HYBRIDS AND PROFESSIONAL COMMUNITIES: COMPARING UK REFORMS IN HEALTHCARE,BROADCASTING AND POSTAL SERVICES

Many countries use state‐owned, for‐profit, and third sector organizations to provide public services, generating ‘hybrid’ organizational forms. This article examines how the hybridization of organizations in the public sector is influenced by interaction between regulatory change and professional communities. It presents qualitative data on three areas of the UK public sector that have undergone marketization: healthcare, broadcasting, and postal services. Implementation of market‐based reform in public sector organizations is shaped by sector‐specific differences in professional communities, as these groups interact with reform processes. Sectoral differences in communities include their power to influence reform, their persistence despite reform, and their alignment with the direction of change or innovation. Equally, the dynamics of professional communities can be affected by reform. Policymakers need to take account of the ways that implementation of hybrid forms interacts with professional communities, including risk of disrupting existing relationships based on communities that contribute to learning.     

Evaluation of the south carolina comr/cunity long-term care medicaid waiver for the elderly and disabled

Medicaid waivers play an important role in the health policy process. Various health care policy initiatives have encouraged states to experiment ith their Medicaid programs by expanding coverage to populations not traditionally covered by Medicaid, or by delivering Medicaid services in non traditional ways. Lessons learned by individual states' Medicaid waivers could be an important part of the health care reform debate. This paper presents an evaluation of a Medicaid waiver operating in South I Carolina. The South Carolina Community Long-term Care Waiver for the Elderly and Disabled is evaluated for cost effectiveness, quality of care, and client satisfaction. This evaluation shows that the waiver is highly effective in offering individuals who are medically and financially eligible for Medicaid supported nursing home care a viable, cost effective, high quality alternate to institutionalization.     

The joint demand for health care,leisure, and commodities: Implications for health care finance and access in Vietnam

This paper explores linkages between the demand for health care providers and the consumption of food, non-food goods, and leisure in Vietnam, using a mixed continuous/discrete dependent variable model. Cross-price elasticities calculated from the model suggest there are strong substitution effects between health care, leisure, and certain commodities. The model allows us to explore the implications of replacing user fees with alternative forms of health care finance, such as commodity taxes. In particular, the results suggest financing public health care services with a non-food sales tax rather than user fees would be more progressive and would improve access to care.     

PUBLICS,PATIENTS, CITIZENS,CONSUMERS? POWER AND DECISION MAKING IN PRIMARY HEALTH CARE

This article uses theoretical approaches to the discussion of power in order to consider the role of public and patient participation in primary health care organizations in the UK. There is considerable evidence to suggest that, despite major national initiatives to extend participation in health services, the role of participation in decision making remains underdeveloped. The primary purpose of this article is to understand how and why this should be the case. Using findings from qualitative research that explored approaches taken by the dominant professional groups on primary care groups (PCGs) to involving patients and the public, we consider how these approaches reflect the exercise of different forms and levels of power. The explanation combines Lukes’ categorization of three forms of power with Bourdieu’s dynamic conceptualization of the relations of habitus and field. It is argued that the models observed represent different opportunities for the operation of power with implications for the role that participation can play.     

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

Restraining mandated service costs: Innovative diffusion of transplant technologies in arizona's medicaid program

Medical technological innovations while usually beneficial are inevitably costly to the medical profession, to government, to the economy, and to society in general. Organ transplantations are prime examples of this dilemma. Such services are mandated by the federal government to state Medicaid programs. A cost-saving effort in Arizona's Medicaid program involving negotiation and competitive bidding with providers of transplantation services could have broad positive implications for states willing to copy Arizona's approach. The approach may even have implications for general health care reform.     

The Political Economy of Village Sanitation in South India: Capture or Poor Information?

