générale» (ou gestion avisée) appliqué à l'Etat est défini de diverses manières. L'approche la plus élémentaire le définit comme l'exercice désintéressé d'un devoir par les pouvoirs publics et/ou leurs agents au nom d'une instance supérieure. Les définitions plus fines sont axées sur la nature du rapport qui existe entre cette administration avisée et la théorie de la délégation, et sur les conséquences de ce rapport sur l'équilibre entre les formes que peuvent prendre la prise de décision et le comportement, selon qu'ils privilégient l'efficacité ou l'éthique. Kass présente cette administration générale comme étant directement subordonnée au rôle du fonctionnaire en tant qu'agent de cette administration. Chez Armstrong, la définition plus gestionnaire de cette notion est basée sur une interprétation constamment mise à jour de ce qu'est le fonctionnaire, directement liée à deux points essentiels de l'élaboration de l'approche de la gestion des opérations fondée sur les rapports humains: la compréhension de la «hiérarchie fondamentale des besoins humains» qui motive chaque individu et la notion d'approche de la gestion des employés selon la théorie des prémisses décisionnelles (théorie Y). Armstrong prétend que la gestion avisée peut consolider les réformes existantes axées sur le marché dans le cadre d'une élaboration des politiques dictée par des considérations d'ordre éthique.
Les aspects positifs de la bonne gestion sont principalement liés à la possibilité qu'elle offre d'améliorer les résultats des politiques. L'affirmation centrale est que, si l'on peut créer un Etat performant en axant le processus politique sur les relations traditionnelles qui existent entre ses principaux agents, en mettant l'accent sur les aspirations normatives, soucieuses d'éthique d'une gestion avisée, il est possible de créer un Etat qui non seulement soit efficace mais qui aussi uvre pour le bien. Cette administration avisée pourrait dans le meilleur des cas servir de principe d'organisation du pouvoir dans la société, en allant au-delà de la seule vision économique, pour se fonder sur l'intérêt commun. Elle offre aussi la perspective de réinsuffler un certain sens du devoir social chez les administrateurs du secteur public et d'aider à restaurer la confiance dans le rôle de l'Etat et la légitimité de ce dernier.
La bonne administration vise à ressusciter sous une forme moderne l'idée de bien commun, c'est-à-dire d'une série de valeurs collectives. La capacité qu'a cette administration avisée de galvaniser les composantes socialement et économiquement responsables de l'Etat peut être particulièrement appropriée dans le secteur de la santé. Une approche basée sur le développement du bien collectif en matière de santé correspond bien au sentiment d'accomplir une mission qui a traditionnellement été la motivation centrale des dispensateurs de soins de santé. Etant donné son double fondement éthique et économique, une stratégie nationale de la santé basée sur cette gestion avisée permettrait de rassembler les données disponibles sur l'efficacité des interventions pour mettre en uvre, dans la population, des mesures susceptibles d'améliorer l'état de santé général.
Il faudra aplanir plusieurs difficultés d'ordre structurel et organisationnel avant que cette administration avisée puisse être perçue comme un modèle approprié aux décisions que doit prendre l'Etat dans le secteur sanitaire. Une question fondamentale a trait à la transition vers une administration soucieuse d'éthique chez les fonctionnaires des bureaux de l'Etat opérant conformément à la théorie de la délégation centrée sur l'économie. Les commentateurs adressent une mise en garde: il n'est pas possible de combiner l'administration avisée et la théorie classique de la délégation. Se pose également la question complexe du degré approprié d'intervention de l'Etat dans la prise de décision personnelle. Une question d'ordre historique et culturel plus vaste a trait à la capacité des différents types d'Etat à adopter un modèle d'administration avisée.
