The Role of Actor Values, Practices and Institutional Hardware in Intersectoral Governance For Health Equity Among The Elderly in South Korea

Abstract

Abstract This dissertation is focused on the governance of intersectoral collaboration because to address complex wicked problems such as health inequity among the elderly requires action across a range of health and non-health sectors and at multiple levels of government. There have been numerous collaborative policy initiatives to improve health equity without much success, and the existing evidence offers little insight into the factors that constrain (or enable) successful intersectoral action. The literature points towards the importance of actors' values in shaping policy collaboration and intersectoral governance, however ways to incorporate values in intersectoral governance for health equity have not been widely investigated. This dissertation is focussed on understanding the role of actor values, practices and institutional factors in shaping intersectoral governance for health equity among the elderly. The thesis employs a value typology from public management literature and the concept of levels of values from organisational cultural theory to operationalise the understanding of values. A software-hardware analogy from health systems governance is incorporated to connect actor values to the rules, regulations, and practices of actors. Two case studies were examined: Korean Senior Employment Program (KSEP) and Housing Pension (HP), are prominent policies of the PCASPP (Presidential Committee for Ageing Society and Population Policy) in South Korea, and address two important social determinants of health among the elderly. The dissertation provides empirical evidence and expands on scholarly knowledge on the role of values and how this influences the intersectoral policy process regarding health equity among the elderly, in the South Korean public systems. The empirical findings of the thesis illustrate that policy actors are constantly employing enabling and constraining practices in their daily tasks, in terms of operationalising health equity in the intersectoral policy process. Some policy actors are habituated with constraining practices which are performance-oriented, compliant to hierarchy, tendencies for interagency competitive, and detached policy process for policy design and policy implementation. Others however, exercised enabling practices, which included voicing inequity, going out of one's given duty to serve the target population, and the commitment to mitigate regional inequity issues. At a societal level, the data shows that the re-morphing the idea of collaboration is necessary to resonate better with existing cultural values, such as ministerial loyalty and the hierarchy, in order to achieve meaningful intersectoral collaboration . At the organizational level, competing framings of the agencies are threatening the achievement of effective collaborations because the idea of health equity is interpreted and supported by the organisational logic or rationale. The lack of intersectoral communication protocol aggravates the ministerial rivalry in the intersectoral policy process. At the individual policy actor-level, 'the cultural fear' of acting against the organizational rationale plays as a burden on individuals, effectively constrain individuals from acting on behalf of their values. In the intersectoral policy process for health equity, this means numerous forgone opportunities that actors are constrained in their actions to promote health equity in every small step of their work.Navigating the policy process is a complex task. This study proposes a shift in focus from performance-driven governance to values-driven governance with longer-term goals and intermediate steps of changing narratives, mind-sets, and enhancing resources, capacity and culture. The proposed value-driven governance model for health equity may enable sectoral actors' need to accommodate a wide variety of apparently inconsistent logics that are grounded in diverse values. Show more