The persistence of cliques in the post‐communist state. The case of deniability in drug reimbursement policy in Poland

Abstract

This article explores a key question in political sociology: Can post-communist policy-making be described with classical theories of the Western state or do we need a theory of the specificity of the post-communist state? In so doing, we consider Janine Wedel's clique theory, concerned with informal social actors and processes in post-communist transition. We conducted a case study of drug reimbursement policy in Poland, using 109 stakeholder interviews, official documents and media coverage. Drawing on 'sensitizing concepts' from Wedel's theory, especially the notion of 'deniability', we developed an explanation of why Poland's reimbursement policy combined suboptimal outcomes, procedural irregularities with limited accountability of key stakeholders. We argue that deniability was created through four main mechanisms: (1) blurred boundaries between different types of state authority allowing for the dispersion of blame for controversial policy decisions; (2) bridging different sectors by 'institutional nomads', who often escaped existing conflicts of interest regulations; (3) institutional nomads' 'flexible' methods of influence premised on managing roles and representations; and (4) coordination of resources and influence by elite cliques monopolizing exclusive policy expertise. Overall, the greatest power over drug reimbursement was often associated with lowest accountability. We suggest, therefore, that the clique theory can be generalized from its home domain of explanation in foreign aid and privatizations to more technologically advanced policies in Poland and other post-communist countries. This conclusion is not identical, however, with arguing the uniqueness of the post-communist state. Rather, we show potential for using Wedel's account to analyse policy-making in Western democracies and indicate scope for its possible integration with the classical theories of the state.

When health technology assessment is confidential and experts have no power: the case of Hungary

“…The organisational and legal framework of the Polish Agency for Health Technology Assessment (AHTAPol) was also established after joining the EU, in 2004. The political significance of AHTAPol recommendations in the reimbursement process was reported to be important, and their support is vital for legitimising reimbursement decisions (Ozieranski et al ., 2012a; Ozieranski and King, 2016). HTA recommendations are publicly available from AHTAPol’s website, and therefore HTA activities can be monitored and compared to reimbursement decisions to gain more understanding on potential influence of AHTAPol (Kolasa et al ., 2011b; Bochenek et al ., 2017).…”

The Emerging Social Science Literature on Health Technology Assessment: A Narrative Review

“…Delegating authority to specialized HTA bodies, however, serves multiple purposes for politicians, including creating a pool of experts capable of resolving complex problems, but also gaining legitimation by adopting an "evidence-based policy" discourse, and avoiding blame in case of controversial decisions. 49,56,59 Potentially, it also "enhances politicians' capacities to institute their ideological preferences within a set of concrete rules and 'expert' decision making procedures." 60 Once established, arm's-length HTA agencies are shown to have significant staying power in the face of efforts to re-politicize decision making, [60][61][62] though not full immunity from politics, especially if the political costs are too high or if the political calculus itself changes exogenously.…”

Contextualizing Corruption: A Cross-Disciplinary Approach to Studying Corruption in Organizations

“…Furthermore, cliques operate under advance mechanisms in which a dense network of relationships between individuals and organizations facilitate illegal activities covered by legal ones such as using one's expertise and professional knowledge to mask illegal deals and decisions (Jancsics and Javor 2012). Similarly, in the field of political sociology, it was argued that the presence and persistence of informal ties referred to as 'cliques' are associated with potential misconduct or procedural irregularities (Ozierański and King 2016).…”