Sont également présents les dilemmes plus généraux associés à l'aliénation progressive de la souveraineté de l'Etat. On en retrouve un aspect dans les conséquences de la régionalisation et de la mondialisation, qui s'accompagne d'une possible diminution de la capacité des Etats à concevoir et à mettre en uvre les stratégies de réglementation voulues. En outre, on s'inquiète de ce que, dans certains pays en développement et dans les pays en transition de l'ex-Union soviétique, l'Etat n'est pas suffisamment fort pour imposer sa volonté une fois qu'il a adopté une stratégie. Ce problème peut s'avérer particulièrement aigu dans le secteur de la santé.
A l'heure actuelle, aucun pays ne présente un exemple satisfaisant de mise en uvre des principes qui gouvernent la notion d'administration avisée, même s'il en existe des éléments, par exemple dans les systèmes de protection sociale d'Europe du Nord.
RESUMEN
En el último decenio se ha prestado mucha atención a la función del Estado en el sector de la salud. Casi todos los observadores entienden que la configuración y la aplicación de la autoridad del Estado en el sector de la salud deben reajustarse para conseguir los objetivos de política deseados. En el presente artículo se examina la idea presentada en el Informe sobre la salud en el mundo 2000 de que la rectoría ofrece la base apropiada para abordar estos asuntos y reconfigurar la función del Estado en el sector de la salud.
Las raíces del concepto occidental de rectoría son religiosas y se encuentran tanto en el Antiguo como en el Nuevo Testamento. En el Islam, la Hisba organiza las funciones de administración pública en las dimensiones tanto moral/normativa como administrativa/técnica. El concepto de buena gestión ecológica que ha surgido en la Europa septentrional y en América del Norte procede directamente de la tradición religiosa. En esta versión ecológica, empero, la noción de responsabilidad ante Dios ha sido sustituida en gran medida por la de responsabilidad intergeneracional.
El término «rectoría», referido al Estado, se ha definido de diversas maneras conexas. En su definición más general el término alude al cumplimiento desinteresado de un deber por parte de los poderes públicos y/o sus agentes en nombre de un superior. Otras definiciones más rigurosas se centran en la naturaleza de la relación entre la rectoría y la «teoría de la agencia», y en las consecuencias de esta relación en el equilibrio entre la eficiencia y la ética en materia de adopción de decisiones y comportamiento. Kass presenta la rectoría como directamente supeditada a la función del funcionario público como agente. La definición de Armstrong, de corte más gerencial, se basa en una interpretación constantemente actualizada del concepto de funcionario público, vinculada directamente a dos puntos fundamentales de la elaboración del criterio de gestión de las operaciones basada en las relaciones humanas: la comprensión de la «jerarquía básica de las necesidades humanas» que motiva a cada individuo, y la perspectiva de gestión de los empleados según la teoría de las premisas decisionales (teoría Y). Armstrong sostiene que la rectoría puede consolidar las reformas actuales orientadas al mercado en un marco normativo guiado por la ética.
Las dimensiones positivas de la rectoría están predominantemente ligadas a su potencial para mejorar los resultados de política. La afirmación básica es que, si bien se puede crear un Estado eficiente centrando el proceso normativo en las relaciones tradicionales en que intervienen los agentes principales, haciendo hincapié en las expectativas normativas y orientadas por la ética de la rectoría es posible crear un Estado que no sólo sea eficiente, sino bueno. En el mejor de los casos la rectoría podría facilitar un principio de organización del poder en la sociedad que trascendiera lo económico y estuviera basado en el interés común. También ofrece la perspectiva de revigorizar el sentido de finalidad social entre los administradores del sector público, y de restablecer la confianza en la función del Estado y su legitimidad.
La rectoría aspira a recuperar, modernizándola, la idea de bien común, de un conjunto de valores colectivos. La capacidad de la rectoría para galvanizar los componentes social y económicamente responsables del Estado puede resultar particularmente oportuna en el sector de la salud. Un criterio basado en el desarrollo del patrimonio de salud colectivo se compadece bien con la arraigada idea de misión que ha constituido tradicionalmente la motivación central de los prestadores de atención de salud. Dado su doble fundamento en criterios éticos y económicos, una estrategia nacional de salud basada en la rectoría puede reunir los datos disponibles acerca de lo que funciona bien para apoyar medidas basadas en la población que permitan mejorar la situación sanitaria general.
