The influence of institutions on programmatic action, and more specifically on the formation and success of programmatic groups, has been little explored. When studying the institutions of programmatic action, it is important to not neglect actors whose resources and interactions are moderated by the institutional settings, but who ultimately use existing resources—including law and legislative power—to achieve their policy goals (Radaelli et al., 2012, p. 547). Against the backdrop of the empirical analyses of the presence and absence of programmatic action in French and German health policy, this chapter summarizes the findings on the influence of institutions on programmatic action. What are the institutional opportunities and constraints for programmatic actors, and what are the institutions of programmatic action?

Drawing on the formulated hypotheses and the empirical case studies, the final question that remains to be answered is under which institutional conditions programmatic action occurs. Answering this question is essential for the application of the PAF in comparative public policy. The main argument that emerged during the study is that programmatic actors are sensitive to institutions, but that other institutions matter more than those known from the discipline of comparative politics. This does not mean that these well-known institutions do not also have an influence on the options for action of programmatic actors. However, the theoretical and empirical work has extrapolated two important institutional conditions that influence the formation and success of programmatic groups. The first is referred to as socialization and elite formation, which is different in Germany than in France. Elites in Germany are socialized not as programmatic groups by definition, but as lawyers or party politicians. As a rule, they do not belong to a predefined group. Programmatic action is thus only possible if certain institutions allow the emergence of actors spanning several areas of the sector. The second requirement lies in the degree of institutionalized involvement of scientific advice in the policy process that stimulates the development of new ideas and policy programs. New ideas emerge from new ways of looking at the world, and scientific dialogue is one way to generate policy ideas. Therefore, the strategic and systematic integration of scientific advice in policy processes and decision-making structures is a key determinant of the emergence of programmatic groups and policy programs.

The analysis of programmatic action in France and Germany during the study period 1990–2020 has shown that programmatic groups occur under certain institutional conditions. France and Germany are institutionally very different. Consequently, the nature of programmatic groups also differs (Hassenteufel et al., 2010). In this context, programmatic groups in Germany and France may require different resources. In Germany, due to the strong role of the working parliament and in contrast to the rationalized parliamentarism in France, the realization of policy programs requires legislative competences and actors. Because of the different federal structure in Germany and France, programmatic groups in the former rely on the support of subnational actors. Also, the strong tradition of corporatism makes it necessary for programmatic groups in Germany to have actors and bodies of self-governance at their side, or at least to grow out of these systems. In France, programmatic groups are more hierarchical, centralized, and homogeneous, largely due to the system of elite formation and the centralized state.

In terms of content, it is striking that France and Germany faced similar challenges in health policy. Both countries were struggling with cost increases in health care system in the early 1990s, which raised fundamental questions about future financing and the services covered by insurance. Both countries also had the problem of excessively high drug prices, which could drive up prices without an additional benefit test, as well as overuse, underuse, and misuse with regard to the hospital landscape. As is well known, countries solved these problems differently, Germany by introducing competitive elements and an institutional restructuring of self-governance, and France by increased centralization and regulation, for example, through global budgets. It can be stated, however, that these crises of cost increase as problem pressure did not automatically lead to programmatic action, but certainly triggered it. In addition, health care reforms in both France and Germany have resulted in a stronger role for the state and a more hierarchical mode of governance to the detriment of self-governance (Bandelow, 2009).

Despite these differences, the analysis has brought to light generalizable institutions that function analogously in institutionally very different countries—such as Germany and France. While the design of these institutions determines the characteristics of programmatic groups, their existence can be demonstrated on a country-specific basis and the presumed influence on programmatic action remains. In accordance with the formulated hypotheses, the following influences of institutions on programmatic action can thus be concluded.

8.1 The Institutions of PAF

The relevant institutions of the PAF were narrowed down to two main aspects, namely the recruitment processes and career paths of administrative actors and the institutionalization of expert advice in the policy process, which is related to the former. Thus, the PAF confirms what Hall (1983, pp. 46-47) calls the four institutional conditions conducive to policy innovation: centralization of power in a few hands, concentration of power in the executive branch (although Hall points out that political leaders rather than civil servants should be seen as initiators of innovation), access to information and expertise, and active collaboration through informal alliances between politicians and civil servants. The PAF adds value to policy process research by providing a theoretical lens that focuses its attention on precisely these processes that are relevant to major policy change.

