Abstract :
Studies of German health policy often highlight institutional
constraints to reform. However, based on a case study of the introduction of
clinical standards as part of the Disease Management Programmes for chronic
illnesses, this article suggests that negotiating reform at an arm’s length from the
state can also lead to governance change, although the strengthening of
hierarchy is not as prominent as that in some of the countries studied in this
special issue. As such, the case of Germany offers interesting insights into the
politics of governance change that occur in the shadow, but largely without the
direct involvement of the state, which is typical of a corporatist health-care state.
In this respect, the analysis identifies three leverages for change. First, the change
in medical governance explicitly builds on earlier reforms and gives the reform
alliance a competitive edge. Second, the organisations of the joint selfadministration,
as a more or less open ally of the state, play an influential role
throughout the reform process. Importantly and third, this is complemented by
the state steering at a distance.