Habrá que resolver diversas cuestiones estructurales y de organización para que la rectoría pueda ser percibida como un modelo apropiado para las decisiones del Estado en el sector de la salud. Una pregunta básica concierne a la transición hacia una administración atenta a la ética entre los funcionarios públicos en las oficinas estatales administradas de acuerdo con la teoría de la agencia orientada hacia la economía. Los analistas advierten de que no es posible mezclar la rectoría con la teoría de la agencia estándar. Por lo demás, no hay que olvidar la complejidad de cualquier intento de determinar la justa medida de intervención del Estado en la adopción de decisiones de carácter personal. Una pregunta más amplia de carácter histórico y cultural guarda relación con la capacidad de los diferentes tipos de Estado para adoptar un modelo de rectoría.
Hay también problemas generales asociados con la reducción gradual de la soberanía del Estado. Un ejemplo de ello son las consecuencias de la regionalización y la mundialización, que entrañan una reducción potencial de la prerrogativa de los Estados de diseñar y aplicar las estrategias de reglamentación que deseen. Además, resulta preocupante que en algunos países en transición de la ex Unión Soviética y en algunos países en desarrollo el Estado no sea lo suficientemente fuerte para imponer su voluntad una vez que ha adoptado una estrategia, lo que puede resultar especialmente grave en el sector de la salud.
Actualmente ningún país ilustra de forma operativa y satisfactoria los principios que fundamenta la rectoría, pero hay elementos de ella, por ejemplo, en los Estados de bienestar de la Europa septentrional.
Introduction
Considerable attention has been focused over the past decade on the role of the state in the health sector. The debate has covered a wide variety of technical and political dimensions, ranging from policy formulation to implementation, from entrepreneurial innovation to regulatory restrictions, from financial efficiency to social equity, and from public to private ownership of institutions. Despite considerable disciplinary and ideological disagreement there has been a common thread of interest in how changes in state behaviour can help to produce better health-related outcomes. Nearly all observers agree that both the configuration and the application of state authority in the health sector should be realigned so as to achieve desired policy objectives.
The intended outcome has strong overtones of a desire for what is frequently termed good governance, which in turn involves policy-making that serves the public interest. Such a new state role conflates institutional process (e.g. efficiency and transparency) with specific substantive outcomes (e.g. health gain and expenditure control). In order to achieve these results the new configuration has to transcend traditional theories on inherent limitations of state organization and behaviour. For instance, it has to transcend Weber's dictum that the only choice in organizing state institutions is between bureaucracy (i.e. a structure of authority based on rules and offices) and dilettantism, unless one reverts to small-scale organization (1). It similarly must transcend the conceptual gauntlet thrown down by Downs (2), Niskanen (3), Buchanan (4) and other public choice economists, who contend that civil servants never serve the state but instead pursue only their own rational self-interest. Furthermore, the new configuration has to accommodate disagreements on whether public officials, acting as agents for the general public, should be delegates or functionaries (5) responding to explicit electoral instructions, or trustees or fiduciaries following their own judgement on the basis of trust given by the people they represent. Most significantly, the newly configured state role should reflect emerging thinking about the importance not only of health care for individuals but also of the need to design and implement mechanisms that can achieve greater health gain among populations (6, 7).
The present paper explores the proposal in The World Health Report 2000 that stewardship is the appropriate basis on which to resolve these dilemmas and reconfigure the role of the state in the health sector. We examine the conceptual character and implications of this proposal. Several alternative definitions for stewardship are set out and contrasted with traditional understandings of how the state exercises power. Consideration is given to the relative strengths and weaknesses of stewardship as the basis for state authority in the health sector, and suggestions are made as to how the discussion on stewardship might be moved forward.