In France, the process of elite formation is very formal. ENA institutions serve to train bureaucrats and politicians who will later significantly shape policy decisions and programs. In Germany, it was mainly informal networks that were formed through formal institutions (Enquete Commission), but then became more and more entrenched until they were no longer entrenched. This shows that in countries with formalized elite-forming structures and institutions that ensure group formation across political and interest-driven perspectives, that is, especially with reference to science, programmatic action is clearly more predictable and longer term. In countries where these structures do not exist, informal networks are more common and can form programmatic groups over the long term. However, these come to an end if they do not perpetuate their exchanges. The Enquete Commission in Germany is described by those involved as unique.

For the generation of policy programs and ideas, the involvement of scientific expertise proves to be a necessary condition for programmatic action. Innovative policy programs need impetus to enable the development of such programs. However, progressive and new ideas are almost exclusively due to new insights and perspectives that often emerge from dialogue and scientific advancement. In France, the integration of expertise into the political system, and especially into health policy, is much more institutionalized through the ministerial cabinets and the IGAS. In France, thus, this occurred through exchanges between members of ministerial cabinets, that is, the bureaucrats in the ministry with their close ties to other sectoral actors, to whom they are often still linked through the institution of the ENA (Gaffney, 1991, p. 9). In Germany, the Enquete Commission and other commissions following this expert body represent an artificially created institutionalization of expert advice and a point of biographical commonality that functioned analogously as a generator of programmatic action. The institutions of programmatic action may thus not be preexistent to begin with, but they can be—and empirical evidence shows that they are—created as a functional equivalent that triggers programmatic action. It is true that German also has long-term bodies for the integration of scientific findings in the form of the SVR-G and the Scientific Advisory Board for the Further Development of the Morbi-RSA at the BAS. However, these scientific institutions work directly on behalf of the BMG. “Free thinking”, as is the case in France, is therefore hardly possible. This was created uniquely in Germany by the Enquete Commission. Furthermore, while these bodies in Germany are institutionalized, there are no institutionalized career paths leading directly to it. The programmatic group has thus also failed to use this institution for its interests in the long term.

8.2 Programmatic Action and Political Institutions of Power

A key question about the influence of political institutions on programmatic action concerned the ways in which federal and subnational institutions affect group formation and influence actors at different levels of policy-making. This question is also relevant from the perspective of veto players, as the Bundesrat is an institutional veto player in Germany. In this respect, France and Germany represented two different institutional settings, with Germany characterized by its distinct subnational structures of policy-making and France by its centralized majoritarian democracy. From the perspective of theoretical considerations, it was initially unclear whether federalist structures tend to favor or hinder the possibility of programmatic group formation. Empirical analysis has shown that both can be the case. Indeed, in states with a strong role for the subnational level of policy-making, programmatic groups can profit from actors at that level by expanding the scope of action and facilitating the implementation of the policy program. More actors in key positions mean more power resources to push for policies and use different venues to pass them. However, if actors at the subnational level are opposed to policy change or a programmatic group’s program, they will probably succeed in blocking these reform attempts. This is consistent with research suggesting a strong role of collective identity formation at the territorial level at the interface between federalist institutions and public policy (Béland & Lecours, 2020). In contrast, this risk does not exist when decision-making structures are more centralized and involve fewer actors, as smaller groups of individuals are more likely to band together.

Not only the number of actors but also the occasions for group formation differ by the degree of federalism. Multilevel structures allow for the formation of cross-level working groups and commissions to jointly develop solutions to problems that affect all levels equally (Benz, 2017). It is not uncommon for major health care reforms to have been prepared through consensus discussions involving actors from these multilevel structures. This creates both opportunities and constraints for programmatic action in particular and for major policy change in general: If actors agree on key points and a common direction for reform, as is the case with programmatic groups, the chances are high that the changes decided upon will have a substantial effect on the structures of the policy sector and that far-reaching changes are possible. If there is no such agreement, it is much more difficult for actor groups (programmatic groups) to achieve major policy change because there are many blocking points (veto players) that can hinder their efforts.

