Path-dependency theory says that complex systems, such as health systems, are shaped by prior conditions and decisions, and are resistant to change. As a result, major policy changes, such as health system reform, are often only possible in policy windows—moments of transition or contextual crisis that re-balance social power dynamics and enable the consideration of new policy ideas. However, even in policy windows there can be resistance to change. In this paper, we consider the role of ideas in constraining change. We draw on political science theory on the dynamic relationship between foreground ideas (policy programmes and frames) and background ideas (deeply held collective cognitive and normative beliefs) to better understand how ideas exert influence independently of the contextual conditions that give rise to them or the actors that espouse them. To do so, we examine two apparent policy windows in the South African National Health Insurance policy process. The analysis reveals how ideas can become institutionalised in organisations and procedures (such as policy instruments or provider networks), and in intangible cultural norms—becoming hegemonic and uncontested ideas that shape the attitudes and perspectives of policy actors. In this way, ideas operate as independent variables, constraining change across policy windows. While health policy analysts increasingly recognise the influence of ideational variables in policy processes, they tend to conceptualise ideas as tools actors wield to drive change. This analysis reveals the importance of considering ideas (values, norms, and beliefs) as persistent features of the policy-making context that constrain actors.

路径依赖理论认为，复杂的系统（例如卫生系统）是由先验条件和决策决定的，并且难以改变。因此，卫生系统改革等重大政策变化往往只能在政策窗口——转型时刻或背景危机时刻——重新平衡社会权力动态并促使考虑新的政策理念——才有可能实现。然而，即使在政策窗口期，变革也可能会遇到阻力。在本文中，我们考虑了思想在约束变革中的作用。我们利用政治学理论来研究前景思想（政策计划和框架）与背景思想（根深蒂固的集体认知和规范信念）之间的动态关系，以更好地理解思想如何独立于产生它们或政策的背景条件而发挥影响力。支持他们的演员。为此，我们研究了南非国民健康保险政策流程中的两个明显的政策窗口。分析揭示了思想如何在组织和程序（例如政策工具或提供者网络）以及无形文化规范中制度化，成为塑造政策行为者态度和观点的霸权和无可争议的思想。通过这种方式，想法作为独立变量发挥作用，限制了跨政策窗口的变化。虽然卫生政策分析师越来越认识到政策过程中理念变量的影响，但他们倾向于将想法概念化为行动者用来推动变革的工具。这一分析揭示了将思想（价值观、规范和信仰）视为约束行为者的政策制定环境的持久特征的重要性。