Traditional definitions of stewardship
The Western concept of stewardship has religious roots. In Genesis, God appoints humanity as the steward of creation. The Old Testament also contains the story of Joseph, sold by his brothers into slavery, who becomes Putiphar's and then the Pharaoh's steward. This parable highlights several key aspects of stewardship. Drawing from Joseph's example, a steward is a selfless servant, who manages assets without owning them, anticipates future trends and devises grand plans. In the New Testament the parable of the talents, in which a master divides his goods between his three servants, emphasizes another aspect of the concept of stewardship. The moral of this parable is that when entrusted with something of value one has an obligation to improve it. The notion of stewardship as a responsibility for protecting and developing one's resources lies at the heart of both the Christian and Jewish faiths.
The doctrine of stewardship has also been employed in Christian theology to justify the notion of private property and the class structure. Even at the end of the 19th century the concept was still used in support of the idea that private property was a natural right (8). God appointed each person to fulfil a certain function, for which a certain amount of wealth was required. Accordingly, God placed wealth on earth for humanity to use in order to accomplish its destiny. Acquisition is, therefore, sanctioned by divine law. People are only responsible for dutifully employing their talents.
Other religious traditions contain a similar concept. In Islam the institution of Hisba organizes public administrative functions in both the moral/normative and administrative/technical dimensions. The first Muhtasib, who serves as head of Al Hisba, was appointed in Medina in the 9th century. The functions of the Muhtasib in precolonial Arab societies included the regulation of medical practice and pharmaceuticals and incorporated requirements regarding the equitable provision of services and the public interest (9).
The concept of ecological stewardship that has emerged in northern Europe and North America flows directly from the religious tradition. In the ecological version, however, the notion of accountability to God has been largely replaced by that of intergenerational responsibility. There is, moreover, a debate in the environmental conservation community regarding the exact contribution of the Judaeo-Christian tradition. Some blame this tradition for the damage done to the environment over the centuries, arguing that people have interpreted God's mandate to be the earth's steward as a licence to dominate, exploit and destroy it. The response to this is that, on the contrary, damage has occurred because people disregarded God's recommendations.
State-oriented definitions of stewardship
The potential perceived advantage in applying to government a term used predominantly to characterize the role of authority in religious and environmental spheres reflects the confluence of theory and practice. The theoretical dimension can be seen in the growth of academic efforts to develop a general theory of the state aimed at explaining the behaviour of states (10). The practical input had three aspects: the collapse of the Soviet Union and the need to reconstitute previously communist states; the collapse of government following civil wars in Bosnia, Cambodia, Lebanon, Somalia, Sudan and other countries; and the rise of globalization and the semi-sovereign roles of private transnational corporations. The combined impact of these theoretical and actual events has served to concentrate the attention of academics and international agencies on the importance of well-functioning states in the achievement of social and economic objectives.
The term "stewardship", as it relates to the state, has been defined in various related ways. The definitions reflect concerns similar to those underpinning the compressed language of WHO's World Health Report 2000, which views stewardship as "the effective trusteeship of national health" (11). They all indicate stewardship to be a particular type of governance linked with agency theory and the concomitant role of the state as an agent for its citizens. The most basic approach defines stewardship as "the disinterested performance of a duty by government and/or its agents on behalf of a superior" (12).
More penetrating definitions focus on the relationship between stewardship and agency theory and on the implications for the balance between efficient and ethical forms of decision-making and behaviour. Kass presents stewardship as directly contingent upon the civil servant's role as agent: "the administrator's willingness and ability to earn public trust by being an effective and ethical agent in carrying out the republic's business". Kass reinforces this connection by stating that since stewardship involves acting for someone else in a trustworthy manner it really amounts to being a good agent for the other party. In Kass's view the notions of trust, ethical behaviour and good decision-making are inherent in the concept of stewardship (5).
