The Discursive Construction Of Public Policy

Modern policy process research is intended to explain the causal mechanisms drivingpolicy choices and changes, and generate “useful knowledge” to improve policypractices. Policy process theories are committed to answering these two basic questions:why to make specific policy choices, and how to make? The existing theories, on theone hand, have neglected the impact of symbolic and argumentative factors, such aslanguage, communication, dialogue, rhetoric, symbol, etc. The impact of these factors isto explain and demonstrate the “rationales” of policy choices and changes. On the otherhand, the existing theories are limited to positivism (objectivism) paradigm, ignoringthe “constructive” nature of the constituent elements of public policy. This “ignoring”will not only allow us to recognize the reality of policy process too “thin”, but also willhinder our accurate understanding of the political nature of policy process. This paper’sresearch on “discourse” or “discursive construction” can make up the defects of existingpolicy process theories, and reflect a post-positivism research orientation.Due to the concerns on “meaning”,“discourse” is defined as a complex composed byconcepts, terms, statements, categorizations, ideas, frameworks or principles. Being asthe “medium of meanings”, discourse can be used by people to understand andexperience social reality, and engage in a variety of practical activities in specifichistorical and social contexts. The “content” of discourse includes not only the“meanings” expressed or claimed publicly, but also the “discourse infrastructure”,which is more important. The “discourse infrastructure” is the social relations in whichdiscourse “embedded”. As an abstract symbolic medium, discourse has some importantproperties including materiality, political, contextuality, anonymity, and interdiscursivity.Besides, discourse has important functions including production function, framefunction, and ideological function. On the philosophical position of constructionism, the basic assumption of discourse study is that, while mapping the world, discourse isactively “create” or “constitute” the world. Based on different positions, cognition, andintentions, different subjects may give different meanings to the same social phenomena,thus, they may construct different social “realities” or “problems”.When applying discursive constructionism to explain public policy,“policy issues”,“policy target populations” and “policy rationales” all have the essential attribute ofdiscursive construction. In the policy process model of discursive construction, policychoices and changes within a specific period are not direct response by policy makers to“objective” social problems. To the contrary, they are specific constructions of social“problems”, relevant groups of "identity", and policy “rationales” by policy makers bycertain discursive argumentation strategies, the aim of which is to achieve theirintentions. Policy process is fundamentally a process of meanings-giving,discourses-claiming and competing around specific policy issues, and the final policyoutcomes reflect the content of dominant policy discourse. Besides of the rationality ofdiscourses, the factors affecting policy discourses competition includes macrocontextual factors, discourse actors’ resources, powers, strategies, and the influence ofpolicy feedbacks. Policy choices or changes in reality are the results of the combinedeffects of those factors above.The policy discursive constructionism model is applied to explain the process ofissues setting, policy making and changes of national cooperative medical policy, andthe focus is to explain how this policy come to being in the construction andcompetition of relevant discourses. Besides, this paper use the research method of“history-comparison” to explain how this policy changed accompanied with changes ofdominant policy discourses. After analyzing kinds of data including policy texts,archival materials, and research literatures, this paper finds that there existed a varietyof policy discourses in different historical periods. In different (dominant) policydiscourses, the policy issues, the peasantry’s status, and policy rationales associatedwith the CMS are constructed into different forms, which laid the foundation for policychoices or changes.In terms of policy issues, the “cooperative medical care”, as a kind of healthfinancing system, is supposed to solve the peasantry’s problem of “having no money tosee a doctor”. However, in the “collectivization” discourse (the mid-1950s to the early 1960s), the “problem” to be solved by the CMS was constructed as the problem of“adapting” to changes of rural cooperation and commune. In the “revolution” discourse(the mid-1960s to the late1970s), the “problem” to be solved by the CMS wasconstructed as not only “difficulty of poor peasants’ having no money to affordmedicine”, but also to implement Chairman Mao’s “highest order” and take the“proletarian revolutionary line of health”, which were more important. In the“modernization” discourse of the early years of reform and opening up (the late1970sto the late1980s), the CMS was constructed as “equalitarianism and transfers” and“increase the burden on the masses”. In order to correct the “Left” mistakes,“cut theCMS” was put into the national policy agenda in a subtle form. In the course ofreconstruction of the CMS in1990s, relevant policy actors focused on peasantry’sproblems of “expensive and hard to visit doctors”. However, different policy discoursesgave different meanings to the “problem” of the cooperative medical policy. Under thedominance of “local cooperation” discourse, the problem of “expensive and hard to visitdoctors” was considered as a problem can be solved without national financialinvestment. By contrary, in the “national investment” discourse, the centralgovernment’s support is regarded as a necessary condition for solving the aboveproblems. In the joint discourse of “national investment” and “alleviate poverty”, theproblems to be solved by the cooperative medical policy were not only “improvehealth” by strengthening peasantry’ ability to pay, but also “alleviate poverty” byreducing peasantry’ health risks. Besides, in terms of policy issues’ property, policydiscourses emphasized not only the “health” property of cooperative