ABSTRACT

This paper presents a comparative analysis of ten selected countries regarding the established relationships of participative governance, socioeconomic profiles, and health care systems with health outcomes and Global Governance Indicators. Significant sources were databases produced or compiled by the World Bank. The analytical model adopts an institutionalist approach to address social protection and participative governance – the latter, as used, recovers notions of societal participation, government porosity, and responsive regulation. Outcomes show a solid convergence of more distributive socioeconomic profiles, more universalist health systems with higher government financing, and better governance indicators. This analysis supports the arguments that socially virtuous institutional paths subjected to positive feedback favor better social and political outcomes over time.

KEYWORDS
Health governance; Health policies; Societal participation

Introduction

This paper studies the relationships between political configurations, governance profiles, socioeconomic characteristics, health financing, and health outcomes. It aims to perform a comparative analysis among ten countries selected from outcomes of governance, socioeconomic profiles, health systems, and health outcomes. To this end, we employed 2019 data on global governance, health financing, and health outcomes. The primary sources were the databases produced or compiled by the World Bank (WB).

Governance results are grounded on aggregated global governance indicators retrieved from several perceptions surveys. The governance concept employed covers political agendas related to social and citizen participation, responsive regulation of collegiate bodies, and factors that induce governmental porosity.

Issues related to social participation and collegiate government bodies are understood on a micro-organizational level as responsive governance mechanisms that attenuate the hierarchical and vertical patterns of the State apparatus and enhance governmental porosity in the development of its policies.

We adopted a premise by which historical processes of democratic, redistributive, and participatory institutions tend to converge and reinforce each other. The traditional parameter is the evolution of the post-war European Welfare State that consolidated protective institutions and virtuous cycles of sustainable social development for several decades¹1 Offe C. Disorganized Capitalism: Contemporary Transformations of Work and Politics. Cambridge: MIT Press; 1985., ²2 Lijphart A. Patterns of Democracy: government forms and performance in thirty-six countries. New Haven: Yale University; 1999.. This trajectory has served as an exemplary political experiment in potential institutional convergence for greater social justice.

The arguments used in this work are based on theories about reiterated institutional paths³3 Pierson P. Politics in time: history, institutions, and social analysis. New Jersey: Princeton University Press; 2004., responsive regulation by participatory collegiate bodies⁴4 Ayres I, Braithwaite J. Responsive Regulation: Transcending the Deregulation Debate Oxford: Oxford University Press; 1992., and social capital formation through long-maturation participatory traditions⁵5 Putnam Robert D. Comunidade e Democracia: a experiência da Itália Moderna. Rio de Janeiro: Editora Fundação Getúlio Vargas; 1996..

Ten countries were selected for the comparative analysis: five South American (Argentina, Brazil, Chile, Colombia, and Uruguay) and five European (Germany, Spain, France, Italy, and the United Kingdom). A typology of health systems is adopted and adapted by the authors from the specialized literature and governance concepts that are equally consolidated.

The premise employed is that sustainable participatory governance mechanisms facilitate the government’s capacity to promote social justice and socioeconomic development. The government’s porosity to the demands and interests of societal players favors the convergence between political systems, socioeconomic characteristics, health outcomes, and the quality of governance in the public sector, which applies to success and failure and is evident from the argument of this work.

Governance and governmental porosity

Current issues about governance and public sector reforms are highlighted by claims for greater porosity of the State apparatus in the face of organized societal demands and affect disputes between political agendas. They reflect ideas about changes in the functions of the State itself. Economic issues with policy impacts involve proposals for property reforms (cycles of privatization of public companies), and fiscal adjustments are not addressed in this paper. On the other hand, organizational themes with relevant political effects traverse:

1. i) Disputes between varying degrees of hierarchical and vertical control versus greater horizontal control and contractualization;

2. ii) Competition for decision-making leadership between experts from the civil service and those external to these careers (advocacy, academics, consultants, and social leaders);

3. iii) Varying degrees of governmental or territorial devolution and decentralization;

4. iv) Induction of civil participation in government decisions in the face of the challenges of decision-making paralysis.

Proposals for changes in governance mechanisms gained momentum in political and academic circles from the 1980s onwards with the spread of New Public Management (NPM). Its criticism and the state of the art of the debate were well established by Hood⁶6 Hood C. A Public Management for all seasons? Public Adm. 1991; 69(1):3-19. and other authors based on accumulated experience⁷7 Pollitt C. Is the Emperor In His Underwear?: An analysis of the impacts of public management reform. Public Management. 2000; 2(2):181-199., ⁸8 Pollitt C, Bouckaert G. A Comparative Analysis: New Public Management, Governance, and the Neo-Weberian State. 3. ed. Oxford University Press; 2011..

