DOI: 10.1002/epa2.

1108

ORIGINAL ARTICLE

The (mis)fit of policy programs to political

institutions and its influence on programmatic
action – How crisis has differently hit French and
German health policy

Johanna Hornung

Comparative Politics and Public Policy, TU

Braunschweig, Braunschweig, Germany
Correspondence
Johanna Hornung, Comparative Politics
and Public Policy, TU Braunschweig,
Braunschweig, Germany.
Email: j.hornung@tu-braunschweig.de
Websites: www.tu-braun​schwe​ig.de/coppp,
https://www.faceb​ook.com/Compa​rativ​
ePoli​ticsa​ndPub​licPo​licy, https://twitt​
er.com/CoPPP_BS
Funding information
The author thanks Deutsche
Forschungsgemeinschaft (DFG BA 1912/3-
1) and Agence Nationale de la Recherche
(ANR-17-FRAL-0008-01) for funding
ProAcTA (Programmatic Action in Times
of Austerity: Competition between elites
in the health sector in France, Germany,
United Kingdom (England) and the US
(2008–2018).
Abstract
The Programmatic Action Framework (PAF) is a relatively
new theoretical perspective that adds a complementary lens
to the explanation of policy processes and policy change.
Yet, a key requirement of a valid policy process framework
is its capacity to be proven wrong. Besides the empirical
cases that provide evidence for the occurrence of program-
matic action, it is necessary to present examples in which
programmatic action did not occur, and to explain why this
is the case. Proceeding from the observation that program-
matic groups and policy programs existed in French and
German health policy throughout the 1990s, this contribu-
tion answers the question why in 2020, programmatic action
is still present in France but not in Germany and why the
German policy program did not survive the financial cri-
sis of 2008. It argues that misfit to pre-existing institutional
logics and changing institutional logics in the course of pro-
grammatic action hinder program success.

KEYWORDS
austerity, health policy, policy success, policy-making in times of
crisis, Programmatic Action Framework

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are
made.
© 2021 The Authors. European Policy Analysis published by Wiley Periodicals LLC on behalf of Policy Studies Organization.

120   | wileyonlinelibrary.com/journal/epa2
 Eur Policy Anal. 2021;7(Suppl. 1):120–138.
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1  |   IN T RO D U C T ION
The Programmatic Action Framework (PAF) explains policy stability and change by focusing on bi-
ographical intersections that form the basis for social groups – programmatic groups – that jointly pro-
mote their policy program throughout the policy process and transform it into policies. Studies have
identified the existence of programmatic groups in French defense policy (Faure, 2020; Genieys, 2010)
and the health care systems of France, Germany, Spain, and the USA (Hassenteufel et  al.,  2010).
While evidence confirms the occurrence of programmatic action in French and German health policy
within a similar period of time alike (Genieys & Hassenteufel, 2015; Hornung & Bandelow, 2020),
recent research shows that as opposed to France, the phase of programmatic action in German health
policy seems to have ended (Bandelow & Hornung, 2020). The question is, what explains these diver-
gent pathways of previously existent programmatic action in the two countries?
This question becomes even more relevant in light of the observation that the financial cri-
sis in 2008/2009, predestined to provide the opportunity for policy solutions to match the arising
problems, marked the beginning of the end of the German policy program. At a time when policy
programs could have focused on new challenges and problems, the German program did not sur-
vive. Why is there no programmatic action in Germany, at a time when policy solutions are deeply
needed?
Answering this question, this contribution draws on the program-related hypotheses of the PAF
and identifies the driving factors that explain the continuation or end of the respective policy program
in the French and German case of health policy. In doing so, it investigates the characteristics that
make a policy program fail or succeed in the long-term. The article argues that the coherence of the
policy program, its ability to address and adapt to emerging challenges, and its narrative fit to the
national mood have been moderated by the institutional design of policy-making. In Germany, the
increasing role of coalition negotiations between political instead of administrative actors constrains
the possibility to react to short-term challenges and strengthens the role of political instead of sectoral
actors. Furthermore, the policy program did not correspond to the institutional logics of the health
care system to begin with. By contrast, the institutions in the French political system are stable, and
the policy program followed the usual French hierarchical governance mechanism. Empirical evi-
dence for this postulation is provided by a total of 31 interviews with French and German key actors
who were or still are members of the programmatic groups.
The article begins by reviewing the program-related hypotheses of the PAF against the backdrop
of the role of institutions. To do so, Section 2 outlines the added value of the PAF by embedding it in
existing research on policy change and stability. With an explicit focus on institutional approaches,
hypotheses are deductively derived from the literature on policy instrument mixes, problem pressure,
and narrative approaches. Subsequently, Section 3 presents the methodological procedure, followed
by the empirical analysis in Section 4 and the discussion of results in Section 5. Section 6 concludes
with the added value of this contribution to the development of the PAF.

