The paper explores the relationship between discourses, narratives and institutional change in the post-communist transformation of the Czech health care. In the paper, based on discourse analysis of the Czech health care since 1990, two dominant discursive imaginaries are identified: (1) the discursive imaginary of health hopes connected with promises of better care, medical innovations, shifting away from an outdated and inefficient care, and increasing life expectancy and quality of life and (2) the discursive imaginary of fiscal fears connected with concepts such as increasing government debt, healthcare spending, insecure fiscal future and economic responsibility. With respect to Laclau, these imaginaries can be defined as a horizon or an absolute limit which structures the field of intelligibility. Both discursive imaginaries can produce different narratives based upon their relation to broader cultural systems of rules and values of community solidarity.
Narrative perspective is ideal for studying the dynamic of health policy, which is characterised by a tension between citizens’ rising expectations, on the one hand, and the imperative of permanent austerity, on the other hand. Using the cultural theory developed by Mary Douglas, narratives can be defined according to how they articulate societal constraints for individual members and how they defy or circumvent the rules and boundaries of their particular social environment. Different regulatory codes construct different types of disorder. Whereas crisis in the individualist code is connected with lack of incentives, crisis in the hierarchist code is associated with lack of reputation.
After 1989, the first period of transformation was characterised by a dominant individualist code, focusing mostly on basic market-oriented reforms such as a pluralistic health insurance model to guarantee up-to-date treatments. It resulted in a growth of total health care expenditure. In the context of accession to the EU in 2004, as reforms of public administration and transposition of European norms were being conducted, a hierarchist code stressing the need to consolidate rules prevailed. The last complex reform was proposed after the parliamentary elections in 2006. The reform plan corresponded with a global shift towards a neoliberal paradigm in health care, focusing on consumer-oriented services obtained in the market and patients as responsible and rational actors.
In the Czech context, the individualist code served predominantly to articulate a combination of the health hopes imaginary and the fiscal fears imaginary. On the contrary, the hierarchist code was often employed to express the fiscal fears imaginary. This historical configuration marked significantly the character of post-socialist welfare, because the positive imaginary of modernisation of health care was always associated with the individualist discourses of market-driven reforms. Efforts to strengthen rules and hierarchies, on the contrary, were much more underscored by fiscal doomsday scenarios.