The NPM focused on the contractual relationships between public institutions and for-profit or non-profit companies, following the logic of the agency model typical of the institutional economy. It aimed to guide government actions towards regulatory functions of direction and policy induction to the detriment of the direct provision of services. Its effects on the vertical and command and control bureaucracy occurred by encouraging the adoption of specific administrative horizontalization standards, the establishment of participatory collegiate bodies, and the proliferation of regulatory agencies. Several incentives were established for monitoring results in the public administration. Likewise, the adoption of mimicry of successful case management models in private companies was encouraged as an organizational strategy⁶6 Hood C. A Public Management for all seasons? Public Adm. 1991; 69(1):3-19..

This change program combines greater societal activism (advocacy) with open competition for contracts, as seen in several experiments in public-private partnerships.

The institutional economy addresses these issues at the micro-organizational level under the premise that decision-making rationality is limited when it involves interactions of greater technological complexity⁹9 Williamson OE. The mechanisms of governance. New York: Oxford University Press;1996.. The resulting information asymmetry and specificity of the assets in question require adopting adaptable and continuously updated governance mechanisms on a case-by-case basis and by delegation to third parties. More significant underlying conflicts and ambiguity are common in environments where social perceptions and values permeate decision-making processes.

Participatory functions involve responsive regulation mechanisms in which societal stakeholders populate decision-making arenas. Their decision-making processes are slower and can promote barriers to the uptake of public resources by private interests⁴4 Ayres I, Braithwaite J. Responsive Regulation: Transcending the Deregulation Debate Oxford: Oxford University Press; 1992.. Altogether, these arrangements would favor more legitimate and sustainable policy decisions.

The traditional criticism of the proliferation of these delegation mechanisms is inspired by Weber, where the rational-legal bureaucracy implies the legitimacy of governmental decisions made by experts endowed with a public status verified by the formal professional training system¹⁰10 Weber M. Economia e Sociedade: Fundamentos da Sociologia Compreensiva. Brasília, DF: Editora da UNB; 1999. p. 517-580.. This Weberian reference remains relevant in the dispute between normative orientations in public sector reforms. As Peters¹¹11 Peters BG. The two futures of governing: decentering and recentering processes in governing. The J. Pub. Adm. Policy. 2009; 2(1):7-24. points out, everything swings between reforms with a greater or lesser degree of Weberianism.

Two issues deserve special attention. One of them addresses changes for greater sub-national decentralization that reduce central government powers, which can reduce the ability of government officials to coordinate and implement policies for which they have been electorally held accountable. This situation would affect the government’s ability to induce and embed the risk of policy and agency fragmentation and greater veto power in the implementation chain¹¹11 Peters BG. The two futures of governing: decentering and recentering processes in governing. The J. Pub. Adm. Policy. 2009; 2(1):7-24.. Some coordination failures are the proliferation of outsourcing services and the risks to the political authority of governments. Case analyses become crucial as the outcomes vary widely.

Another point concerns governance failures. These arise from ‘noises’ in the decision-making process caused by excessive negotiations and vetoes. Compensation for these failures is sought through meta-governance strategies, such as protocols, parameters, agreements, and analysis of results and performance¹¹11 Peters BG. The two futures of governing: decentering and recentering processes in governing. The J. Pub. Adm. Policy. 2009; 2(1):7-24., ¹²12 Gjaltema J, Biesbroek R, Termeer K. From government to governance…to meta-governance: a systematic literature review. Pub. Manag. Review. 2020; (22):1760-1780.. Jessop¹³13 Jessop B. Governance and Metagovernance: on reflexivity, requisite variety, and requisite irony. Lancaster: Lancaster University; 2003. points out that such mechanisms antagonistic to traditional hierarchies and markets adopt a dialogue-dependent decision-making structure. This organizational mode is reflexive, and the consensus is established by networks of interaction between actors or organizations. As a mediation, political rationality tends to predominate over administrative or economic ones, and territories influence decision-making processes less.

These debates affect different countries per discursive connotations that must be carefully observed. In Brazil, for example, the relationship between social participation and governance has synergies that were strengthened throughout re-democratization from the 1990s onwards with the multiplication of public policy coordination bodies. The tradition of health reform and the political regulations deriving from the new Constitution influenced the participatory culture through public councils that promoted several social protection policies. These processes have been analyzed in the relevant specialized literature on government capacity and equity policies¹⁴14 Carvalho AI. Conselhos de Saúde, Responsabilidade Pública e Cidadania: a Reforma Sanitária como Reforma do Estado. In: Fleury S, organizadora. Saúde e democracia: a luta do Cebes. São Paulo: Lemos Editorial; 1997. p. 93-111., ¹⁵15 Moreira MR, Escorel S. Conselhos Municipais de Saúde do Brasil: um debate sobre a democratização da política de saúde nos vinte anos do SUS. Ciênc. Saúde Colet. 2009; 14(3):795-805., ¹⁶16 Moreira MR. Reflexões sobre democracia deliberativa: contribuições para os conselhos de saúde num contexto de crise política. Saúde debate. 2016; 40(esp):25-38.. As for governance in macro-institutional terms, political reforms in the European and North American contexts influenced the national State Reform agenda. Analyses of Brazilian regulatory agencies in the 1990s¹⁷17 Costa NR, Ribeiro JM, Silva PLB, et al. O desenho institucional da reforma regulatória e as falhas de mercado no setor saúde. Rev. Bras. Adm. Púb. Brasil. 2001; 35(2):193-228. and their longer-lasting effects on local management¹⁸18 Ribeiro JM, Alcoforado F. Mecanismos de governança e o desenho institucional da Secretaria de Saúde do Município do Rio de Janeiro (RJ), Brasil. Ciênc. Saúde Colet. 2016; 21(5):1339-1349. exemplify these trends.