2  |   P RO G R A MMAT IC AC T IO N AND THE SUCCESS

FAC TO R S O F P O L IC Y P RO G R A MS

The Programmatic Action Framework (PAF) provides an explanation for policy change and stability
that relies on the assumption that policy actors form social groups on the basis of biographical inter-
sections and use policy programs to push themselves as a group in their careers and in their normative
desire to shape policy sectors in a certain substantial direction (Bandelow et al., 2020; Hassenteufel
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& Genieys, 2020). Thereby, the key characteristics of this programmatic group are the attachment
to a policy program and the subjective identification (Hornung et al., 2019) with the group and the
program. As opposed to the Advocacy Coalition Framework (ACF), according to which policy actors
engage in collective action on the basis of shared policy core beliefs and encompass a variety of policy
elite actors, from politicians to journalists (Weible et al., 2019), programmatic actors coalesce as a
result of shared biographies and consist of actors directly involved in decision-making processes. It
is argued that programmatic action, defined as the instance of policy change as a result of a program-
matic group transforming its policy program into law, is more likely in sectors close to the state. These
encompass a large bureaucratic apparatus and power positions that serve as incentives for program-
matic actors, given that they ensure the exertion of authority once occupied and a significant number
of resources at the individual's command.
Originating from observations of French public policy (Genieys & Hassenteufel, 2001), the idea
of programmatic groups has grown and, after application to other empirical examples, been system-
atized both theoretically and empirically with a set of hypotheses and a standard empirical procedure
to analyze programmatic action (Bandelow et al., 2020; Hassenteufel & Genieys, 2020). While the
hypotheses have been derived from empirics and possess a theoretical groundwork, they can be further
connected to the state of the art on policy analysis and the role that institutions play in program devel-
opment and adoption. This is ever more relevant as the influence of institutions on the shape of pro-
grammatic groups has been discussed already in research by Hassenteufel et al. (2010), who trace the
existence of programmatic elites to the French education system and account for the German political
system by labeling the programmatic group a programmatic coalition. To assess the interdependent
influence of political institutions and policy programs, it is sensible to incorporate insight from the
literature on policies and institutions into the PAF's hypotheses that relate program characteristics to
policy program success.
Although this process is informed by the research on political institutions, and although the PAF
borrows some of its arguments from the literature on path dependency, it still presents a distinct logic.
While historical institutionalists and scholars of path dependence are more often concerned with the
question of what hinders policy change (Pierson, 1993), the PAF is seeking factors that enable policy
change. Especially in health policy, path dependence has explained much of the inability to achieve
major changes (Brown, 2010; Steinmo & Watts, 1995). Recent developments in institutionalist per-
spectives increasingly focus on how ideas and agency produce critical junctures that enable substantial
policy change (Hogan, 2019). The PAF is an actor-centered perspective on policy change that takes
from this perspective the assumption that institutions evolve and manifest themselves (Thelen, 2003),
which can be a strength to programmatic groups when they achieve to sustain their policy program.
A different perspective to institutional change is provided by institutional isomorphism that sup-
poses the change of institutional structures as a result of force, imitation, or the creation of knowl-
edge foundation around groups, instead of the search for efficient structures in a competitive setting
(DiMaggio & Powell, 1983). Reviewing the application of this perspectives to explain policy change,
van der Heijden and Kuhlmann (2018) find that the latter form of normative isomorphism, during
which an organization transforms and homogenizes due to the professionalization of staff, is the least
observed empirically in the literature on policy change – although it is unclear whether this is due to
the low interest in this form or the lack of evidence. While the PAF also takes a look at the recruitment
of personnel as one aspect of biographical trajectories, its focus is much less on organizations and the
economy, but on state agencies and state apparatuses and the actors occupying these positions. In that,
it assumes that policy actors come together around policy programs and pursue these programs in key
decision-making positions with the aim of fostering their careers and normative implications. If they
achieve this goal, they can be credited with success.
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Before focusing further on the drivers of policy program success, it is necessary to provide an
operationalizable definition. Research in public policy presents a range of explanations why pol-
icies fail or succeed. However, the definitions of policy success and policy failure often recur to
normative questions of whether the policies adopted led to an improvement in outcomes. Marsh and
McConnell (2010) distinguish between three dimensions of policy success, whereby the evaluative
assessment of whether a policy has met its previously defined objective is termed programmatic
success, and another concerns the consequences of a policy for the government. The third dimen-
sion, which is furthermore the most relevant to the PAF is that of process success, which describes
the successful adoption of a proposed policy. Posing the question of who should benefit when a
policy program is successful, and drawing on the work by McConnell et al. (2020), one can assert
that a policy program is equitable with the increase of power for the programmatic group in the
sense of their accomplishment in policy processes, rather than a substantial improvement of the
situation of others.
In order to explain such a successful adoption of not just a policy but a policy program, the PAF
formulates a set of actor-related and program-related hypotheses. Programmatic action designates the
observation that a group of policy actors joins on the basis of biographical intersections and success-
fully promotes a joint policy program over at least a decade. In doing so, the PAF provides a novel
lens on policy change by explaining a directional change over a long period of time by a nameable
policy program promoted by a programmatic group in the struggle over authority. This contribution
intentionally focuses on the program-related characteristics to explain the existence and non-existence
of programmatic action and to test the formulated hypotheses. It furthermore assesses in what way
institutional settings moderate the effect of program-related characteristics on policy program success,
thereby essentially contributing to the question under which conditions policy programs live on and
enable long-term directional policy change.

