Explaining Quality Management in the Danish and Swedish Public Health Sectors: Unintended Learning and Deliberate Co-Optation

This article examines the development of diverse quality systems in the otherwise quite similar Danish and Swedish public health sectors. After decades of numerous piecemeal medical and managerial quality development programs in both countries, a nationwide mandatory accreditation system was introduced in the Danish health services in 2009. Nationwide quality indicator projects are also found in Sweden, but there has been political attempt to introduce a compulsory system. This article seeks to explain this difference. It argues, first, that resistance from the medical professions blocked the introduction of compulsory, nationwide quality systems in both countries for decades. Second, the implementation of the Danish accreditation system was triggered by a combination of unintended policy learning produced by local reforms in two counties and of the Ministry of Health’s carefully orchestrated policy process that served to co-opt critical voices in the medical profession.     

Knowledge Utilization in Canadian Health Service Organizations: A Path Analysis

The aim of this article is to study direct and causality effects of variables involved in knowledge utilization (KU) explanations. Based on a survey of 928 managers and professionals in Canadian health service organizations (HSOs) (ministries, regional health authorities, and hospitals), the results of the path analysis indicate that the extent to which research results are used in policy and practice is influenced by the format of research results, by organizational and contextual variables (e.g., research culture and absorptive capacity), by the formal partnership activities initiated between the producers of research and users (formal linkage mechanisms), and by the user’s relational capital (informal linkage mechanisms), among other variables. Formal and informal linkage mechanisms have a positive and significant impact on KU in different causal explanations. The article shows that utilization processes are interdependent in their causes and effects, and thus complicated to study.     

Public participation

’Evidence‐based practice’ is a term used in Britain's National Health Service to describe the use of research evidence in policy, management and practice decisions. This article develops this idea and explores its use in local government decision making, using case studies of social care and education. It argues that the absence of a funding stream to support local authorities’ own research reinforces a view of local authorities as essentially administrative arms of the state, supervised through service‐by‐service performance measurement, rather than ‘intelligent’ agents using local research to develop evidence‐based policies.     

The public valuation of religion in global health governance: spiritual health and the faith factor

ABSTRACT

This article explores how the role of religion is evaluated in global health institutions, focusing on policy debates in the World Health Organization (WHO) and the World Bank. Drawing on Luc Boltanski and Laurent Thévenot’s pragmatist approach to justification, I suggest that religious values are creative and worldly performances. The public value of religion is established through a two-pronged justification process, combining generalizing arguments with particularizing empirical tests. To substantiate the claim that abstraction alone does not suffice to create religious values in global public health, I compare the futile attempts of the 1980s to add ‘spiritual health’ to the WHO’s mandate with the more recent creation of a ‘faith factor’ in public health. While the vague reference to some ‘Factor X’ inhibited the acceptance of spiritual health in the first case, in the second case, ‘compassion’ became a measurable and recognized religious value.     

Weberian Public Administration Versus New Public Management in Eastern Europe: The Case of Romania

As a recent member of the European Union (EU), Romania aligned its public policies to Westernized models of civil service reform. This article critically analyzes the impact of Human Resource Management (HRM) models as compared to a Weberian Easternized public administration culture, which continues to display strong hierarchical relationships, rather than the “networked” governance favored by some Western European countries.

The focus will be on the development of HRM policies and practices, taking as a set of case studies Romanian central government organizations. The key problem to be addressed is to understand why such organizations remain locked in ineffective systems of personnel administration. Yet, Romania, along with other Eastern European states, has been exposed to international reform movements in public management through policy transfer. The article will look for evidence of New Public Management (NPM)-type practices, in addition to HRM.

Moreover, the countries of Eastern Europe are far from homogeneous, and so an understanding of both the institutional and cultural context is crucial to ascertain the acceptability of NPM. In the case of Romania, this article considers HRM developments in a multi-culturally influenced state, which has also experienced Socialist regimes. However, policy innovations have started to appear, not only as a consequence of the international diffusion of “good practice” and “policy learning, ” but also stemming from the demands of European directives. Thus, the aim of this article will be to assess the role of policy learning in relation to HR reform in the public service.     

Regional Offices in the New NHS: An Analysis of the Effects and Significance of Recent Changes

This article reports on a two-year, multi-method, qualitative study in two regional offices in the UK National Health Service of the changing role of the regional tier from the autumn of 1994. The nature of the changes from fourteen semiautonomous regional health authorities to eight regional offices of the NHS Executive, whose staff became civil servants, are described together with the way this reorganization changed the role and relationships of NHS Executive HQ, the regional offices and the field. By the end of our research in the autumn of 1996, the change from regional health authority to regional office had gone well in the two regional offices studied; they had become smaller organizations, had established closer working with HQ and believed they had more influence over policy, while retaining good relations with health authorities. Emerging issues from the changes and some of their implications are discussed, particularly the pressures towards greater centralization and the particular forms that these have taken, despite the aim, and in part the achievement, of greater devolution, and the cultural differences between the NHS and the civil service. We conclude by assessing what the future holds for regional offices, in the light of the recent NHS White Paper (Secretary of State for Health 1997)     

