General health practitioners as a public service? Mayors and their emerging role in securing health care provision in rural municipalities in Germany

In Germany, mayors oversee a set of public services, which they organize based on the principle of local self-governance. Generally, health care provision isn’t one of those services. However, over the last couple of years a growing number of structurally disadvantaged regions are confronted with unequal access to health infrastructures. In particular, local shortages of general practitioners challenge rural municipalities. They serve not only as health care for the locals but are relevant also as a location factor in terms of employment and rural development. It has proven to be rather difficult to mobilize young practitioners to open a medical practice in rural regions. On top, municipal resources in the areas of personnel, finances and expertise are limited. Nevertheless, many mayors are rather eager to engage in the securitization of this social infrastructure. Mayors acquire knowledge, build networks, offer financial incentives and show a substantial interest in policy solutions. Scholars have so far gathered data on the problem definition of said mayors. In four of the 16 Länder, studies have assessed whether mayors and county commissioners feel it is their duty to support and secure local supply conditions. There is however a fundamental lack of data on the political processes taking place once supply shortages are considered to be of public interest. This article therefore seeks to illuminate the local political organization of general practitioner shortages in structurally disadvantaged rural areas. To achieve this, I have gathered and analyzed data in six German counties which are challenged by general health practitioner shortages. Firstly, I have analyzed the local newspaper discourses via discourse network analysis. This data illustrates possible shifts in the problem definition of central local actors and gives an overview of the discussed and tested solutions. Secondly, I assessed policy documents and written statements by the relevant local actors to further analyze their argumentative and behavioral self-positioning. Lastly, I have conducted 32 interviews with experts of the local political processes. For the article at hand, I apply the Multiple Streams Framework to the collected data. This will shed light on the politicization of the problem, local negotiations on feasible solutions and prominent actor constellations pushing or hindering local initiatives. In doing this, I contribute to the further investigation of local health care governance by reflecting the role of mayors as political entrepreneurs in terms of material solutions, knowledge, and emerging network structures. Furthermore, I produce novel empirical evidence on health policy in rural areas, which is still an under-researched area.