2.1  |  The content of policy programs

In the original version of the PAF, the Program Coherence Hypothesis states that policy programs
once enacted are more successful if the program is coherent. Beginning with the literature on policy
instruments and policy mixes, policy design research not just points to the importance of coherence
of policy instrument mixes (Howlett & Rayner, 2017), which predominantly concerns the question
whether the policy objectives and measures align with each other, but also emphasizes the congru-
ence of instruments with existing institutional structures for a successful policy (program) design.
Put differently, “assessing the reasons for instrument choice in any policy area requires a multivari-
ate explanation since actors exist within an institutional structure in which the nature and types of
resources they possess and the level of overall government capacity are crucial factors affecting
policy decisions and actions.” (Howlett, 2009, p. 84). From an institutional point of view, the ad-
dition of new “layers” of policy instruments to existing structures of regulation must observe the
agencies already in place to not produce incompatibilities between policies and institutional struc-
tures (Edmondson et al., 2019, p. 4). At the same time, the creation of new institutions may help
to implement policies and shield the new governance arrangements from alteration through other
actors (Béland et al., 2020). This has been integrated in the PAF as a Program Institutionalization
Hypothesis (Bandelow & Hornung, 2020).
Integrating the institutional dimension of policy program design, one can add the Program
Congruence Hypothesis postulating that policy programs are more successful if they are con-
gruent with the existing institutional arrangement of the policy sector and the political system.
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This wording is inspired by existing research, although there remains some terminological con-
fusion when congruence and coherence are used synonymously (Lenz & Glückler, 2020; Rodrigo
et  al.,  2009). Congruence means the extent to which an adopted policy fits the existing mode
of governance. Coherence concerns purely the policy adopted and assesses whether the policy
instruments is coherent with the defined problem to which it is to present the solution, and with
the policy goal to be attained. The later empirical analysis uses illustrative evidence to test both
hypotheses. Nevertheless, the concepts are volatile insofar as the institutional settings may change
and a policy once congruent may alienate the existing setting if it changes. In a similar vein, the
policy itself can alter existing institutional settings. However, the better a designed policy fits the
original logics of a governance arrangement, the more likely will it be successful in acquiring the
envisaged objectives.

2.2  |  The flexibility of policy programs

In the naïve understanding of policies as solutions to problems and challenges, a successful policy
program can be referred to as a policy program that is able to provide answers to pressing regula-
tive questions in a given policy sector. The PAF terms this the Program Responsiveness Hypothesis,
which sees the program's capacity to address existent and emerging challenges and use them for
its own sake as a factor of programmatic success. Other research strands designate such explana-
tions of policy changes differently, for example with reference to policy-making in times of crisis
(Savage, 2019; Steinebach et al., 2019; Wenzelburger et al., 2019) or as a reaction to problem pres-
sure, for example rising health care expenditures and the lack of efficiency (Schmid et  al.,  2010;
Weinstein & Skinner, 2010).
Given that future challenges cannot be anticipated correctly and thus underlie great uncertainty, a
policy program's success can also be considered as dependent on its ability to adapt to new situations,
and to solve upcoming problems in an at least apparently functional way, even if the proposed policy
does not exactly fit the identified challenges (Hannah, 2018). Only recently, the COVID-19 pandemic
has outlined the importance of health policy responses within the established structures of the health
care structures and political system (Petridou, 2020; Sager & Mavrot, 2020; Weible et al., 2020). Put
in a hypothesis, one would assume that a policy program is more successful if it is able to adapt to
new challenges.
The role of institutions can be considered only as marginal here. External problem pressure does
not stop at institutions, nor do new challenges interest themselves for institutional structures that they
encounter. Nevertheless, it might be the case that there are institutional structures designed as early
warning systems that ensure a fast recognition and help to deal with emerging challenges. Such struc-
tures would facilitate a policy program's ability to react to such challenges.

2.3  |  The communication of policy programs

Besides the content of the policy program, and related to the flexibility of a policy program, a third
and final predisposition for programmatic success lies in the communication and narrative packag-
ing of the proposed reforms. In the view of the PAF, the Program Fit Hypothesis states that a policy
program is more likely to persist and be successful if it provides a narrative that fits into and is respon-
sive to the dominant national mood. Narrative approaches have gained evermore prominence in the
analysis of public policies (Shanahan et al., 2017). Any content can be framed according to a narrative
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that presents the potential to overcome or actively exploit the knowledge and empathetic fallacies of
recipients (Crow & Jones, 2018), to persuade actors independent of the exact content and the actual
problem-solving capacity of a policy.
As such, it is important to take into account the national mood when communicating reform pro-
grams. The concept of national mood is also inherent in the MSF, which in this context describes
the public's stance on certain issues. Similar to the research on the NPF, MSF scholars have pointed
towards the ability of leaders not only to use the national mood for the promotion of their policy
proposal, but also to frame the mood in order to fit it with a policy proposal, by making use of public
opinion polls, the media, and activist groups (Zahariadis, 2015, p. 468). With regard to institutions,
MSF research emphasizes how political parties may take up the national mood, which may be visible
through strong interest groups and protest, or act against it out of partisan interests (seeking office
and votes) (Herweg et al., 2015). The role of political parties and interest groups and their respective
embeddedness in the political system appears as a relevant factor for the way in which national mood
influences the narrative fit of a policy program. Institutional settings may furthermore moderate the
need for responsiveness to the national mood, depending on whether policy actors can make use of
blame avoidance strategies (Zohlnhöfer et al., 2016).
Inspired by the literature review, institutions can be expected to play an important role here:
Depending on the extent to which actors claiming to present the public climate with respect to the
reform proposal formally participate in the policy-making process, be it through party democracy
(Karremans & Lefkofridi,  2020) or corporatist structures (Godt,  1987), the policy program must
be able to provide an anchor for identification for actors that appear as relevant in these structures
(Program Connectivity Hypothesis).
Building on these theoretical considerations, Figure 1 presents the theoretical model to be tested
empirically with regard to the examples of programmatic action in French and German health policy,
and the observation that in German health policy, the policy program did not survive the financial
crisis, which would have required a stable and strong policy program to address arising challenges.
Besides the direct effect of the single explanatory factors on policy program success, the following
empirical analysis will shed light on the political institutions and their independent dynamics with the
formulated hypotheses.