Turning to the corporatism perspective, a similar ambivalent conclusion can be drawn: Although the programmatic group in German health policy weakened the sectoral actors, it was the existence of associations and their strong role in the self-governance of the sector that enabled the formation of programmatic actors in the first place. Indeed, it was the scientific institute of the local sickness funds that served as a cadre for the later successful members of the programmatic group. The programmatic actors who began their careers in this institution and then spread to key positions at the subnational level, in decision-making bodies of the self-governance, or in the ministry shared a biographical experience that would bind them over the period of programmatic action. In France, the relationship with corporatist actors was less tense, partly due to the lower degree of institutionalized involvement of these actors in decision-making processes. Health reforms in France were accompanied by persistent strong protests by sectoral actors—a well-known phenomenon in French politics. This may explain why the measures adopted in German health policy were more substantial (but not permanent), while the French reforms were more stable but less far-reaching. Similar to the structures of federalism, then, the structures of corporatism cannot be unanimously assessed as either conducive or obstructive to programmatic action. Whether they prove favorable or not depends on the constitution of the programmatic group and the inclusiveness of the policy program.

In general, the empirical analysis has revealed that the openness of a political system (e.g., through many points of contact such as decentralized structures, corporatist structures, and a large number of veto players) can also form constant points of contact for programmatic actors. The examples of France and Germany also show that in Germany’s political system, which is more open in this respect, programmatic groups “change” more frequently. At the same time, however, there is a greater chance that there will be no programmatic groups, since many actors must also be involved in programmatic action. Insofar, established institutions as well have a substantial impact on whether programmatic groups form and are successful or not.

8.3 The Challenge of Institutional Change

Having identified the relevant institutions for programmatic action, it remains to be stated that this is also accompanied by a potential influence of the dynamics of institutional change. Because the empirical study looked at political institutions in a policy sector, institutional change can affect both the political system and the policy sector. Programmatic groups may benefit or be hindered by these institutional changes. It is therefore useful to distinguish between sectoral institutional changes, which are often induced by programmatic actors, and political institutional changes, which may challenge an existing programmatic group or provide incentives for a new group to form.

As a consequence, an important conclusion regarding the institutions of programmatic action is that of institutional change and stability. Distinguishing between political and sectoral institutional change, one can see that the latter can be favorable for programmatic groups, provided that they are able to shape sectoral institutions in a way that is advantageous to them. However, the changing nature of political institutions makes it more difficult for programmatic actors to predict the institutional setting in which they operate and which allowed them to become successful initially. The programmatic group in French health policy changed sectoral institutions and strengthened itself and its members. The programmatic group in German health policy also changed sectoral institutions and placed its members in these newly created positions. However, the German political system has undergone an institutional change in that coalition negotiations and the resulting agreements that shape policies in the coming legislative period play an increasingly important role. As a result, the institutional conditions for programmatic action have changed. Programmatic actors now need to have access to coalition negotiations in order to get the content of their policy programs into coalition agreements, or they need to push for the creation of bodies that can be agreed upon in order to use these bodies later to achieve policy changes. The institutional changes in Germany can be seen as a major explanation for the decline of the programmatic group (Hornung, 2021), along with the insufficient consideration and inclusion of expert advice in policy formulation, and the lack of opportunities for group formation in elite recruitment.

Sectoral institutional changes often occur when responsibilities are redistributed, agencies are created, abandoned, or merged, and when structural features of policy-making are rearranged to alter existing decision-making procedures. If organizations and agencies are understood as groups of actors that also shape social identities (Gioia et al., 2010), the premises on which an organization is built also manifest the preferences its members hold. An agency charged with evaluating the additional benefits of treatments based on medical evidence will not generally question the value of evidence-based medicine. The strengthening of parliamentary oversight of health spending in France has paradoxically strengthened the executive level of the state, in the form of the DSS in the ministry. Moreover, when agencies are created, the bureaucracy often continues to influence policy-making through existing networks (Gains, 2003, p. 75). As a result, agencies have a substantial influence on policy-making (Bach et al., 2012), and policy-makers have an ongoing influence on implementation—the two spheres are not as separate as they may first appear (Verschuere, 2009). Programmatic groups can thus intentionally shape institutions by creating agencies and new regulations with those agencies that ensure their long-term influence on policy-making. The institutional rules that dominate a policy sector may likewise be adapted by programmatic groups to serve their goals. Thus, sectoral institutional change is profitable and important for programmatic actors.

In contrast, political institutional change tends to be detrimental to programmatic groups. If they have used existing political structures to advance to top positions, programmatic actors often lack connections to other venues and processes that may become more important as a result of institutional change. A prominent example of such institutional change is the increasing importance of coalition negotiations for the policies of a legislative period (Klüver & Bäck, 2019; Romeijn, 2020). This strengthens the political versus the administrative level of governance and gives more weight to the advisors and professionals of the parties involved in the negotiations. The politicization of reforms and the modes of negotiation—but at the political rather than the sectoral level—are revived to some extent.