Armstrong takes a similarly ethical as well as an efficiency-oriented view of stewardship. However, he defines it as broader and more inclusive than traditional agency theory (13). He borrows his definition of stewardship from Block (14): "Stewardship is ... the willingness to be accountable for the well-being of the larger organization by operating in service rather than in control of those around us". Armstrong bases this rather managerial definition on a self-actualizing view of the individual civil servant, linked directly to two seminal points in the development of the human relations approach to organizational management: an understanding of the "basic hierarchy of human needs" which motivates every individual (15), and the concept of a Theory Y approach to managing employees (16). This self-actualizing civil servant, Armstrong argues, is notably different from the administrator of agency theory, who is oriented towards economic efficiency. He cites Davis et al. on this key point (17): "Economic approaches to governance such as agency theory tend to assume some form of Homo economicus, depicting subordinates as individualistic, opportunistic and self-serving ... Sociological and psychological approaches to governance such as stewardship theory depict subordinates as collectivist, pro-organizational and trustworthy".
Armstrong argues that, precisely because it is based more broadly than agency theory, stewardship has the capacity to combine efficient, market-like behaviour with trust-based, ethical forms of decision-making in a way that the narrower, economically based agency theory cannot achieve. He contends that this broader capacity of stewardship enables it to consolidate market-oriented reforms into an ethically driven policy-making framework: "It is a model that appears suited to both the need for efficiency and cost-effectiveness put forth by market-driven reforms and the higher-order tasks and responsibilities that are the calling of public servants". Thus, like Kass, Armstrong ultimately understands stewardship as being capable of bringing together efficiency of organizational operation and ethical, trust-based representation. However, he arrives at this position by opposing stewardship to agency theory (Fig. 1) and focusing more on the personal development of the individual civil servant than on the behaviour of the organization as a whole.
Having examined the conceptual basis for the state acting as steward, we think it useful to consider how this relates to other terms used in discussing the role of the state in setting social policy (18, 19). In many respects, as Kass implies, the notion of stewardship can be viewed as an ethically informed or "good" form of governance. Governance has been defined as having very similar functions to stewardship, i.e. as the traditions and institutions by which authority in a country is exercised for the common good (20).
Stewardship also bears a strong relationship to the concept of regulation (21). The emphasis on trust, legitimacy and pursuit of the common good bears a direct resemblance to Baldwin's first rationale for regulation, which is to serve the public interest (22). Similarly, stewardship appears to be a lineal descendent of the notion of modulation (23), reflecting the latter concept's economic and policy-making authority in the interest of achieving ethically preferable results. Stewardship further seems to be implicitly dependent on the sovereignty of the state as an autonomous source of power (24). However, it moves beyond solely process-based notions of the state as an efficient agent to substantive-based ones in which the state is an ethically motivated representative of the popular will and the common interest.
Lastly, there is the question of how the concept of stewardship relates to the notion of the welfare state. The European welfare state has a strongly normative dimension to its social policies, emphasizing the redistribution of income from better-off to less well-off citizens on the grounds of solidarity and justice (25). In this sense the welfare state has sought to fulfil the ethical component of the "good agent" that Kass and Armstrong seek in the state as steward. However, the traditional welfare state model has differed from the concept of stewardship in the area of economic efficiency, defined either in macroeconomic terms (e.g. national economic growth) or microeconomic terms (efficient administration). Although fierce battles continue to rage over the impact of the welfare state on the growth rate of national economies, most analysts now regard the rigidly technical, expert-driven character of human services in the welfare state as unnecessary and often counterproductive, particularly in the health sector (26). Recent reforms have made some progress towards diminishing the rigidities of services provided by the welfare state. Nevertheless, the welfare state can evidently provide only a partial model for the simultaneously ethical and efficient structure of state authority which stewardship implies.
The various concepts of stewardship discussed above imply it to be a function of governments responsible for the welfare of populations and concerned about the trust and legitimacy with which its activities are viewed by the general public. This raises a question concerning the suggestion in The World Health Report 2000 that stewardship can extend beyond duly constituted national governments to the role of international agencies. International organizations can be appropriately termed stewards only in relation to their role as good agents for national governments, whereby both normative and efficiency- oriented objectives are combined in the expenditure of public monies allocated to the organizations by sovereign states.