F I G U R E 1   Theoretical model and hypotheses explaining policy program success

Source: Explanatory factors taken from Bandelow et al. (2020) and theoretically further elaborated; own illustration
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3  |   M ET H OD O LO G ICA L A P P ROACH: INVESTIGATING

PO L IC Y P RO GR A MS ' S U C C E SS AND FAILURE

To test the theoretically derived hypotheses and the theoretical model, the empirical study turns to
a comparison of French and German health policy. The case selection is based on three premises.
First, there is the empirical phenomenon that there has been programmatic action in both French and
German health policy, but there is none anymore in German health policy. This circumstance will
be illustrated in more detail in the case studies. Secondly, France and Germany present two distinct
political systems with different roles of partisan competition and even though the health care sys-
tem is Bismarckian with contribution-based insurance systems, the sectoral actors (sickness funds,
physicians' associations) differ in the extent to which they are incorporated in the decision-making
processes of public policy. As a consequence, a comparison of these two cases provides the possibil-
ity to assess the effect that different institutions have on the shape of policy programs and the way
in which the program-related characteristics impact the programs' success. Thirdly, apart from these
differences, all other conditions are constant or change equally, such as the political orientation of
governments, the general organization of health care and the relation between ambulatory and station-
ary care.
The empirical study therefore proceeds in two steps: The first step reviews the programmatic action
that has occurred in French and German health policy, intentionally not with respect to the program-
matic actors but in regard to the policy program and its characteristics. It looks at the phases in which
programmatic action existed, namely in France between 1981 and 2020 and in Germany between 1990
and 2010, and at the phase in which programmatic action cannot be observed, namely in Germany be-
tween 2011 and 2020. Against this backdrop, the empirical study tests the program-related hypotheses
regarding the effect of program characteristics on policy program success and traces their explanatory
power to the institutional settings existent in the two institutionally different countries. The selection
of health policies to determine programmatic action bases deductively on a review of major health
reforms, and inductively on the expert interviews.
Methodologically, the three driving forces identified in the theoretical part with each two explana-
tory conditions serve as analytical scheme to assess the conditions under which programmatic action
took place or not. A table visualizes the identified conditions and in what way they lead to the non-ex-
istence or existence of programmatic action to heuristically compare the very small N of only four
cases. Based on the flow diagram presented in Figure 1, the analytical scheme that will later be applied
in the detailed case studies of French and German programmatic action in health policy consists of
a total of six conditions which are coded as present or absent. The moderating effect of institutions
particularly within the context of the conditions of congruence and connectivity is later discussed in
the qualitative analyses of the interviews.
Step two, that is Section 5, discusses the empirical results, in detail the factors that resulted in
the end of programmatic action in German health policy. It does so by discussing the presence or
absence of conditions according to Figure 1 in the cases under study, and their respective relevance to
the outcome of programmatic action. For both purposes, documents, literature, and 31 expert inter-
views with health policy actors and programmatic actors are analyzed to shed light on the aspects of
program coherence, problem pressure, and partisan competition. The interviews were conducted be-
tween November 2018 and January 2020. Only six interviews are quoted in this analysis; this is done
anonymously only with reference to the function of the interviewee to guarantee the confidentiality
of statements.
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4  |   P RO G R A MMAT IC AC T IO N IN FRENCH AND GERM AN

H EA LT H P O L IC Y

Reviewing the state of the art has resulted in three perspectives, each of which provides two general
hypotheses that link the program characteristics, and the institutional environment in which these
characteristics present themselves, to policy program success. Figure 1 has visualized these conditions
and presents the analytical scheme according to which the empirical cases are to be tested. The analy-
sis is supposed to shed light on the way in which these factors explain why there is still programmatic
action in French but not in German health policy.

