The diffusion, modularization, and institutionalisation of Direct Social Actions in healthcare. The Greek Healthcare Arena: 1983-2019

This thesis is the product of my political and scholarly engagement with healthcare activism in Greece during the past decade and, more specifically, with the Social Clinics-Pharmacies’ movement that emerged in the country over the course of the most recent cycle of anti-austerity contention. The Social Clinics-Pharmacies’ movement was composed of grassroots clinics and/or pharmacies that provided free healthcare services and pharmaceuticals and engaged in protest tactics for reform in the Greek National Healthcare System. In just two years the movement became prominent and affected opportunities for itself. As such, and upon the closure of the cycle of contention and the rise of its ally-party SYRIZA into power in 2015, representatives of the movement were invited to participate in the drafting of healthcare reform around two of the most pressing and unresolved issues of the Greek National Healthcare System since its establishment in 1983. These pertained to the extension of coverage and the development of a comprehensive Primary Care level. I argue that this involvement of the movement into policymaking is an instance of movement institutionalization that reinforced convergence around tactics of healthcare provision from below as well as divergence in their strategic employment. By 2016 the movement had dissolved while individual clinics and/or pharmacies continued their operations. Departing from this case study, this thesis contributes to the existing social movement scholarship in at least three directions. First, it enriches analyses on repertoire innovation by providing a contextual and strategic perspective to the appropriation of tactics of healthcare provision by different actors. The expansion of Direct Social Action tactics (henceforth DSAs) has received attention over the past years and has been interpreted as reflecting a double deficit in democratic and welfare politics. I argue that healthcare DSAs compel us to study the configuration of strategies against fluctuating socio-economic and political environments and within particular institutional arrangements that advance as central for the domain of healthcare. In addition, this thesis advances the recent literature on DSAs by introducing a relational, dynamic and longitudinal perspective to their employment. This is achieved through the close investigation of healthcare DSA tactics from (i) the first instances of their utilisation after the establishment of the Greek National Healthcare System, (ii) their diffusion and modularization in the years following the 2010 crisis and the cycle of anti-austerity contention, as well as (iii) their solidification following movement institutionalization. Those three periods highlight the contextual and dynamic, interactive and strategic dimensions of the employment of healthcare DSAs. Last, this thesis embellishes accounts on movement institutionalization. More specifically the longitudinal investigation of the Social Clinics-Pharmacies allows us to approach institutionalization as at once a process and an outcome of the diffusion of healthcare DSAs in the Greek healthcare arena. As I hope to show the healthcare arena molded the profile of the movement as particularly institutionally oriented, and prone in assisting in and negotiating over progressive healthcare reform. This led to the swift institutionalisation of the movement at the peak of the Social Clinics-Pharmacies’ paradigm. Institutionalization, therefore, was a process composed of the various interactions between all those actors animating the Greek healthcare arena in the direction of repertoire innovation and healthcare reform. Institutionalization was also an outcome of collective action, with direct implications onto healthcare policy and indirect, unintended effects for the movement. Following movement institutionalisation, movement dissolution and the advent of reform, I observe the carving of different trajectories to and fro the same tactics of healthcare provision configured around the different interpretations of the reform and, relatedly, distinct strategic uses of healthcare DSAs.