INSTITUTIONAL LAYERING IN GOVERNING HEALTHCARE QUALITY

Since the 1980s, regulated markets and New Public Management have been introduced in the public sector across the world. How they have affected existing governance mechanisms such as self‐regulation and state regulation has remained largely unexplored, however. This article examines the origins and consequences of institutional layering in governing healthcare quality. Dutch health care, where a market‐based system has been introduced, is used as a case study. The results show that this market‐based system did not replace but modified existing institutional arrangements. As a result, hospitals have to deal with the fragmentation of quality demands. Using the concept of institutional layering, this study shows how different arrangements interact. As a consequence, the introduction of a certain policy reform will work out differently in different countries and policy sectors. Our ‘archaeological’ study in this layering can be seen as an example of how such incremental change can be studied in detail.     

Dealing with Diversity in the Construction of Indigenous Autonomy in the Sierra Norte of Oaxaca

Building autonomy in the Sierra Norte of Oaxaca has not depended on the development of Zapotec ethnic identities, isolation or rejection of the integration of outsiders into the communities. The communities of Ixtlán and Guelatao have developed strong local identities and strategies related to the appropriation of external legal categories, and the combination of these with their own customary practices to integrate newcomers into their social, political and economic organisation. Dialogue has been one of the main tools for building autonomy and achieve the integration of outsiders, while continuing the dynamic reproduction of their internal organisation and way of life.