4.1  |  Coherence and congruence of policy programs

In French health policy, the policy program that was developed at the beginning of the 1980s was pre-
dominantly designed to answer the challenges of rising health care expenditures. Following the failure
of the measures to decrease health care costs, the program tried to contain health care spending by
introducing parliamentary oversight over expenditures. More concretely, the Plan Juppé in 1995 man-
dated the parliament to annually set an expenditure target for the social security, in the framework of
an annual budget act prepared by the responsible department in the health ministry. This measure does
not correspond to the institutional logic that dominates French health policy-making, which is nor-
mally characterized by a weak parliament and a rationalized parliamentarism. However, it is congru-
ent with the logic of centralization of decisions in the French political system, and through the factual
strengthening of the state through the Directorate of Social Security (Direction de la Sécurité Sociale,
DSS) in the executive branch of government, the reform followed the French policy style. The pro-
grammatic action continued to strengthen the state by merging agencies on the regional and territo-
rial level, for example through the creation of the Regional Hospital Agencies (Agences Régionales
d'Hospitalisation, ARH) and their later restructuring in Regional Health Agencies (Agences Régionales
de Santé, ARS), the creation of a monopoly for representation of sickness funds, and the strengthened
health ministry's advisory body, the Inspection Génerale des Affaires Sociales. The last major reform
in this direction was affected through the Loi Hopitals, Patients, Santé, Territoires (HPST) in 2009.
Thus, the non-introduction of competition elements and the focus on planning and contracting mecha-
nisms were perfectly in line with the governance tradition (Bellanger & Mossé, 2005).
However, policies adopted after 2010 still followed the policy program promoted by the program-
matic group. Although the reforms made use of new public management tools, the general tendency
towards a re-centralization of competences remained (Simonet, 2017), even though there are some
recent tendencies of marketization of the private health insurance, though unintended (BenoÎt &
Coron, 2019). The regulatory mechanisms remain consistent with the political system in France, and
the consistency of objectives and instruments is ensured as the measures taken still aim at increasing
efficiency in health care spending, being oriented towards prevention and digitalization, and strength-
ening the state (Lombrail, 2015). This is circumscribed by one of the programmatic actors:
The introduction of elements of competition in the German health care system originally did not fol-
low the logic of self-governance, which also explains the strong resistance that the Health Care Structure
Act in 1992 and the Health Modernization Act of 2002 faced. The reform of 2007 was even labeled “Act
to Strengthen Competition in the SHI”. The institutional changes that these reforms caused were further-
more designed to weaken some of the interest groups and to strengthen centralization of interest represen-
tation. It is still debated whether the reforms actually served or diminished corporatism (Allen & Riemer
Hommel, 2006). Accordingly, the original benefits of self-governance and corporatist agreements that
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traditionally served to reach bargaining agreements between the interests of health care providers and
payers and hand them down to their members got lost in what scholars labeled “competitive corporatism”
(Rhodes, 2001). The functional logic of self-governing corporatist actors moved from internal coherence
and the unanimous external representation of interests to a situation in which competition prevails even
within the associations, the rules of the game being negotiated by the association representatives. The
originally intended neo-corporatist institutions of bargaining, emerging from negotiations over wage and
labor costs up to agreements on benefits for the insured, payments by the sickness funds and services
offered by the health care providers, changed substantially over the years (Molina & Rhodes, 2002).
Besides, the German health care reforms show an increasing turn to evidence-based decision-mak-
ing. With the establishment of the Institute for Quality Assurance and Efficiency in Health Care
(Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWIG), which provides the de-
cision-making basis for the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA), which
in turn determines the evaluation of treatment methods and the benefits catalog on this basis, evi-
dence was institutionalized as a maxim guiding action. The G-BA, in which the service providers
and payers sit opposite each other with five votes each and an impartial chairman has the final say
in the event of a dispute, is not called the “small legislature” for nothing (Klafki & Loer, 2017). For
example, it assesses the additional benefit of pharmaceutical products newly developed and entering
the market, without the state or the pharmaceutical companies themselves being part of the decisions
(Ruof et al., 2014). The body of the G-BA thus presents a centralization of competences at the level
of self-governance, but without state control or a shadow of hierarchy (Töller, 2017) that enables the
state to intervene – the state only holds a legal but not a functional supervision over the G-BA. In
sum, a tendency of centralized decision-making away from bargaining also does not correspond to the
historically grown institutional logics of the health care system in Germany.
With regard to the key interest of the current health minister Jens Spahn, observers criticize the
coherence of policy reforms for example in the area of digitalization. While digitalization is a catch-all
term but essentially designates a development that is not a question of whether or when its time has
come (Klenk et al., 2020), the reforms recently adopted do not clarify the problems to which digitali-
zation has the answer. This is also expressed by interview partners:

B: I would also see things differently with digitalization. There is perhaps too little evi-
dence of the solutions to problems that people actually have.
(Interview G1, 2020)

The fact that Jens Spahn took over the majority parts of the responsible Society for Telematics
Applications of the Health Card (Gesellschaft für Telematikanwendungen der Gesundheitskarte, ge-
matik) that had originally been in the hands of the self-governing actors again presents an instance
of centralization of competences, this time at the state level. However, Germany is characterized by
a consensus-oriented style of policy-making (Zohlnhöfer & Tosun, 2019). Introducing reforms that
alienate these structures run the risk of not being of long continuance.

4.2  |  Problem pressure and challenges faced by policy programs

Both the French and the German health care system faced substantial financial problem pressure in
the 1980s. Rising health care costs and the dominance of strong sectoral interests, particularly the
physicians' associations, prevented major reform steps in the direction of cutting remunerations by at
the same time maintaining the benefits for the insured. In both cases, the financial pressure was only
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to be relaxed in the course of the 2000s, the French ONDAM only recently developed its impact on
reducing health care spending, namely since 2010, after the effects of a newly established alert com-
mittee became visible (Chevreul et al., 2015, p. 80). Nevertheless, the challenges of financial problem
pressure remained and are still shaping French health care policy today (Hassenteufel & Palier, 2014).
For example, the trends towards increasing efficiency through the introduction of market-based ele-
ments mark a period of increasing globalization and internationalization of health economics exper-
tise. Although these did not substantially alter the existing institutions in France, they shifted the
state-bureaucracy-oriented style of policymaking to new bureaucracies, which act in transnational
networks and by default promote more liberal reforms (Benamouzig & Lebaron, 2018).
The German policy program achieved its objectives of reducing health care expenditures by in-
troducing elements of competition into the health care system. More specifically, the free choice of
sickness funds alongside the possibility to conclude selective contracts between single sickness funds
and single service providers created a competitive environment for the sickness funds in which they
were – at least theoretically – competing for the insured. Financial sustainability was a major goal
(Hogwood, 2016), and the social security system could record a substantial financial surplus since the
beginning of the 2010s. This surplus resulted from an overreaction to the financial crisis, as one of the
interview partners states:

The financial crisis was there, or was coming and people were afraid that it would have a
direct impact on the employment situation and thus on social security contributions. So,
the federal subsidy was increased and further measures were taken to control expenditure
[…] we had zero problems with the contribution rate.
(Interview G6, 2019)