Introducing Purchaser/Provider Separation in the Catalan Health Administration: A Budget Analysis

This article examines the extent to which the Catalan reform launched in 1990 effectively introduced the purchaser/provider separation within the public health administration. The reform had two formulation sources: a law passed by the Catalan Parliament, which left this principle vague, and a further 'new public management' discourse, which interpreted the law in terms of a clear purchaser/provider separation. This study uses Dunleavy's (1991) analytical model of agency types to compare the impact of the reform on the budget structures of the health administration agencies affected — namely, the Department of Health and Social Security, the Catalan Health Service and the Catalan Health Institute. The data show that while the provider role was clearly defined and implemented, the purchaser role was not. Instead, the role of the health authority embodied the complex blend of functions established by the text of the law, which was also reflected in its budget structure, and which blurred the separation between purchaser and provider.     

Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from Clinical Commissioning Groups and Shadow Health and Wellbeing Boards

Statutory responsibility for health care and social care has long been separated between National Health Service (NHS) bodies and local government authorities. Repeated policy attempts to promote service integration through collaboration between such authorities have achieved little. The latest of such policy interventions are the Health and Wellbeing Boards (HWBs) established by the 2012 Health and Social Care Act (HSCA) alongside a range of other organisational innovations, including Clinical Commissioning Groups (CCGs). These organisations await full legal and operational status but have begun to develop structures and processes. HWBs are intended to lead the integrated assessment of local needs to inform both NHS health and local authority social care commissioners. We undertook detailed qualitative case studies in eight CCGs during 2011–2012 and here report observational and interview data related to CCGs’ perspectives and observations of early HWB developments. We found that developing HWBs vary greatly in their structure and approach, but we also identified a number of significant issues that are familiar from earlier research into health and social care integration. These include heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.     

Trade Liberalization in Indonesian Health Services: Prospects and Policies

The worldwide increase in demand for health services offers developing countries, like Indonesia, significant opportunities to expand international trade in this area. However, policy aimed at achieving this objective must carefully consider the World Trade Organization's (WTO) General Agreement on Trade in Services (GATS). For signatory nations and those considering becoming signatory nations, the procedural, structural, and other effects of the GATS make it a formidable challenge for national health policy alongside its impact on trade liberalization. Invoking the four GATS health care trade modes, this article develops possible approaches to Indonesian health services in the context of trade liberalization.     

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.     

Evaluating Health Care Reform: the Case of the NHS Internal Market

The NHS internal market, introduced in an atmosphere of controversy, continues to generate much disagreement. This article examines the evidence on the impact of this policy with regard to a range of criteria, including efficiency, accountability, effective planning and co-ordination, patient choice and service quality, equity, and the culture of the NHS. It explores the different ways in which this evidence is perceived and seeks to make explicit the assumptions and biases of those involved in the debate about the reforms. The article also examines the policy process behind the reforms and the extent to which it has added to the problems of evaluation. By way of conclusion, the implications for future health care reform are considered and a number of procedural changes suggested.     

Joint Planning across the Health/Social Services Boundary since 1946

This article reviews the development of post-war policy on the joint planning of health and social services for older people in the context of broader theoretical ideas about inter-organisational collaboration. It identifies the lack of organisational homogeneity and the absence of domain consensus across the health/social services boundary as the main obstacles to progress. However, the article hrther suggests that, if these problems are to be properly understood, the broader policy context within which joint planning took place must also be investigated. In this regard, the article suggests that central government's attempts to encourage joint planning since the 1960s have repeatedly been hampered by distrust among local agencies of its more general policy intentions in this area.     

The politics of HIV/AIDS in South Africa: government action and public response

A decade ago it seemed likely that African governments would be destabilised by the impact of the HIV/AIDS epidemic. This article tests some of the presumptions in such forecasting with an examination of the South African case. It begins with an assessment of the effects on the public health system of the South African government’s efforts to cope with the illness. Efforts to implement universal treatment of people who are HIV-positive appear to have strengthened government, while the costs have been affordable. The efforts have extended the embrace of the public health system and prompted the engagement of civil society in policy formation and implementation. Survey evidence suggests that the government has gained public approval and that its health service delivery has become more socially accountable. Civil protest to engender political reforms in the treatment of AIDS patients has enhanced the role of constitutional checks on executive authority.     