medical issues, butalso their “political” or “economic” property repeatedly, which were also the results ofspecific discourse’s interpretation.In terms of policy target populations, the social status of peasantry, major“beneficiaries” of the cooperative medical policy, had different “positioning” indifferent policy discourses, which have affected the “deserving” qualification of thisgroup in national medical benefits supply. In the “collectivization” discourse, theemphasis on “mutual cooperation” among the peasantry made them unable to obtain asubstantial allocation of state benefits. In the “revolution” discourse,“poor peasants”gained the superior “people” status, and the CMS became a special political statusenjoyed by the group. However, the peasantry still didn’t have access to the national care of substantial financial investment. In the “modernization” discourse after thereform and opening up, the “people” status with ideological characteristics given to thepeasantry no longer sustained, and begun to return to the status of “national”. Butduring the process of commercialization and market-oriented reforms, the social rightsincluding health rights of the peasantry were ignored, and they had to rely on their ownto bear the medical expenses. The national efforts to reconstruct the CMS in1990sreflected the increasing emphasis on the health protection problem of the peasantry.However, in the “local cooperation” discourse, the social security rights of peasantrystill didn’t receive enough respect. In contrast, under the auspices of “nationalinvestment” and “alleviate poverty” discourses, the policy-making of the New RuralCooperative Medical Scheme showed that health has become a basic welfare for thepeasantry, and it’s a proof of national recognition of their social security rights.However, the design of current national policy shows that there still exist limits in thisnational welfare and deserving qualifications given to the peasantry.In terms of policy rationales, in the “collectivization” discourse, the CMS wasregarded as the welfare of socialism (communism), and was the transition form to thegoal of “free medical care” in the communism, reflecting the superiority of socialism. Inthe “revolution” discourse, the CMS was regarded as the “New Things” in the “CulturalRevolution”, and was the reflection of “take the proletarian revolutionary line of healthof Chairman Mao”. In contrast, the negative treatments to the CMS were regarded as“counterrevolutionary (revisionist)”. In the “modernization” discourse in the early yearsof the reform and opening up, the CMS was regarded as the outcome of the “Left” lineof the “Cultural Revolution”,“unproductive expenditure” and the uncultured primaryhealth care system, thus, it was “denied” or doubted. In the “local cooperation”discourse in1990s, the emphasis on the retreat of the state from “blanket” whilebuilding a market economy, the “public welfare” property of medical and healthservices, and national “low” level of economic development, made the CMS withoutnational financial investment gain the “reasonableness” status. In contrast, in the“national investment” discourse, associated with “improve the peasantry’s health”,“promote rural economic development”,“maintain social stability”, and alleviate thesituations of “poverty caused by illness” and “return to poverty caused by illness”, the“necessity” of central financial investment has been demonstrated. The research on the discursive construction property and discursive constructionprocesses (competitive interaction process among discourse coalitions) of the nationalcooperative medical policy in specific period have reflected the real impacts of“discourse” on the content and form of public policy. The social “reality”, as the basesof policy choices, is no longer “objective and only”. In contrast, there are “multiplerealities” as the results of discursive “construction” and “interpretation”. Due todiscourse’s nature of competition (or “hegemony”), it is always associated with theexercise of powers. Simultaneously, as a form of practice,“discursive construction”process itself is a process of power exercises. In addition, because of relating to theproduction of knowledge or the “truth”, the power operation of discursive constructionis “hidden”, which bases on people’s “consent”. Due to this characteristic of “discourse(construction)” factors, the policy processes in practice often reflect as a complex of“political” and “rational”. That is, the nature of policy process is a political process, butoften Show a "rational" appearance. This feature indicates that the policy processes inreality can be understood as a “rhetorical” process, that is, a power operation processwith means of “argumentation” or “persuasion”.Policy discourse (construction) research reflects a new understanding of public policyand policy process, which is different from traditional positivist research orientation.Besides, discourse research also has a normative implication to help improve the humanpolitical and social practice, that is, the possibility of a “dialogue” between differentdiscourses. In the field of public policy-making, promoting a new policy-making ideaand form called “policy deliberation” can help improve policy-making practices. Policydeliberation requires all policy stakeholders and the people interested in specific policybe given equal rights and real opportunities to participate in discussions aboutpolicy-making, and express their interests, claims, ideas and viewpoints in a free, openand full discussion. And this discussion should have a substantial impact on the finalpolicy outcomes. Thus to re-examine the cooperative medical policy in rural China, themost important reason why the peasantry has long been “discriminated” or “excluded”from the supply of national health welfare is the absence of their participation ordiscourse rights. In terms of rights, while gaining economic and social rights (healthcare, social security rights) gradually, the peasantry still didn’t gain political rightstaking political/policy participation as its core. The defects in current policy design of the NCMS show that, the CMS needs to achieve the transformation from the top-downstate-led welfare-given to basic civil rights. Besides, after gaining the real “national”identity, the peasantry also need obtain the status of “citizenship”.