As a result, the financial situation of German health care relaxed substantially from 2010 on-
wards, diminishing the problem pressure and the financial challenges that initiated the policy program
in the first place. A long-term effect resulted from the Pharmaceutical Market Restructuring Act
(Arzneimittelmarktneuordnungsgesetz, AMNOG). Making it necessary for pharmaceutical compa-
nies to prove an additional benefit of newly developed drugs (apart from orphan drugs) before enter-
ing price negotiations with the SHI Peak Association (GKV-Spitzenverband, GKV-SV), it lowered
pharmaceutical expenditures significantly by almost two billion per year (Cornejo Müller et al., 2020,
p. 214). But financial problems are not the only ones that arise in health care. In the years after 2010,
the shortage of skilled care workers, Germany as a late runner in digitalized health care, and the short-
age of physicians in rural areas could and should have been addressed. Despite some attempts by the
health ministers Hermann Gröhe (in the case of prevention and care policies) and Jens Spahn (partic-
ularly in the area of digitalization), though, this did not happen. Most importantly, these reforms were
made by the ministers alone and did not result from a collective group action. Instead of new groups
forming around policy programs, or the old programmatic group still shaping reforms, major policy
change did not occur and the adopted measures, among them new possibilities to conclude selective
contracts, were placed in the settings shaped by previous programmatic action.
With regard to new challenges, and as opposed to Germany, France has taken some important steps
towards the digitalization of health care with the early introduction of the Dossier Médical in 2004,
which also takes up current trends and is further developed according to new standards (Séroussi
& Bouaud,  2020). Although not directly being a frontrunner, France's approach of centralization
was able to deal much better with the new challenges posed. Against the currently arising challenge
of ensuring public health particularly in times of pandemics, such as COVID-19, it remains open
whether the policies will be able to adapt to arising challenges, not just with respect to digitalization
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(Ohannessian et al., 2020), but also with respect to enforced requirements regarding prevention and
infections (Islam et al., 2020).

4.3  |  Narratives and inclusiveness of policy programs

With regard to the ability of policy programs to provide inclusive anchors of identification for politi-
cal and sectoral actors, both instances of programmatic action provide an interesting example of how
sectoral actors were excluded from negotiations between political actors to circumvent resistance
faced from interest groups and interest representatives. Although Alain Juppé attempted to incorpo-
rate some actors in a summit (Dive, 2016, p. 108), the later adopted policies produced significant pro-
test on the side of interest groups. More importantly, what was frequently criticized was the lacking
representation monopoly of sickness funds, which resulted in the acceptance of reform proposal only
partly on the side of the health insurance actors. The physicians' associations were naturally against
the budgeting plans and formed a fierce opposition against the Juppé plan. Nevertheless, the reform
passed and further reforms of centralization and regionalization were not stopped.
As the French party system is much more fragmented, the health care reforms were not involved or
instrumentalized in partisan competition. Indeed, as it is usual in France, the major reforms are labeled
after the respective health minister in office, or – in the case of the Plan Juppé – after the then prime
minister under president Jacques Chirac. Despite this personal connection between individual policy
actors and policy proposals, the narrative with which the reforms were communicated fitted the na-
tional mood of advocating justice and solidarity, which can only be achieved through statist regulation
(Nay et al., 2016). They were communicated as being hardly avoidable against the pressing financial
problems of the social security system. In the years to follow, and especially after 2000, the narrative
increasingly centered around the policy program being devoted to improved prevention and care, and
more patient-centered through the means of the electronic health record of patients.
By contrast, the German policy program of “competition in a solidaristic framework” was neither
particularly popular among the public, nor was it able to shield itself from partisan competition. The
narrative was not well thought through by the acting policy actors, considering that health policy is
traditionally a field in which the people do not support a profit-oriented system of order, but in which
equal access, safety, and steady availability of resources rank higher. A more suitable narrative to push
for policy programs would be that of a quality-centering, which did not make it to the top of the agenda
yet (Reimann & Trefzer, 2009). While the ideas of the reform program had been prepared before in
several expert commissions and continued through the level of civil servants, the first steps of the
policy program resulted from a grand coalitionary compromise between the health minister and the
health policy expert of the two biggest parties, the Christian Democratic Union (CDU) and the Social
Democratic Party (SPD). In 2005, one key change in health care policy, the establishment of the health
care fund, emerged from a compromise between the financing preferences of the SPD, which opted for
a citizen insurance, and the CDU, which promoted a capitation fee (Reiners, 2009). Since the 2010s,
health policy was first beyond spotlight under a weak health minister, who predominantly adopted
policy reforms that were previously agreed on in the coalition negotiations.

G6: “The new instrument is, as already mentioned or as mentioned at the beginning, fed-
eral and state commissions, scientific working groups, there is even more in the coalition
agreement.” ‐ I: “And then there is, then there won't be such a powerful clique growing
out of it, (G6: Yes) that has all the power.”
(Interview G6, 2019)
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|
Besides a central role of the subnational governments, which partly even act as negotiation partner
of the sickness funds (Böhm et al., 2018), coalition negotiations have emerged as an arena of new
institutional importance, given that the coalition treaty on which the governing parties agree after an
election essentially determines the later policy (Hübscher, 2019). This leads to, first, a great identi-
fication of the governing parties with the reforms but, secondly, prevents major reforms due to the
bargaining processes in the negotiations. With respect to emerging challenges, the predefined policies
in the coalition treaty leave few rooms for maneuver during the rest of the legislative period.
Since the assumption of office through Jens Spahn actively used to foster the career of the minister,
who does not hide the fact that he has ambitions to become chancellor one day. Experts in the health
care system also view the collaborators of Jens Spahn as people whom he trusts personally indepen-
dent of whether they have any competencies in health policy.