One idea of the PAF is that policy programs can bring about institutional changes that underpin the ideas of the policy program, thus generating policy feedback effects. However, there is also the possibility that policies will be dismantled (Jordan et al., 2013), which is close to the idea of the end of policy programs. In this context, a feedback effect of a policy program can also be the dismantling of the policy program if it has proven inadequate to address emerging challenges or if other actors try to dominate a sector’s policy with their own ideas. The PAF also argues for viewing policies as irrevocably linked to the programmatic group, which can also explain the rise and fall of policy programs (Bandelow & Hornung, 2020).

8.4 Limitations and Research Agenda

While this contribution has expanded research on the PAF and policy processes to include the role of institutions in programmatic action, there remain limitations and opportunities for future research that need to be addressed. These primarily relate to the falsification of the PAF both theoretically and empirically, the methodological procedure that relates to this falsification, and other explanations for programmatic action that should be explored in the future.

The theoretical and empirical part of this book also discussed how the PAF can be refuted, or more explicitly, whether biographical linkages systematically lead actors to cooperate and promote a policy program aimed at policy change. What the network analyses of both the French and the German cases have shown is that programmatic actors not only have biographical entanglements among themselves, but are also themselves characterized by biographical diversity. Thus, there appears to be at least one additional factor necessary to become a programmatic actor, which is the availability of points of contact with the various domains of a policy sector, including the bureaucracy, academia, and politics, as well as self-governance, where appropriate.

Related to this is the puzzle why some members of commissions such as the Enquete Commission and some individuals who share biographical ties with others have not climbed the careers ladder or become part of the programmatic group, or that some who have not shared these experiences have. Why is this the case? Why are there people who theoretically could have been (or perhaps should have been) part of the programmatic group but are not, and vice versa. The empirical study provides some starting points for answering this puzzle that need to be explored further. The first is that some actors simply did not identify with the elaborated policy program. It may be that they had competing social identities that prevented them from identifying with the programmatic group, or that some characteristics of the programmatic group made it impossible for them to integrate it into their social identity. It could also be that the frequency of contact had an influence here, namely that the contact between these actors and the programmatic actors was not sufficient for them to build trust and join the programmatic group. In addition to the social psychological determinants, a psychological finding of the analysis conducted is that personality plays a role in becoming a programmatic actor. This has turned out to be an ancillary aspect of the studied role of institutions on programmatic actors and therefore has not been further explored in this book. However, it seems worthwhile to research more about the psychological determinants or personality traits that make actors become programmatic actors, as these appear to influence the likelihood of certain actors to participate in programmatic groups.

Following this puzzle, a limitation can be named regarding the theoretical perspective of the PAF in general. How can it be prevented that the evidence produced in the empirical analysis is not inherently anecdotal, considering that the theoretical perspective grew out of the French political system, which by definition is designed to produce networks of elites that know and cooperate with each other? The actively created Enquete Commission also had the goal of incorporating expertise and enabling innovation from the outset. To be sure, this is the case. Nevertheless, the PAF offers the possibility of finding analogous institutional conditions that systematically produce programmatic action. Normally, the variance in the French and German institutional systems should provide different conditions for major policy change to occur. Nevertheless, the PAF formulates mechanisms that link similar political institutions to similar modes of policy change that go beyond purely rational logics of policy-making. It considers institutions that foster ideational thinking and group formation. Even noting that there are existing institutions that differ from country to country, such as party systems, one can assess that they perform similar functions in generating ideas and recruiting personnel, although this alone does not produce programmatic action. To do this, parties must be viewed in the context of the PAF institutions: The goal of a policy program is always to strengthen the programmatic group in terms of careers (authority and resources). This also creates new institutions. The program itself is interchangeable, as are the problems it is supposed to address. For example, France and Germany both had the goal of making the health care system more efficient. Germany has tried to do this through competition and centralization, France through hierarchical control of spending and territorialization with centralized competences. These are also sometimes the result of party effects or corporatism, or institutionalist conditions. Ultimately, however, the goals of the two programmatic groups were the same: career, authority, resources.