Due to these traditions, in this article, the government porosity concept is adopted in and within the framework of the public sector reforms implemented in Brazil¹⁷17 Costa NR, Ribeiro JM, Silva PLB, et al. O desenho institucional da reforma regulatória e as falhas de mercado no setor saúde. Rev. Bras. Adm. Púb. Brasil. 2001; 35(2):193-228., ¹⁸18 Ribeiro JM, Alcoforado F. Mecanismos de governança e o desenho institucional da Secretaria de Saúde do Município do Rio de Janeiro (RJ), Brasil. Ciênc. Saúde Colet. 2016; 21(5):1339-1349. and adapted, for this study, by approximation with the open government agenda on a global scale¹⁹19 Organização para Economia Cooperação e Desenvolvimento. Open Government: The Global Context and the Way Forward. Paris: OECD Publishing; 2016. [acesso em 2022 abr 25]. Disponível em: http://dx.doi.org/10.1787/9789264268104-en.
http://dx.doi.org/10.1787/9789264268104-... . It translates into the capacity of public institutions, hierarchies, and the civil service to receive, process, and select civil society’s organized demands.

There is a thin dividing line that separates societal intervention in government decisions in favor of its socially distributive functions and the uptake of public funds by interest groups.

Propositions of new governance mechanisms have become more diversified from weakening political projects of retreating from direct state action (retrenchment) and fiercely disputing the political leadership. Public sector reform initiatives driven by global agencies and forums have increased in favor of topics such as citizen participation, public sector transparency, and sustainable development. Several global political and economic coordination committees, such as the European Union (EU) and the Organization for Economic Co-operation and Development (OECD), have disseminated alternatives to the propositions of absolute contraction of the State apparatus in academic, political, and economic environments and participate in this dispute for political leadership.

Governmental porosity converges with such ‘open government’ strategies and the monitoring of their results, and the frequent use of indicators of interactions between governments and societal actors is observed. The OECD defines open government as the result of innovative and sustainable public policies in which the dominant principles are transparency, accountability, and participation oriented towards democracy and inclusive economic growth¹⁹19 Organização para Economia Cooperação e Desenvolvimento. Open Government: The Global Context and the Way Forward. Paris: OECD Publishing; 2016. [acesso em 2022 abr 25]. Disponível em: http://dx.doi.org/10.1787/9789264268104-en.
http://dx.doi.org/10.1787/9789264268104-... .

There is a normative character in these strategies and countries, such as Brazil, which claim full membership of the OECD; for example, they must commit to such reforms aimed at greater citizen participation.

The United Nations (UN) Sustainable Development Goals (SDGs) are a central part of this open government agenda, as is the intensive use of monitoring results. Furthermore, the World Bank’s Global Governance Indicators (GGI) are part of this plan for disseminating ideas and inducing policies.

Implementing participatory governance is part of the premises for the legitimacy of the public sector as a structure for promoting social justice. As such, they are subject to adaptive processes for each country. Although these policies occur under local and unique conditions, reciprocal influences must be considered in analyses of their government policies. This paper aims to identify and analyze these articulations.

Research structure

We employed data produced or compiled by the WB. The health data are from the World Health Organization (WHO) and result from the information provided by national governments, original research, or estimates imputed to historical series. These sources produce objective information, despite restrictions on self-completion by governments and varying consistency by year and case.

The WB uses WHO data and can supplement it with its estimates. We chose to use health data as presented by the WB. The databases were accessed in 2020 and are available at http://info.worldbank.org/governance/wgi/#home.

The sources used for the governance indicators are mainly based on perception surveys and address unobservable factors that vary according to the respondents’ understanding. The methods adopted to prepare the GGIs were detailed by their developers, as were the control of restrictions on perception surveys, the handling of statistical errors, and comparisons between countries and historical series²⁰20 Kaufmann D, Aart Kraay A, Mastruzzi M. The Worldwide Governance Indicators: Methodology and Analytical Issues, World Bank. World Bank Policy Research Working Paper. 2010 [acesso em 2022 abr 25]; (5430). Disponível em: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1682130.
http://papers.ssrn.com/sol3/papers.cfm?a... .

The GGIs are aggregations presented by countries and territories within the WB’s sphere of action. Around 200 cases are observed depending on the year and indicator. We have six governance measures: voice and accountability; political stability; government effectiveness; regulatory quality; the rule of law; and corruption control.