Despite efforts to mandate and finance local governments' provision of environmental sanitation services, outcomes remain poor in the villages surveyed in the four South Indian states. The analysis indicates some key issues that appear to hinder improvements in sanitation. Local politicians tend to capture sanitary infrastructure and cleaning services for themselves, while also keeping major village roads reasonably well-served. Their decisions suggest, however, that they neither understand the health benefits of sanitation, nor the negative externalities to their own health if surrounding areas are poorly served. Our findings suggest that improving sanitary outcomes requires disseminating information on the public goods nature of their health benefits, as well as on the local government's responsibilities. It also requires putting public health regulations in place, along with measures to enable accountability in service provision.     

USER INVOLVEMENT IN COMMUNITY CARE: ORIGINS, PURPOSES AND APPLICATIONS

Whilst the drive towards public sector consumerism is intensifying, it is also evident that somewhat different 'brands' of consumerism are currently being marketed. This article develops a framework to assist in the disaggregation and understanding of the range of approaches to consumerism currently being pursued in the field of health and social care. Its principal elements concern the ideological origins of consumerism in this field; their purposes; and the forms through which consumer preference are expressed. This framework is applied to the Birmingham Community Care Special Action Project, a major developmental initiative which the authors have been studying. An important area for further investigation is the extent to which users and carers seek to exercise greater collective control over services as opposed to influencing the development of services more responsive to their individual needs.     

CONSUMERISM AND THE PUBLIC SECTOR: HOW WELL DOES THE COAT FIT?

Consumerism attempts to redress the imbalance of power that exists between those who produce goods and services, and those for whom they are provided. To achieve this end, five basic principles have been evolved which seek to improve consumers' access, choice, information, redress and representation. The article examines the relevance of these principles to services provided by local government and the health service. Its conclusion – that they are useful but not necessarily enough – is perhaps surprising, given the author's concern to place consumers' interests centre stage in discussions about what public services are for, and how they should be run. The article then considers whether the messages of consumerism are reaching their mark, and finally points to those issues which managers of public services – both politicians and professionals – must face if consumerism is to leave a legacy of real value.     

Planning,Budgeting, and Health Care Performance in Ukraine

Abstract

The Government of Ukraine has not pursued health care reforms now commonplace in the rest of Europe and Central/Eastern Europe that rely less upon centralized, state delivery of services and more on decentralized operational responsibilities and competition for services that increase patient choice. The Ukrainian health sector suffers from personnel overspecialization and facility overcapacity, resulting in high-cost, low productivity services. Budget funds are unavailable for operations and maintenance resulting in poor quality services. The state provides health care as a constitutionally-protected monopoly, relying on the traditional command and control model which ignores cost/quality competition options and responsibilities to patients. Overall, the system which produces these results is over-centralized, requiring achievement of physical service norms without providing sufficient funds. The centralized system does not monitor or evaluate services beyond narrow financial accountability and control requirements. The health care system is paradoxically over-centralized but unable to regulate or control local health care official decisions to ensure compliance with national standards. Needed are reforms in the health care policy and operational areas to produce the supply of services needed for national economic recovery. In the short-term, the budgetary framework can be improved as an operational/management guide through development of comparative information on results. Most of this information can be based on the economic classification consistent with the chart of accounts. Funding stability can be increased to improve expenditure control by implementing a new fiscal transfer formula that provides discretion (i.e., block grants) and performance criteria (i.e., outcome measures). In the medium-term, building on the technical foundation of physical norms and statistical reporting, the health care budgeting and financial management system should shift emphasis to: program planning, policy and management analysis, and public communications. The results of these reforms should lead to decentralized health care operations, service analysis, and delivery responsibilities. At the same time, the reforms should lead to proper centralization of responsibilities for strategic policy decisions, safety regulation, national standards, and program evaluation.     

How social capital shapes citizen willingness to co-invest in public service: The case of flood control

Why are citizens in some communities more willing to co-invest in public services than citizens in other communities? Citizen co-investment has become an important policy tool for governments to finance public services, yet little research has theorized and empirically examined the impacts of community contexts on citizens' willingness to invest their personal resources in public services. As social capital is often viewed as an important determinant of citizen behaviours, we propose two competing hypotheses explaining the relationship between social capital and citizen co-investment: the facilitation effect hypothesis and the inhibition effect hypothesis. Based on three data sources, our statistical analyses consistently show that citizens living in counties with more social capital are less willing to co-invest in local flood control. This finding provides empirical evidence to support the inhibition effect hypothesis. Key implications of our research and suggestions for future research are discussed in the conclusion.     