Between willing and reluctant entrapment: CEE countries in NATO's non-European missions

The article focuses on Central and Eastern European (CEE) countries' experiences related to Afghanistan, Iraq and Libya, three non-European theatres of Western military operations, in predominantly Muslim lands, in the decade between 2001 and 2011. CEE countries readily became involved in two of these foreign missions (Afghanistan and Iraq) because of their deep ties to Western politico-economic structures, without direct security interests compelling them to do so, but not without normative convictions regarding what were seen by them as virtues of the two missions. In Libya, however, they were reluctant to join the Western intervention. In light of this, the article is interested in examining how political elites within the region relate to the generally constrained security policy agency that they have. A key argument advanced is that such agency may be located in how external hegemony is mediated in elite discourses of threat and legitimacy construction. This as well as the three case studies outlined in the article show that the seeming changes in CEE countries' behaviour in fact boil down to a simple set of rules guiding their behaviour. Having identified this “algorithm” as an implicit pattern of CEE foreign policy behaviour, originating in the intra-alliance security dilemma within the North Atlantic Treaty Organisation (NATO), the article formulates its conclusions about the alliance policy of these countries largely within a neorealist framework.     

INTERROGATING INSTITUTIONAL CHANGE: ACTORS' ATTITUDES TO COMPETITION AND COOPERATION IN COMMISSIONING HEALTH SERVICES IN ENGLAND

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.     

Public Sector Commissioning: Experiences of Voluntary Organizations Delivering Health and Social Services

The perceived benefits to users and beneficiaries of voluntary organizations delivering public sector services have been well documented and include the engagement with parts of society that the state cannot reach, personalized service delivery, and improved services. There is a lack of clarity, however, as to whether these perceived benefits are being realized. This article presents the experiences of voluntary sector organizations involved in public sector commissioning. The research suggests that the public sector is limiting the voluntary sector's engagement in service design and performance monitoring. These findings raise questions about the role of the voluntary sector in public service provision.     

Health in the United States.

On the whole, the American people consider themselves healthy and, according to the major health indicators, they are becoming healthier all the time. The expectation of life at birth is one and one-half times what it was at the beginning of the century. Many of the leading causes of death have experienced significant declines in rates in the last decade. Nevertheless, the minority populations frequently lag behind the white population with respect to health indicators. Prevention in the health field is being stressed through immunization programs and programs to influence individuals to change their habits. Nutrition is playing a larger role in public life; considerable publicity has been given to dietary goals for promotion of good health. The health service industry has grown rapidly. Health care has expanded and its costs have trebled since 1970. In the 1980s, interest will undoubtedly focus on minority populations and health, on how the economically disadvantaged may better be served, on the effects of an aging population on the health care system, and on how life-styles which undermine health care can be changed. The U.S. Surgeon General has established national health goals for the 1980s that will improve the nation's health if they are achieved.     

Progress in Health around the World

Health is a key component of human development. This article looks at how health is measured, and the convergence of health across countries. We argue that health measures should account for illness as well as mortality, but in practice life expectancy is a reasonable proxy for population health. While health is improving we see two distinct groups of countries in the data, clustering around different long run steady states. Many countries have experienced large health gains without prior income gains and in countries not affected by HIV/AIDS the last 40 years have been a success story in terms of health.     

Health care for the poor.

In the 1980s the convergence of a number of factors is causing government at all levels, industry, and labor to plan or initiate major reductions in health spending. Important among these are rising health care costs, a troubled national economy, mounting federal deficits and state revenue shortfalls, and the philosophical course and domestic policy of the Reagan administration. In this context government has been rethinking its capacity to finance health services for the poor, and new and sometimes controversial arrangements for delivering these services are being developed. The dilemma government officials face now is how to cut costs while still assuring that quality medical services are available. This article focuses on what these new policy developments and arrangements are and whether the significant gains in access and in health achieved over the past 20 years will be sustained. Because truly sweeping reforms are unlikely, whether government will maintain earlier commitments and established arrangements for financing and delivering health services to the poor will be worked out piecemeal over the next several years.     

Like Red Tulips at Springtime: Understanding the Absence of Female Martyrs in Afghanistan

In an era where female suicide terrorism is on the rise in conflict regions such as the Middle East, the North Caucasus, and South Asia, why has Afghanistan been largely immune to this trend? Why do some violent groups use female suicide terrorism and others avoid it? This is a critical question for policy makers and analysts attempting to understand a dangerous terrorist phenomenon and how it may evolve in Afghanistan. During the anti-Soviet jihad, narratives were woven of men and women marching through the mountains of Nuristan to “offer their blood for the Islamic revolution like red tulips at springtime.” But today, women are wholly absent from the Taliban and their jihad in Afghanistan. This article analyzes, in particular, the absence of women in Taliban martyrdom operations. There are three primary findings from this study that explain the low propensity for female suicide bombers in Afghanistan. First, a permissive social and geographic environment in Afghanistan gives insurgents freedom of mobility and a resistance capacity characterized by a reduced necessity for female suicide bombers; second, the capacity of a fiercely conservative culture restricts female participation in both Afghan society and within insurgent organizations; and third, the pronounced absence of a female culture of martyrdom limits women from participation in insurgent actions and narratives.