For these measures, governance was defined as the result of traditions and institutions that shape the type of authority exercised in each country, including the process of choosing, monitoring, and replacing governments; government capacity to formulate and implement sound policies; and respect of citizens and the State for the institutions that govern their economic and social interactions²⁰20 Kaufmann D, Aart Kraay A, Mastruzzi M. The Worldwide Governance Indicators: Methodology and Analytical Issues, World Bank. World Bank Policy Research Working Paper. 2010 [acesso em 2022 abr 25]; (5430). Disponível em: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1682130.
http://papers.ssrn.com/sol3/papers.cfm?a... . Thus, the concept is not confused with the contractual notions of institutional economy discussed above⁶6 Hood C. A Public Management for all seasons? Public Adm. 1991; 69(1):3-19., ⁷7 Pollitt C. Is the Emperor In His Underwear?: An analysis of the impacts of public management reform. Public Management. 2000; 2(2):181-199., ⁸8 Pollitt C, Bouckaert G. A Comparative Analysis: New Public Management, Governance, and the Neo-Weberian State. 3. ed. Oxford University Press; 2011., ⁹9 Williamson OE. The mechanisms of governance. New York: Oxford University Press;1996., ¹⁰10 Weber M. Economia e Sociedade: Fundamentos da Sociologia Compreensiva. Brasília, DF: Editora da UNB; 1999. p. 517-580., ¹¹11 Peters BG. The two futures of governing: decentering and recentering processes in governing. The J. Pub. Adm. Policy. 2009; 2(1):7-24., ¹²12 Gjaltema J, Biesbroek R, Termeer K. From government to governance…to meta-governance: a systematic literature review. Pub. Manag. Review. 2020; (22):1760-1780., ¹³13 Jessop B. Governance and Metagovernance: on reflexivity, requisite variety, and requisite irony. Lancaster: Lancaster University; 2003., although it is convergent at the political level.

This model allowed standardizing data from different sources into comparable units, building indicators aggregated by weighted averages of the variables calculated, and defining error margins reflecting the imprecision of generic political perceptions. Overestimating not statistically significant differences is avoided by reporting each standard error and Confidence Interval (CI).

The GGIs were grouped into three blocks: i) social protection (‘voice and transparency’ and ‘government effectiveness’); ii) regulation (‘regulatory quality’ and ‘rule of law’); and iii) insulation (‘corruption control’ and ‘political stability’).

GGIs are calculated from insights into governance that reflect underlying, implicit notions that are hard to measure directly. The argument of its formulators that the method adjusts the variability and generates imperfect proxies on the analyzed themes²⁰20 Kaufmann D, Aart Kraay A, Mastruzzi M. The Worldwide Governance Indicators: Methodology and Analytical Issues, World Bank. World Bank Policy Research Working Paper. 2010 [acesso em 2022 abr 25]; (5430). Disponível em: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1682130.
http://papers.ssrn.com/sol3/papers.cfm?a... is accepted. The unobserved elements (insights) are transformed into objective results. Concerning this paper, validation is also due to these consistent results against other data and configurations analyzed together. Additional consistency is observed when institutional patterns of each country and the results converge at the analytical plane.

Each GGI is presented as a normal distribution unit (−2.5 to +2.5) and in a hierarchy of percentiles (0-100) across all countries. The percentile position (100 is the highest) and country positions for each year and indicator vary with country totals in each situation. Therefore, these positions vary according to data coverage.

The estimate for each indicator is also standardized for the normal distribution, and its standard error indicates its accuracy. Larger standard error values indicate less accurate estimates.

The year 2019 data were employed for ten selected countries, and the rankings in the percentiles are the positions calculated for each universe per the distribution of each indicator. Historical series were not analyzed to avoid more significant cumulative restrictions on errors by countries, although the method admits such a possibility. The policy analysis model follows that of a previous study²¹21 Vaitsman J, Ribeiro JM, Motta JIJ, organizadores. Sistemas híbridos de saúde: uma análise comparada internacional de políticas de proteção e equidade. Rio de Janeiro: Cebes; 2019., ²²22 Ribeiro JM, Vaitsman J, Motta JIJ. Brasil. In: Ribeiro JM, Vaitsman J, Motta JIJ. Sistemas híbridos de saúde: uma análise comparada internacional de políticas de proteção e equidade. Rio de Janeiro: Cebes; 2019. p. 59-110., including the typology of health systems.