It is clear that stewardship can infuse normative, content-oriented values into what remains a set of largely technical, process-oriented institutions. The pursuit of policy-making that is both ethical and efficient distinguishes stewardship from other concepts but it also presents obstacles to the full development of a theory of health sector governance.
The potential of stewardship
The positive dimensions of stewardship are predominantly tied to its potential for improving policy outcomes. The core contention is that while focusing the policy process on traditional principalagent relationships can create an efficient state, it is possible to create a state that is not only efficient but good by emphasizing normative, ethically oriented expectations of stewardship. Stewardship, at its best, could provide an organizing principle for power in society transcending economics to base itself on the common interest. Stewardship also offers the prospect of reinvigorating the sense of social purpose among public sector administrators and of helping to restore a sense of trust and legitimacy to the role of the state.
Stewardship, moreover, unlike some other normatively driven policy processes, appears to be compatible with a broadly pluralist society. A stewardship-based regime could conflict with particular interests of specific groups and generate considerable opposition from them in a pluralist society. However, the stewardship-based approach could also be based on the more fundamental democratic ideals of society as a whole. Underlying pluralism there is a social system and an associational consensus constituting the real principle and interest to be secured by the public agent (5).
In effect, the role of stewardship in a democratic society can be anchored to Rousseau's notion of the general will, which sometimes differs from the electorally expressed will of all (27). Furthermore, this approach suggests the legitimacy of a steward acting as a public agent of the general will, much like Rousseau's legislator, able to make unpopular decisions securing the underlying interests of the citizenry.
More deeply, stewardship attempts to resurrect in modern form the idea of the commons, a collective set of values. In the classical language of political philosophy, stewardship raises the notion of a social contract for reinterpretation in a modern light, and specifically for application in sensitive areas tied to values, such as the health sector. This orientation is not surprising, given the roots of stewardship in what is one of society's most fundamental contracts, that of organized religion. Nor is it surprising as an emerging reaction to the relentlessly atomistic consequences of basing social policy exclusively on narrow notions of individual preference and cost containment associated with the policy hegemony of market-oriented economic theory in the late 20th century. The capacity of stewardship to subsume and incorporate concerns about efficiency into a more socially responsible, normative framework holds out the promise of taming economic theory in a manner that reinvigorates rather than undercuts the broader social contract on which the state is based. This is particularly important for achieving socially desirable outcomes in the health sector, and reflects recent work demonstrating the structural incapacity of economic theory to serve as the basis for normative decisions essential to formulating effective or even efficient health policy (7, 28). In this regard the concept of stewardship also bears a resemblance to the notion of socioeconomics put forward in communitarian theory (29).
The capacity of stewardship to galvanize socially as well as economically responsible dimensions of the state can be particularly appropriate in the health sector. A stewardship approach based in developing the collective health commons fits well with the sense of mission that has traditionally been the central motivation of health care providers. For physicians, this mission-oriented framework lies at the core of the Hippocratic oath. The notion of stewardship, if properly developed, is also consistent with an evidence-based health policy framework. Given its dual grounding in ethical as well as economic criteria, a national health strategy based on stewardship can marshal the available evidence about what works well to support population-based measures that can improve overall health status.
More controversially, stewardship would appear to be consistent with the interventionist role adopted by some European states during the 1990s in designing a publicly accountable hybrid market for certain health care services. Carefully calibrated market mechanisms, variously termed planned markets (26), quasi-markets (30) and managed markets (31), have emerged at the centre of health reform strategies in Sweden, the United Kingdom and other countries. As publicly designed and publicly accountable market instruments these new models harness specific elements of traditional economic incentives to broader social and political values, seeking in particular to maintain equity of access to care while improving the efficiency and effectiveness of service delivery (18). Aspects of these hybrid mechanisms may also be applicable to developing and post-communist countries (32).