Public hospitals as competitors for medicaid revenue: the case study of St. Louis regional medical center

Medicaid revenues may determine whether public hospitals will survive. Public hospitals participate aggressively in the public market competition for their states’ Medicaid dollars. States must decide whether the survival of public hospitals, as providers of last resort to both Medicaid and uninsured patients, is of continuing importance to their Medicaid programs. Cities, if the states were willing, alternatively could voucher uninsured patients and direct Medicaid patients to the private hospitals that would outlive closed public hospitals. In fact, Medicaid's managed care programs already have heightened this competition, by organizing sufficiently large populations of prepaid Medicaid patients to attract networks of private providers to offer discounted prices, in competition with public hospitals for this market.

Although Medicaid has been a comparatively poor payer, nationally, almost half of public hospitals⁷ funding comes from this source of revenue. Urban public hospitals can barely live with Medicaid revenues, but the extent to which they can live without Medicaid revenues is being determined by surprising new turns in market competition for the revenue. A period of expansive and expensive new congressional mandates for the joint federal-state program was followed in the early 1990s by the introduction by the states of Medicaid revenue maximization strategies. The states’ funding levels, the bases for matching federal contributions, were artificially elevated by provider taxes, provider donations, and intergovernmental transfers. The revenue from all these sources was returned to these providers through the Disproportionate Share Hospital subsidy program for Medicaid-dependent hospitals, as soon as the federal revenue match was calculated, based upon the inflated figures. These practices currently are being stymied, and states simultaneously have escalated competitive bidding by private market managed care providers for Medicaid patients. Missouri has been in the forefront of states moving to maximize the federal Medicaid revenue match and to return Disproportionate Share Hospital funds to providers. St. Louis's public hospital, Regional Medical Center, has been weaned off its local government subsidies, as the intergovernmental transfer and DSH enticements compromised the stability of that hospital's revenue picture. Now, unprotected by an integrated healthcare system or other major role in a regional hospital network, this urban public hospital must struggle to survive within its Medicaid managed care competitive market. The question for the state of Missouri is whether perpetuating a future for Regional will ensure its Medicaid patients a traditional caring public medicine alternative as a fallback position, if Medicaid's present foray into the private market goes awry. For Regional and the city of St. Louis, the question is whether they can any longer count upon traditional state Medicaid revenue and financial support.     

Territorial Boundaries as Limits: A Foucauldian Analysis of the Agglomeration of Municipalities

Public management theories have focused scholars' attention on agglomeration processes between public administrations. Such processes are relevant at a local level to increase efficiency and effectiveness in the provision of public services. Scholars and practitioners have pointed out economies of scale and efficiency in the production of public services as the most important incentives for adopting agglomeration policies.

All kinds of related discourse, such as that relating to economics for example, need to be coordinated in order to change the behaviour of citizens and make the agglomeration process acceptable. The present article adopts a Foucauldian approach in highlighting an additional variable/discourse in addition to all the others used to foster agglomeration processes: the identity and culture of the communities involved in this kind of process.     

Remittances,Regime Type,and Government Spending Priorities

Previous work suggests that remittances enable governments to reduce spending on public services and divert resources to serve their own interests. We argue this need not occur. Building on recent work which shows that the impact of remittances is contingent on the domestic environment in remittance-receiving countries, we hypothesize that (1) remittances are more likely to increase government spending on public services in democracies than in autocracies and (2) remittances are more likely to finance activities that deter political competition in autocracies than in democracies. Using a sample of 105 developing countries from 1985 through 2008, we find strong support for our hypotheses when examining the impact of remittances on public education, health, and military spending. We also provide suggestive evidence for the mechanism underpinning our results: micro-level evidence on remittance recipients’ preferences and political engagement.     