The research: political institutions, public governance, and health systems

We adopt the postulate by which political systems that are more porous and open to the participation of groups and individuals in their decision-making processes reduce inequalities and protect social rights¹1 Offe C. Disorganized Capitalism: Contemporary Transformations of Work and Politics. Cambridge: MIT Press; 1985., ²2 Lijphart A. Patterns of Democracy: government forms and performance in thirty-six countries. New Haven: Yale University; 1999., ³3 Pierson P. Politics in time: history, institutions, and social analysis. New Jersey: Princeton University Press; 2004., ⁴4 Ayres I, Braithwaite J. Responsive Regulation: Transcending the Deregulation Debate Oxford: Oxford University Press; 1992., ⁵5 Putnam Robert D. Comunidade e Democracia: a experiência da Itália Moderna. Rio de Janeiro: Editora Fundação Getúlio Vargas; 1996.. We discuss the thesis in which the consolidated feedback and reinforced³3 Pierson P. Politics in time: history, institutions, and social analysis. New Jersey: Princeton University Press; 2004. paths of configurations of political systems, types of health systems, and governance mechanisms subject to the participatory dynamics of consensual democracies tend to produce more favorable results in social protection policies.

The analysis of the health history series was only exploratory (it compared medians of the last ten years). These results (not shown) do not conflict with the picture observed for 2019, but additional studies should be carried out to control their cumulative errors. Regarding this paper, the 2019 results represent a point of arrival for the paths of change.

This sample includes an evident association between per capita Gross National Income (GNI) and the Human Development Index (HDI), as expected by the weight of income in the HDI composition. These data are highlighted separately for analytical support.

The HDI-2019 data were calculated by the UN (https://www.cnedu.pt/content/noticias/internacional/hdr_2019_pt.pdf), and the results are classified in the ‘very high’ strata (greater than or equal to 0.800); ‘high’ (0.700-0.799); ‘medium’ (less than or equal to 0.554); and ‘low’ (0.555-0.699). In this group, Germany, the United Kingdom, France, Italy, Spain, Chile, Argentina, and Uruguay had a ‘very high’ HDI. In turn, Brazil and Colombia had a ‘high’ HDI. South American countries had lower rates than European countries in the stratum of ‘very high’ HDI countries.

The positions in descending order of per capita GNI (current US$, 2019) were: Germany (47,110.00), United Kingdom (41,790.00), France (41,090.00), Italy (33,740.00), Spain (29,300.00), Uruguay (15,650.00), Chile (14,670.00), Argentina (12,390.00), Brazil (9,080.00), and Colombia (6,180.00). Considering the decreasing order of the values of each country for HDI and per capita GNI, we observed high convergence between these hierarchies. This convergence is identified by the high positive correlation coefficient of 0.93. Therefore, this intentional sample behaves in socioeconomic terms per the list presented above.

Regarding the typification of political systems, incremental changes alter their traditional forms over time. Furthermore, country constitutional changes have increased, and certain hybridity requires greater care with generalizations.

An example is the adoption of various mechanisms of political devolution and power decentralization toward the ‘central-local’ direction, affecting countries with more centralized traditions. Mixed (or hybrid) configurations are found in French semi-presidentialism, Spanish (de facto) semi-federalism, and unitary UK devolutions.

The results of the indices of the ‘The Economist’ magazine for 2019²³23 The Economist. Democracy Index 2019: A year of democratic setbacks and popular protest – A report by The Economist Intelligence Unit, London: The Economist Intelligence Unit; 2020. pointed out Germany, Chile, Spain, France, the United Kingdom, and Uruguay as ‘Full Democracy’ countries. On the other hand, Argentina, Brazil, Colombia, and Italy appeared as ‘Imperfect Democracies’.

Countries with better quality democratic systems tend to have health systems more responsive to regional demands from their citizens and civil organizations. Therefore, a better quality of democracy is expected to favor more inclusive policies.

By its very nature, the federative nature can induce greater decentralization in policies. However, there are severe controversies when cases are studied, and their results are compared. Under certain conditions, more centralized institutions produce a more equitable distribution of public resources, which occurs in health policies in which factors such as national coordination and progressive fiscal regimes play an essential role in their configuration.

Poorly regulated decentralized systems can exacerbate regional inequalities due to political power and fiscal capacity differences. In this paper, Germany, Argentina, and Brazil are federative countries. Chile, Spain, France, United Kingdom, Uruguay, Colombia, and Italy are unitary.

Due to their electoral system, parliamentary regimes tend to represent districts and regions better. However, the results can go in opposite directions and depend on factors such as solid bipartisanship and local uptake of public policy resources. Presidential regimes, in turn, can have advantages, such as more direct accountability of rulers and their effects on national policy coordination.

