Not Immune: Politics, Bureaucracy, and the Limits of Professional Autonomy

bureaucracy;health politics;vaccine politics;state politics;American political institutions;public administration;Public Health;Political Science;Health Sciences;Social Sciences;HlthSvcsOrgPlcy&PoliSci PhD

Lillvis, DeniseKirkland, Anna R ;

University of Michigan

关键词: bureaucracy;    health politics;    vaccine politics;    state politics;    American political institutions;    public administration;    Public Health;    Political Science;    Health Sciences;    Social Sciences;    HlthSvcsOrgPlcy&PoliSci PhD;   

Others  :  https://deepblue.lib.umich.edu/bitstream/handle/2027.42/138675/dlillvis_1.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: The Illinois Digital Environment for Access to Learning and Scholarship

【 摘 要 】

State public health agencies play a crucial role in disease prevention and health promotion by implementing policies that advance population health. This dissertation examines how institutional, organizational, and political factors affect the implementation decisions of health professionals who work within these agencies. In particular, I focus on the effects of bureaucratic professionalism, which I define as the extent of self-regulating, networked experts in a policy-relevant field within a government agency. I elucidate how bureaucratic professionalism influences agency health policy implementation decisions within certain institutional and political contexts. I begin by developing a theory of bureaucratic professionalism, which I refine through interviews with state government employees and professional association representatives. I then examine why we see variation in bureaucratic professionalism across state health departments and over time. I hypothesize that bureaucratic professionalism will increase when the legislature is more professionalized and of the opposite party. While some of my empirical results support this hypothesis, they are inconsistent across different measures of professionalism and are sensitive to model specification. Next, I elucidate how and under what conditions variation in bureaucratic professionalism affects state public health policy by focusing on childhood immunization rulemaking. The particular conditions of interest include: the existence of a board of health, the level of bureaucratic professionalism, and the presence of divided government. I find that states with a greater proportion of bureaucrat-professionals in state government propose fewer immunization rules under divided government. This is surprising, as the literature on science-driven, federal-level bureaucracy suggests that bureaucrats enjoy a certain amount of autonomy based on the professional reputation of their field. Finally, I shift my focus from rulemaking to program implementation to ascertain the effects of professionalism on this aspect of policy implementation. I conduct a case study of a recent childhood immunization rule in Michigan to understand how bureaucrat-professionals at the local level implement a state rule. Local-level professionals appear to use their discretion to accommodate parents’ decisions not to vaccinate their children, which at first appears to be at odds with what the effects of professionalism might suggest. However, the rule also represents a shift in the types of professionals responsible for implementing the policy, replacing school secretaries with health professionals who are committed to providing education about vaccination and may be held accountable for vaccination rates. The main effect of this policy is that it makes obtaining a vaccination as convenient as obtaining a nonmedical exemption, as both require an appointment with a health professional. Additionally, my analysis of the implementation of this rule reveals an overlooked aspect of bureaucratic professionalism: professionals within local health departments are absorbing and managing conflict between the public and public health through the departments’ approach to the education sessions.This dissertation helps us better understand the role of bureaucrat-professionals in state government, and the conditions under which they employ their expertise to implement health policy. Concern for reputation and the potential for reduced policy implementation authority lessens professionals’ desire to make rules in challenging political environments. And, in implementing a rule that helps parents avoid vaccines, professionals appear to be utilizing their long-term mindset and commitment to education to overcome the short-term focus of vaccinating all children. The long-term goals of the profession lead health professionals within bureaucracies to adopt a strategic mindset toward agency policy implementation.