Learning as a Necessary but Not Sufficient Condition for Major Health Policy Change: A Qualitative Comparative Analysis Combining ACF and MSF

Following the financial crisis, Bismarckian health systems underwent some major reforms. This article analyzes under which conditions major reforms occurred. To do so, it theoretically combines conditions from the Advocacy Coalition Framework (ACF) and the Multiple Streams Framework (MSF) to emphasize the added value of merging them to explain major policy change. By combining these two approaches, it is possible to present a more comprehensive picture of the reform processes, relying on the significance of both policy learning within actor coalitions (as particularly important in the ACF) and the role of ambiguity and timing (as particularly important in the MSF). Empirically, the article focuses on the health care reform packages from 2009 to 2013 in the four traditional European Bismarckian countries, Austria, Belgium, France and Germany. The analysis reveals learning as a necessary condition for major policy change. Consequently, a major reform only happens as a result of learning processes, either combined with a negotiated agreement, which presents a pure ACF-related configuration, or combined with a window of opportunity opening in the problem stream. The latter configuration thus confirms the need for integrating a condition from the MSF into the ACF to explain major policy change.