The relationships between the quality of democracy, federative or unitary nature, and parliamentarism or presidentialism are contextual aspects that must be considered in the analysis and argumentation of this paper. There is abundant specialized literature on these topics, and some references are representative¹1 Offe C. Disorganized Capitalism: Contemporary Transformations of Work and Politics. Cambridge: MIT Press; 1985., ²2 Lijphart A. Patterns of Democracy: government forms and performance in thirty-six countries. New Haven: Yale University; 1999., ³3 Pierson P. Politics in time: history, institutions, and social analysis. New Jersey: Princeton University Press; 2004., ⁴4 Ayres I, Braithwaite J. Responsive Regulation: Transcending the Deregulation Debate Oxford: Oxford University Press; 1992., ⁵5 Putnam Robert D. Comunidade e Democracia: a experiência da Itália Moderna. Rio de Janeiro: Editora Fundação Getúlio Vargas; 1996., ⁶6 Hood C. A Public Management for all seasons? Public Adm. 1991; 69(1):3-19., ⁷7 Pollitt C. Is the Emperor In His Underwear?: An analysis of the impacts of public management reform. Public Management. 2000; 2(2):181-199., ⁸8 Pollitt C, Bouckaert G. A Comparative Analysis: New Public Management, Governance, and the Neo-Weberian State. 3. ed. Oxford University Press; 2011., ⁹9 Williamson OE. The mechanisms of governance. New York: Oxford University Press;1996., ¹⁰10 Weber M. Economia e Sociedade: Fundamentos da Sociologia Compreensiva. Brasília, DF: Editora da UNB; 1999. p. 517-580., ¹¹11 Peters BG. The two futures of governing: decentering and recentering processes in governing. The J. Pub. Adm. Policy. 2009; 2(1):7-24.. The restrictions pointed out indicate caution in the search for possible causal relationships.

Box 1 presents the national health systems’ configurations. The classification criteria were established in a previous study²²22 Ribeiro JM, Vaitsman J, Motta JIJ. Brasil. In: Ribeiro JM, Vaitsman J, Motta JIJ. Sistemas híbridos de saúde: uma análise comparada internacional de políticas de proteção e equidade. Rio de Janeiro: Cebes; 2019. p. 59-110. and are summarized below. The health systems’ types vary by combinations of (more or less progressive) fiscal or securitarian (with different subsidies) regimes and different rules for entitlement to rights. These settings tend to stabilize over time or undergo incremental changes. They can be seen as hybrids²⁴24 Schmid A, Cacace M, Götze R, et al. Explaining health care system change: Problem pressure and the emergence of ‘hybrid’ health care systems. J. Health Pol. Policy and Law. 2010; 35(4):455-486. when they preserve the pre-established social contract, but change some essential operational elements.

The configurations in box 1 are linked to data on sectoral financing in table 1. Countries are ranked by patterns of universalization, out-of-pocket expenses, configuration, and type.

The universalization of health systems can be complete or partial and responds to the combined criteria of the share of expenditures by out-of-pocket expenses of individuals with the participation of government health expenditures in the total expenditure of this sector of the economy. The regressive nature of individuals’ direct expenditures and the progressive nature of government expenditures support the arbitrated cutoff points presented in box 1. The out-of-pocket expenditures’ profile (high, relevant, and residual) follows this logic, and its ranges are shown in the captions.

The configuration per the four types of hybrid systems and the two traditional universal systems follows the criteria of the studies mentioned above²²22 Ribeiro JM, Vaitsman J, Motta JIJ. Brasil. In: Ribeiro JM, Vaitsman J, Motta JIJ. Sistemas híbridos de saúde: uma análise comparada internacional de políticas de proteção e equidade. Rio de Janeiro: Cebes; 2019. p. 59-110., ²³23 The Economist. Democracy Index 2019: A year of democratic setbacks and popular protest – A report by The Economist Intelligence Unit, London: The Economist Intelligence Unit; 2020., ²⁴24 Schmid A, Cacace M, Götze R, et al. Explaining health care system change: Problem pressure and the emergence of ‘hybrid’ health care systems. J. Health Pol. Policy and Law. 2010; 35(4):455-486.; the compositions are shown in the captions. Finally, in summary, the type is defined as homogeneous universal (no predominance of hybrids), heterogeneous universal (hybrid with relevance to fiscal financing), and restrictive (hybrid with relevance to private insurance).

In analytical terms, the patterns shown in box 1 are directly related to the results of health and governance indicators discussed below.

Data in table 1 illustrate differences between countries. The share of out-of-pocket expenditures by individuals and households on health against the total sector expenditures is critically essential. It is a regressive expenditure and not subject to the public (tax or social insurance) or private (prepaid plans) smoothing mechanisms (pooling) and strongly indicates catastrophic financial risk. Another variable of interest is the share of public spending by all levels of government against sectoral spending. Due to their fiscal nature, countries with more progressive taxation systems tend to return more distributive health policies.

The more significant share of public expenditure in the GDP protects individuals from out-of-pocket expenditures. These are linear relationships – verifiable in historical series – that accompany the greater availability of resources (beds and doctors) and the best health outcomes (infant and maternal mortality and life expectancy).

According to table 1, sorted by the highest government weight to health to the lowest, health outcomes accompany more equitable financing and the GNI and HDI results. Tables 2 to 4 show that this is valid for governance indicators.

Table 2 addresses the social protection environment of these countries. ‘Government Effectiveness’ measures perceptions about the quality of civil service and public services, their independence from political pressures, the quality of public policies, and confidence in the commitment of governments. ‘Voice and Transparency’ measures the ability of citizens to participate in the choice of governments and enjoy political and associative freedoms. This national environment favors the participation of citizens and groups, the emergence of coalitions to defend interests, and the existence of collegiate bodies typical of consensual democracy through which conflicts and competition for ideas, values, and policy alternatives flow.