I: “Where do they come from, what inspires them, is it known?” G7: "The party and all.
So take a look at Ludewig, who was brought in for the digital sector, he is a man who, I
think, has somehow attracted attention from the party, then he [Jens Spahn] […] brought
in this one advisor, who was also […] State Secretary with Schäuble. […] He has noth-
ing to do with health, really. […] I have already said publicly that in the end he [Jens
Spahn] is really someone like that, in the political business, who simply puts the issues of
content, at some point at least, behind his personal development. In other words, a total
power-political calculation behind everything.”
(Interview G7, 2019)

G6: "He [Jens Spahn] certainly has a large network and I would say he has an agenda too.
digitalization, then. Everyone is doing something good with digitalization, but I trust him
to really push and move something, I trust him to do it."
(Interview G6, 2019)

His personal program for the health care sector is characterized by a focus on digitalization and pa-
tients. Although popular, he did not manage to provide an inclusive narrative that connects the solution
that digitalization might present to the problems that it might solve. Nor does the health minister act in
groups, so programmatic action has ended to the minister's personal advantage.
In France, by contrast, the inclusiveness of policy programs and narratives fitting to the respective
actors are much less oriented towards parties and corporatist actors. While there, too, the scientific
committees play a major role for giving impulses to the health care system, these are much more inte-
grated in the French policy process than in the German policy process:

Each party does its reflection exercises with the health professions and therefore with repre-
sentatives of the health professions, medical unions, etc., so the party plays – finally played,
because perhaps now political parties have a small problem in our country, but that was still
the traditional role of political parties. The other actors who also play a very important role
in relation to political parties are precisely health professionals, we mentioned the doctors'
unions, which are a little fragmented in France, it is certainly less so in Germany
(Interview F2, 2019)

As a result, the bureaucratic structures and the style of policy-making in France are not necessarily
more or less inclusive but definitely more stable. Furthermore, the steady inclusion of scientific advice
into the decision-making processes guarantees a certain acceptance of concepts on most sides of interest
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132       HORNUNG

F I G U R E 2   Program-related conditions of programmatic action

Source: Own illustration based on the detailed case studies

representatives, or at least legitimize hierarchically decided policies towards the public and the national
mood.

5  |   D IS C U S SION : WHAT CO N TINUES AND ENDS

PRO G R A M M AT IC AC T IO N ?

Contrasting the two cases, or to be more specific the four cases of time periods under study, one can
compare how the conditions identified as potentially relevant program-related characteristics link
to programmatic action. Section 4 analyzed the instances of programmatic action (and its end) in
Germany and France against the backdrop of these conditions. Figure 2 presents the coding of condi-
tions based on this case analysis, yet without suggesting claims of causality by this illustration. The
analytical scheme is applied heuristically to visualize the conditions under which programmatic action
was present or absent in the investigated cases, without implying a causal logic at work. The remain-
der of this section is devoted to the discussion of how the conditions link to the outcome of program-
matic action, by placing particular emphasis on the question under which conditions programmatic
action does not occur (anymore).
With regard to the first two factors of program success – the coherence and congruence of policies
– the former affects long-term and short-term success alike. If a policy program is coherent to begin
with, it will remain so in the future, provided that the actors do not make substantial modifications with
regard to the goals and instruments. Here, the only question is whether policies added to the program
correspond to the original logic. In the French case, the ongoing reforms in health care were continu-
ously oriented towards a regionalization and territorialization of health care and followed the tradition
of centralist decision-making (Hassenteufel et al., 2020). Thus, the institutions ensure coherence of
the policy program, and further reforms did not substantially alter the institutional setting previously
put in place by the program's reforms. In Germany, the logic of reforms is different due to the strong
focus on competition, which does not necessarily correspond to the pre-existing institutional logic of
self-governance. After the policy program ended, policy-making turned to different objectives, with
an increasing focus on prevention and care policy under health minister Hermann Gröhe, and an even
further rejection of the original Lahnstein ideas of competition through Jens Spahn who places much
emphasis on the patient and digitalization (Bandelow et al., 2018; Bröcker, 2018). One can conclude
here at least that as opposed to the French case; the German policy program did not correspond to the
institutional logics of the health care system to begin with. What is more, the strengthening of the role
of the state following the reforms of the current health minister Jens Spahn explains his predominant
view that the self-governance can only be sustained if it functions (van Elten, 2016).
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Secondly, with regard to problem pressure and the programs' ability to adapt to new challenges,
what is striking in the German case is the lacking pressure from “exploding” health care costs and
a factual situation of surplus, which had been solved through the policy program and partly resulted
from an overreaction to the financial crisis in 2008. By contrast, French health policy is still largely
pursued with the desire to meet the target for sickness fund expenditures annually set by the parlia-
ment. In this case, the policy program better achieved an institutionalization of the policy program
through the regulation of a strengthened parliament, which ensures parliamentary supervision and a
strong role of the department responsible for preparing this annual law against potentially competing
programmatic actors. The centralist structures in France also enabled a better adaptation to emerging
challenges by hierarchical modes of governance. The German policy program in health policy did
not achieve such an institutionalization. Its ideas of competition originally designed to achieve cost
containment were not able to adapt to the new challenges of prevention, care, and digitalization, while
not being needed anymore to achieve cost containment in times of financial prosperity of the health
care system. It is however not conceivable that the policy program can be revived when the COVID-19
pandemic will bring back financial problem pressure, as it is currently feared and expected.
Thirdly, the focus on narratives and the fit to the national mood of a policy program has revealed
that the institutions of corporatism and party democracies make a long-term success of a policy pro-
gram less likely because of the requirements imposed on the program to serve the cognitive endorse-
ment on the side of political parties and sectoral actors alike. The instance of programmatic action in
German health policy emanated from a unique moment in history when a cross-partisan consensus was
able to overcome the hurdles of corporatist actors that previously had prevented any major reform in
the health care sector. However, these are still relevant to public policy particularly with regard to im-
plementation. Furthermore, the partisan polarization and pluralization complicates the task of provid-
ing a narrative with which the decisive political parties (whoever they may be in a given moment) can
identify with. In Germany, the very clear narrative of competition was too much oriented towards mar-
ket-based reforms, which were still popular in the 1990s, potentially also connected to the time after
reunification, but not so anymore since the beginning of the 2000s. The French narrative of increased
control and regulation fits the traditional logic of policy-making and the sentiments of the population.
Finally, an arena that is evermore gaining importance in German policy-making, that of coalition
negotiations, presents a new institutional feature that alters the conditions under which programmatic
action becomes more or less likely. With a large part of public policies being determined at the begin-
ning of a legislative period, these negotiations and the resulting treaty hamper the reaction of policy
programs to emerging challenges and a change in the national mood, and are liable to the dynamics
of arguing and bargaining in negotiations, which impedes the coherence and congruence of policies
agreed on in these. Moreover, this supports the estimate that programmatic action is more likely, and
policy programs more successful, if the programs are not associated with prominent party figures and
not subject to partisan competition, as this would probably result in a stronger determination of such
policies through coalition negotiations.
While the theoretical perspectives that have informed the PAF's hypotheses in this study them-
selves present explanatory factors for policy change and stability, the PAF still adds a unique lens on
policy change by its focus on long-term policy programs and programmatic actors that are attached
to this program as a group. The combination of ideas and institutions thereby also allows to formulate
recommendations for policy actors who intend to shape a sector's policies over a longer period of time.
It integrates the insights from policy design literature, narrative approaches, institutionalists theories,
policy-making in times of crisis, and health care reforms. As a result, the PAF is able to present a
holistic picture of how a policy sector at times undergoes substantial changes and later stops to do so.
The claim that the PAF may extend existing approaches has also been confirmed by existing studies.
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134       HORNUNG