One particularly attractive attribute of the stewardship approach may be its capacity to channel emerging systems of integrated care in more socially responsible directions. Stewardship, an explicitly ethically based, outcome-oriented policy approach, is substantially more interventionist than the economically driven agency approach to state regulation which some health economists have proposed. For example, stewardship holds out the possibility of replacing the minimalist notion of economically motivated sponsors (33) with a more activist state that designs the rules of competition in a socially accountable manner. In this sense, stewardship involves an emphasis on good outcomes in the European style rather than a concentration predominantly on transparent processes in the style of the USA. The ability of stewardship to reassert a normative outcome-oriented focus in health sector policy-making through a relegitimized social contract model could conceivably become its greatest contribution to the future role of the state in this sector.
Dilemmas of stewardship
Various structural and organizational issues have to be resolved before stewardship can be perceived as a suitable model for state decisions in the health sector, in addition to the task of transcending the Weberian and public choice hurdles noted above. One basic question concerns making the transition to ethically oriented stewardship among civil servants in state offices run in accordance with economically oriented agency theory. Davis et al. (17) note that, managerially speaking, it is difficult to introduce stewardship into an administrative infrastructure and that successful introduction requires commitment to the new strategy by all affected actors. Furthermore, they warn that it is not possible to mix stewardship with standard agency theory. Armstrong considers that stewards would be betrayed by opportunistic agents and that the resulting tension would push the organization back towards an agency model (13).
A related concern is the type of pressure a state office receives from its superiors in government. If they are exclusively interested in economic efficiency an untenable situation can be expected to arise for civil servants seeking to carry out public service on the basis of stewardship.
There is also the complicated question of the appropriate degree of state intervention in personal decision-making. When does a steward become a nanny? In Sweden there is a debate as to whether the government should submit to pressure from the European Union to abolish the state monopoly on the sale of alcohol. The government argues that tight restrictions in this field have significantly benefited health and that loosening them would have serious social consequences. Swedes who favour easier access to alcohol argue that the state is engaged in an unwanted intrusion into their personal lives.
A broader historical and cultural question concerns the capacity of different types of state to adopt a stewardship model. It may be that certain political, social, economic and/or religious patterns help or hinder the implementation of the stewardship approach. Can a society whose political system emphasizes self-serving interest groups, political coalitions and legislative logrolling become as effective a steward as one that structures its institutions along a corporatist, consensus-oriented approach to policy-making? Can an authoritarian state be a good steward? When does a narrowly theocratic government cross the boundary between stewardship and zealotry?
There are also general dilemmas associated with what can be termed the gradual de-sovereignization of the state. One dimension reflects the consequences of regionalization and globalization, which can potentially diminish the ability of states to design and implement desired regulatory strategies (34, 35). There are also concerns that in some post-Soviet transitional and developing countries the state is not strong enough to impose its will once it has adopted a strategy (36, 37). This problem can be particularly acute in the health sector, where public revenues and providers may be severely constrained, encouraging parallel sources of private funding and service delivery (18). In both developed and developing countries the Internet is breaking down various informational and supply restrictions that states have traditionally imposed upon health sector activities with a view to ensuring care of high quality and reliability.
Ultimately, the most important challenge to those who visualize the potential advantages of a stewardship approach is to implement it in the real world of governance. At present, no country presents a satisfactory operating example of the principles that stewardship implies. There are positive elements of stewardship in the behaviour of certain states, e.g. the welfare states of northern Europe, but one cannot as yet point to a fully fledged embodiment of the stewardship model at national level.
Conclusion
The leap to a stewardship model of making health policy is a complicated exercise in state leadership. As Armstrong says, choosing stewardship is risky and courageous, and if cost-cutting is the only objective the agency model is preferable (13). Thus, while stewardship is potentially a model of governance which can infuse state policy-making and regulatory functions with an explicitly normative dimension, it requires clear and consistent strategic direction. States themselves have to generate this if stewardship is to provide a successful model of health policy-making. 
Acknowledgements
The authors are grateful for valuable comments made by three reviewers and by participants in a seminar during Human Development Week at the Swedish International Development and Cooperation Agency in Stockholm.
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Richard B. Saltman
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