Social protection is favored by the effectiveness of governments and political vocalization. The public nature of this participatory environment refers to traditional notions of social capital and impacts on the quality of government⁵5 Putnam Robert D. Comunidade e Democracia: a experiência da Itália Moderna. Rio de Janeiro: Editora Fundação Getúlio Vargas; 1996.. It is consistent with the Welfare State ideology portrayed in exemplary analyses¹1 Offe C. Disorganized Capitalism: Contemporary Transformations of Work and Politics. Cambridge: MIT Press; 1985., ²2 Lijphart A. Patterns of Democracy: government forms and performance in thirty-six countries. New Haven: Yale University; 1999.. They are pillars of the post-war welfare state and its neo-corporate arrangements, reflected in redistributive policies, social minimums, and work and income protection.

We highlight the lowest government effectiveness in Argentina and Brazil according to estimates and percentile classifications (90% CI). Colombia and Italy also have comparatively lower estimates. The higher standard error in European countries may explain the borderline position of Italy and its overlap with those of lower estimates and those of Chile and Uruguay with those of higher estimates.

For the positions in the percentile, a cutoff point was set at 80.00, with the division into Group A (upper) and Group B (lower). This criterion was applied to all GGIs.

Regarding ‘Government Effectiveness’, Argentina, Brazil, Colombia, and Italy were in Group B. In ‘Voice and Transparency’, Group B was restricted to Argentina, Brazil, and Colombia. Therefore, Chile, France, Germany, Spain, the United Kingdom, and Uruguay ranked higher in the percentile for the indicators in this social protection block.

Table 3 addresses public regulation indicators. The ‘Rule of Law’ measures perceptions of trust and adherence to rules such as enforcing contracts, property rights, the functioning of the police and judiciary, and the likelihood of exposure to crime and violence. ‘Regulatory Quality’ measures the government’s ability to formulate and implement sound policies favoring private sector development in adequately regulated markets.

The ‘Rule of Law’ includes elements sensitive to the presence of more significant social capital. It reflects the trust between public and private stakeholders and the contractual guarantees enjoyed by more democratic societies. They have privileged Enlightenment dimensions of political liberalism since its emergence in the 18^th century and matured in the social contracts typical of the 20^th century. These are classic functions of the modern State as a guarantor of contracts, territorial defense, and a monopoly on using force and legitimate coercion. It presupposes institutionalizing social conflicts.

Estimates regarding the ‘Rule of Law’ vary the most. The percentiles indicate more positive perceptions for Chile, France, Germany, Spain, and the United Kingdom. Lower estimates were observed for Argentina, Brazil, Colombia, Italy, and Uruguay. As this indicator deals directly with guarantees of political and economic rights, the negative numbers in Argentina, Brazil, and Colombia are noteworthy. As for the ‘Regulatory Quality’, the pessimistic estimates are restricted to Argentina and Brazil. Concerning the previous indicator, the difference was the inclusion of Italy, one of the commuting countries, in Group A.

In table 4, the indicators measure the insulation of the State apparatus. ‘Political stability’ measures perceptions about the possibility of politically motivated crisis or violence. Insulation presupposes protected public bureaucracies and sustainable rules of government succession. They reflect the capacity to manage extra-institutional conflicts. ‘Corruption Control’ addresses the ability of the public power to exercise control over the gains arising from corruption at the micro-organizational level up to the institutional uptake of the State by elites and private interests.

The lower ‘Political Stability’ reflects the greater fragility of the central government in controlling territories. These results are the lowest among the measures analyzed. Only Uruguay exceeds the set threshold of 80% (with 86.19). Germany is in Group A (66.67) due to flexible CI. These estimates are directly comparable due to the same standard error.

The results of state insulation show that the challenges of political stability and control of violence are the most significant in terms of governance. In this sense, the turmoil and political uncertainties of the 21^st century on the European continent narrow the gaps between these countries and South America. However, Brazil and Colombia continue to stand out for their worst results.

‘Corruption Control’ is a constant topic on the political agenda, and the uptake of the State by private interests is part of the traditional critique of capitalism. In current terms, it involves the legitimacy of defending the role of the State in social and economic development and confronting the theses of a minimal State.

Government uptake by market elites and their penetration into public bureaucracy compete directly with formal and legitimate mechanisms of social participation and are more focused on responsive regulatory mechanisms. According to Putnam⁵5 Putnam Robert D. Comunidade e Democracia: a experiência da Itália Moderna. Rio de Janeiro: Editora Fundação Getúlio Vargas; 1996., in his study of the regions of Italy, clientelism thrives with lower civic community levels.

Higher corruption control estimates are expected to reflect participatory dynamics that weaken veto structures promoted by the action of private interests in the State Apparatus. Group A includes Chile, France, Germany, the United Kingdom, and Uruguay. The other countries are in Group B, and pessimistic estimates are restricted to Argentina, Brazil, and Colombia.