THE QUASI-MARKET,THE ENTREPRENEUR AND THE EFFECTIVENESS OF THE NHS BUSINESS MANAGER

The recent changes in the UK National Health Service were heralded by the publication of the Griffiths report in 1983 which highlighted the need for a business-like’approach to management. The policy makers’generic strategy of the late 1980s and early 1990s centred around the concept of‘quasi-markets’. These were artificial internal markets encompassing the purchasers and providers of public services. Little research has been undertaken into this new phenomenon of the‘quasi-market’but entrepreneurship economic theory would suggest that for markets to be efficient would require a supply of alert and aware entrepreneurs. Within the restructured NHS, the mantle for entrepreneurial management seems to have been placed firmly on the shoulders of the newly created‘business managers’. A 1993 survey amongst NHS business managers in first and second wave trust hospitals in the Trent Regional Health Authority indicated that whilst business managers were knowledgable of what entrepreneurial activity is, they currently feel constrained in their new roles for a variety of reasons. The authors suggest that rational economic analysis is insufficient to explain this lack of innovatory endeavour. Instead policy makers’attention should be devoted to liberating health managers from their current constraints to encourage their entrepreneurial development.     

NEW PUBLIC MANAGEMENT VALUES AND PERSON‐ORGANIZATION FIT: A SOCIO‐PSYCHOLOGICAL APPROACH AND EMPIRICAL EXAMINATION AMONG PUBLIC SECTOR PERSONNEL

This paper takes a socio‐psychological approach to NPM and its value‐based theory in public administration. We develop a model for the study of NPM values based on the idea of Person‐Organization Fit (POF) and examine it empirically. Findings, based on a survey of 205 Israeli local governance personnel, revealed that the POF of several core NPM values (that is, responsiveness, transparency, innovativeness, and achievement orientations) was positively related with job satisfaction, organizational commitment, and service climate, as reported by these public personnel. The findings suggest that, beyond modern strategies and effective policies for the public sector, lies an essential quest for NPM value‐fit with public personnel. Consequently, the study advocates a better theoretical and practical understanding of the socio‐psychological interfaces, such as POF, in public administration. Implications and directions for future studies are discussed, both in the context of public administration research and in the generic field of organizational behaviour theory and practice. The detailed results of the factor analyses are available directly from the authors.     

THE PUBLIC/PRIVATE SECTOR CLEAVAGE REVISITED: THE IMPACT OF GOVERNMENT EMPLOYMENT ON POLITICAL ATTITUDES AND BEHAVIOUR IN 11 WEST EUROPEAN COUNTRIES

This study explores a refined model of public/private sector cleavage voting. Assuming that market and work experiences are crucial for people to develop common political views, it investigates three contexts that shape government employees' willingness to vote as a single constituency: the branch of public sector production, the occupational status, and the type of service economy. Estimation results obtained from regressions on European Social Survey (ESS) data indicate that government employees in public health, education and service production rather than public administration utilize sector cleavage voting. Regardless of their actual occupational status, public health and education employees show persistently stronger attitudes in favour of expanding state responsibility. With respect to party choice, stronger signs of alignment along the sector cleavage are observed in Social Democratic service economies. In sum, the public/private sector cleavage continues to matter in a more complex way than a simple sector dichotomy would suggest.     

Navigating tensions in co‐production: A missing link in leadership for public value

New forms of public leadership are needed to design and implement co‐production of public value. We draw on narrative analysis to explore the barriers to developing the capacity for co‐production of public value in disadvantaged and vulnerable Indigenous communities and find that existing norms not only crowd out efforts at reform, but can work against them. In particular, we find that upward accountability and a focus on expert knowledge are the most problematic for co‐production of public value. We focus on how more traditional practices of public administration mediated the achievements of public leaders in their co‐production efforts when Australian governments introduced strategies for partnership with Indigenous communities for services design and delivery. The analysis suggests that creating a broader enabling environment of supportive logics would allow public leaders to engage more productively with inherent tensions between old and new ways of working.