One way to overcome the danger of anecdotal evidence is for the PAF to follow a systematic and rigorous research protocol that also allows for evidence that programmatic action did not occur, such as in German health policy between 2011 and 2020. In terms of the methodological procedure, the order in which the tasks of the research protocol are carried out can be adapted depending on the research question. For an application in policy research, it makes sense to start with the analysis of policies with a view to a possible underlying policy program. Subsequently, the actors surrounding the policy program and finally their biographies can be explored. For researchers interested in elite studies and why certain actors become influential in the policy process and under which conditions, it seems more useful to begin by analyzing formal actor positions and biographies before examining a potentially shared policy program around which they have coalesced.

Also, with regard to the methodological procedure, the empirical analysis supports network analysis as a suitable tool for visualizing and analyzing programmatic groups. However, a distinction must be made here: A discourse network analysis based on media reports in daily newspapers runs the risk of ignoring the specialized discourses. Moreover, the actors appearing there are often assigned to the legislative or executive political level, depending on whether it is a parliamentary or presidential system. Depending on the political orientation of the newspapers, which in both countries was center-left, it may also be that policy ideas and/or policy actors are presented and selected for reports based on ideological premises. While the cross-checking of the results with interviews and document data suggests that the media analysis had a high validity, a potential bias cannot be ruled out completely. A future analysis of other media sources with different political views would help to present further evidence for the research question, and stress as well as explain potential discrepancies. Also, scientific experts or civil servants of the state apparatus do not always make it into this discourse. Discourse network analyses therefore serve in every case to identify a potential policy program and can also provide clues to a programmatic group behind it. However, this is not the same as the visibility of programmatic actors in a discourse. In order to visualize the connections between programmatic actors, social network analysis proves to be profitable in modeling the connections between actors through commissions and occasions for collaboration.

In health policy, there are other arenas and occasions that bring actors together besides those mentioned in the empirical analysis. However, these do not always turn out to be programmatic or lead to the formation of programmatic groups. The structures of federalism and corporatism and their associated venues may also be evaluated differently in light of the PAF. Until now, they have often been viewed from the perspective of competences and the prevention of policy proposals, that is, subnational and corporatist actors are present here mainly in the role of veto players. However, the PAF allows for understanding these structures as breeding grounds for new policy programs and to perceive their role in the cross-arena elaboration of policy programs. To this end, the diversity of venues allows for the identification of actors who populate multiple arenas and serve as liaison points between these structures, increasing the resources of the programmatic group to which they belong.

In addition to health policy, programmatic groups are potentially found in other policy fields. Previous studies show programmatic groups in defense policy and higher education policy (Duque, 2021; Faure, 2020). The institutions identified in this study function analogously in these policy fields: In order to research and analyze programmatic actors, it is always necessary to get an overview of the relevant structures of elite formation and group formation. The occasions and predispositions for these processes will differ from policy field to policy field. Furthermore, the PAF needs to assess the extent to which scientific impulses drive new policy programs. Again, this will vary across policy fields. However, generalization allows for comparable applications of the PAF across countries and issues. This is strongly recommended for future research projects.

More specifically with respect to health policy developments in France and Germany, the COVID-19 crisis clearly represents a turning point in the study of programmatic action as well. Developments surrounding the pandemic make existing problems in the health care system more visible. While the programmatic group is still active in France, programmatic actors in Germany have lost influence but remain visible in the discourse, for example, in thesis papers (Schrappe, François-Kettner, Gruhl, Hart, et al., 2020a; Schrappe, François-Kettner, Gruhl, Knieps, et al., 2020b), with first author Matthias Schrappe also being a long-time member of the SVR-G. The need for local solutions has triggered a potential reorientation toward greater regionalization of health care in both France and Germany, combined with a greater focus on public health and the design of service provision (Hassenteufel, 2020; Hildebrandt et al., 2020). It is possible that new programmatic groups will form and provide responses to such challenges. However, for programmatic action to be initiated, a look at the PAF institutions teaches that the opportunities for group formation and involvement of expertise are needed. The COVID-19 pandemic also holds potential even in countries where institutions for programmatic action are less formalized or hampered by strong political parties, but institutions must prove conducive or be created to enable major policy change. It remains to be seen and evaluated whether this will succeed.

To conclude this book with a reference to the beginning: The Chilean change in economic policy is challenged at the end of 2019 by demonstrations claiming that capitalism has failed. Every program has its end, just as the era of the group associated with it ends when the main actors disappear from the stage. But while people can die, ideas can live on and new programmatic actors can rise to substantially shape policy sectors if institutions allow them to.