Chapter 10 presents a conceptual framework complementary to the one that informs the rest of the book, to explore the role of “institutional entrepreneurs” in the course of reform. Like economic entrepreneurs, an institutional entrepreneur is a risk-taking agent who identifies opportunities to recombine existing resources to create new value for some set of consumers, and who reaps profits (or incurs loss) from this innovation. The distinguishing feature of institutional entrepreneurs, as I develop the concept, is that they operate at the interstices of the public and private sectors, combining public mandates with private-sector resources to develop new, hybrid institutional arrangements that span public and private sectors and reconfigure control of key power bases – state authority, private capital and professional expertise. The emergence of an agenda of “redesign” in the health policy arena - and particularly an enthusiasm for “market-oriented” reforms – was ripe for such activity. The role played by institutional entrepreneurs in each case, however, depending on the strategy of scle and pace that political decision-makers were pursuing. In some cases, such as in the Netherlands, institutional entrepreneurs shaped the course of reform; in others, like England, they lay the groundwork during the implementation period that would shape the landscape on which the next window of opportunity opened. In yet others, such as the US, they added unanticipated elements to the reforms. In each case, exploring the activity of institutional entrepreneurs takes us into the implementation period and into the politics and economics of the health care arena itself.

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