Final considerations

Historical institutionalism³3 Pierson P. Politics in time: history, institutions, and social analysis. New Jersey: Princeton University Press; 2004. highlights the influence of changing paths in institutions that delimit and affect decisions as they consolidate. Stakeholders’ decisions tend to become embedded and dependent on these paths. Interrupted, vetoed, or altered courses also underpin the typical institutional analysis framework. Reinforced paths do not, of course, imply virtuous outcomes.

The argument developed in this paper adopted the premise that the institutional arrangements analyzed influenced allocative decisions from long consolidation periods. This way, profiles do not result exclusively from open games of subsequent interactions.

The dominant institutional characteristics in each country and their results in governance, socioeconomic development, and health policies converge. The countries with the highest government participation in health financing had the best health outcomes and the lowest household financial risk. Likewise, these countries showed better GGIs and had higher HDI and GNI. The detailed study of causal relationships that would require the analysis of time series was not the object of this stage.

There is, however, an evident association between social protection policies, government capacity, the porosity of the State apparatus, and greater openness to societal intervention in public decisions. This set of regularities allows us to point out three types of results: ‘more favorable’, ‘commuting’, and ‘less favorable’.

The countries with the ‘most favorable’ results were Germany, France, and the United Kingdom, with high HDI and per capita GNI of high-income countries. Their health systems are universal and homogeneous, and out-of-pocket health expenditures are residual. Public and total health expenditures are among the highest. Their health outcomes are among the best, as is the availability of care resources. All are in the best GGI group. These countries have had institutionalized and consolidated protection systems for several decades. Socioeconomic and governance indicators work as social protection factors. Thus, they represent a benchmark in this paper.

The countries with intermediate results – Chile, Spain, Uruguay, and Italy – show a commuting behavior per the institutional configuration and the social and governance results. These countries are closer to the reference countries concerning GGI, and gaps are more visible in the socioeconomic and health indicators.

These ‘commuting’ countries have high HDI and high-income country GNI. Only Uruguay reveals complete universalization and residual out-of-pocket expenditures. Spain and Italy have complete universalization, but direct out-of-pocket expenditures are relevant. In Chile, universalization is only partial, and out-of-pocket expenditures are high. Spain, Uruguay, and Italy have universal health systems, albeit heterogeneous, and Chile shows a restrictive system. Public health expenditures in Spain, Uruguay, and Italy are close to the highest, and those in Chile are among the lowest.

As for the size of the health sector economy, they are more in line with OECD means. Health outcomes are favorable in all of them, and Italy and Spain rank among the best. Chile’s health resources, while smaller, are adequate to international standards. They are pretty favorable for Spain, Uruguay, and Italy.

Regarding the GGIs, the least favorable position is Italy, with four indicators in Group B. The others are in Group A. The exceptions were Chile (‘Political Stability’), Spain (‘Political stability’ and ‘Corruption Control’), and Uruguay (‘Regulatory Quality’ and ‘Rule of Law’).

In the case of countries with ‘less favorable’ results, which are very distant from the main ones in terms of governance, there is a significant difference in Argentina, where the health and social results are the best in this group.

Argentina, Brazil, and Colombia are upper-middle-income GNI countries. Brazil and Colombia have the lowest HDI in the sample, and Argentina’s is high.

Argentina’s health characteristics are better. Its health system is universal, albeit heterogeneous, due to the strong stratification of social insurance. This arrangement protects residual out-of-pocket expenditures. Public sector health expenditures are intermediate, and sector funding approaches OECD means. Health outcomes are better than in Brazil and Colombia, although the high Maternal Mortality Ratio is negatively contrasting. Health resources are high.

Unlike Argentina, Brazil and Colombia have more negative features. In Brazil, universalization is partial, and in Colombia, it is complete, despite the stratification of access by subsystems. This factor is related to out-of-pocket expenditures being high in Brazil and residual in Colombia.

Both countries have restrictive-type systems; that of Brazil, due to the dysfunctional cohabitation between private insurance, inadequate fiscal financing, and competitive federalism; that of Colombia, due to the type of mix between fiscal financing and social and private insurance promoted by its sectoral reform. Public expenditures in Brazil and Colombia are among the lowest, although the size of the health sector economy in Brazil is large and in line with that of Europeans. Brazil and Colombia’s health outcomes are the most unfavorable. The exception is the higher Life Expectancy at Birth in Colombia. As for health resources, they are among the most limited and are aligned with Chile.

For all GGIs, Argentina, Brazil, and Colombia are in the group with the lowest estimates. Germany was the only country to rank higher on all six measurements. When political stability is ruled out, France and the UK partner in governance.

Argentina, Brazil, and Colombia were in all measurements below the 80^th percentile, although these percentiles often exceed half of all nations included in the global base of two hundred.

This paper highlights the strength of the traditional theses of historical institutionalism as valuable tools for analyzing public policies. The analysis of causal relationships is the necessary development for this study.

References

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