In France, Germany, Spain, and the United Kingdom, the decades from the late 1980s to the present have witnessed significant change in health policy. Although this has included the spread of internal competition and growing autonomy for certain nonstate and parastate actors, it does not follow that the mechanism at work is a "neoliberal convergence." Rather, the translation into diverse national settings of quasi-market mechanisms is accompanied by a reassertion of regulatory authority and strengthening of statist, as opposed to corporatist, management of national insurance systems. Thus the use of quasi-market tools brings state-strengthening reform. The proximate and necessary cause of this dual transformation is found in the work of small, closely integrated groups of policy professionals, whom we label "programmatic actors." While their identity differs across cases, these actors are strikingly similar in functional role and motivation. Motivated by a desire to wield authority through the promotion of programmatic ideas, rather than by material or careerist interests, these elite groups act both as importers and translators of ideas and as architects of policy. The resulting elite-driven model of policy change integrates ideational and institutionalist elements to explain programmatically coherent change despite institutional resistance and partisan instability.

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This article introduces the Programmatic Action Framework (PAF) as a supplementary perspective in policy process research. It focuses on professional biographies of programmatic actors, policy programs, and programmatic identities as driving factors for policies. Programmatic actors are individuals in direct interaction with the state apparatus. Civil servants, politicians, and similar individuals under certain predictable circumstances form stable alliances called programmatic groups. These programmatic groups are bound by commitment to the creation and promotion of a specific policy program, a definable set of instruments intended to attain an explicit policy objective. This policy program, rather than more diffuse beliefs or preferences, provides the defining element of the social group and corresponding social identity for such programmatic groups. Programmatic groups compete with each other for legitimate authority within and across policy sectors by seeking to impose their preferred instruments. Homogenous career trajectories, continuous linkages, and a coherent and strong joint program are essential determinants for the formation and success of programmatic groups.