Faure (2020) shows how the rationalist choice institutionalist view falls short in explaining French
arms policy by paying too little attention to actors. Hassenteufel et al. (2010) showed that problem
pressure alone does not explain similar developments in the two countries and that the institutional
settings differently enable and constrain programmatic actors.

6  |   CO NC LUSION
Building on these insights, this contribution has reviewed the program-related factors that explain
the presence or absence of programmatic action with a specific view to the institutions that moder-
ate these conditions. In doing so, the results of the analysis reveal several insights into the study
of programmatic action in general. It becomes clear that the factors expected to have an influence
on programmatic action unfold divergent explanatory power in the empirical application. While
program coherence existed in all four time periods under study, program congruence, that is, the
extent to which the policy program fitted the existing institutional structures existed in France but
not in Germany. This points towards a greater importance of policy program congruence than co-
herence, at least in this case of analysis. Put more generally: Policy program coherence may well
explain why a policy program is successful at all, while policy program congruence rather explains
why a policy program will stay successful in the long-term. This is in line with findings from
policy design research that connect policy design congruence to output performance (Thomann
et al., 2016).
Secondly, with regard to the policy program's ability to address problem pressure and arising chal-
lenges, the result is similar to the previously analyzed factors of coherence and congruence. While
giving an appropriate answer to pressing problems of the policy sector is an important characteristic
of a policy program to be successful to begin with, the question whether the policy program will be
successful in the long-term rather concentrates on its capacity to adapt to new challenges and to be
flexible enough to match the solutions formulated in the policy program also to new challenges. This
is largely independent of institutions, although existing institutions may provide early warning sys-
tems and structures within which it is easier to flexibly react to upcoming problems.
Thirdly, the narrative and inclusiveness with which a policy program is promoted has a substantial
influence on whether programmatic action takes place and is steadily successful over a longer period
of time. Choosing a narrative for the policy program is particularly difficult as the national mood can
be subject to changes and an once fitting name of a policy program may become unpopular a few years
later. Here, it might be sensible to choose a name that is less conflictive and rather vague in nature. A
great role of political institutions becomes visible when looking at the role of inclusiveness of a policy
program. The German example of a strong role of corporatism and coalition negotiations shows that
the more actors are generally involved in decision-making, the less likely is the success of program-
matic action, especially in the long-term.
An important limitation that must be taken into account when reflecting on these conclusive con-
siderations is the missing focus on the actor-related characteristics that drive programmatic action.
Independent of the program-related features that explain the existence or non-existence of program-
matic action, which are necessary but not sufficient conditions for programmatic action to occur,
actor-related factors may play an equally relevant role. Future research should therefore shed light on
the question under which conditions actors form programmatic groups, and how, for example the per-
sonality of actors, the specificity of their biographies and careers, up to their strategies and resources
help to explain programmatic action. It is sensible to view the insights presented by this contribution
in a new light in the future.
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ORCID
Johanna Hornung  https://orcid.org/0000-0001-6542-3985

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How to cite this article: Hornung J. The (mis)fit of policy programs to political institutions
and its influence on programmatic action – How crisis has differently hit French and German
health policy. Eur Policy Anal. 2021;7(Suppl. 1):120–138. https://doi.org/10.1002/epa2.1108