Governance, Government, and the Search for New Provider Models

Abstract

A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcome.

Governance in Health – The Need for Exchange and Evidence Comment on "Governance, Government, and the Search for New Provider Models"

“…These changes generated the need to revisit governance arrangements in an altered service delivery landscape, with the introduction of marketlike incentives and management structures, as well as nonstate actors attaining an important role alongside with public entities. 2 The authors use the framework developed by Duran and colleagues 3 which identifies governance in the health sector at the three levels of macro (national, policy-making), meso (institutional), and micro (operational at provider level), to examine challenges and suggest mitigation solutions at these levels that might ideally complement specific management techniques for effective service delivery practices. Saltman and Duran look at tax-based systems, where governments have -in a somewhat secular trend -gradually pulled out of direct service provision and focussed on governing the more independent providers of care, recognising that the engagement of non-governmental actors require regulations about minimum standards on quality and access and allowing to compete in a fair environment.…”

Risks and Opportunities of Reforms Putting Primary Care in the Driver’s Seat Comment on "Governance, Government, and the Search for New Provider Models"

“…1 One of the examples springs from Swedish primary care and discusses governments' strategies of steering providers based on market incentives and management structures encouraging efficient performance and citizens' possibility of enlisting with a primary care provider of their choice. 1 Their article is interesting in several ways, covering a substantial change in favor of primary care centers. The rapid development of new ways to operate primary care and new private actors implies a break with traditionally public provision and organization, which has dominated Swedish healthcare the last 50 years.…”

“…At the micro level, flexibility is necessary to handle local conditions and adapt to needs. 1 One negative consequence is that organizations can take on formal decisions from central levels to satisfy demands for change, without letting changes have a real impact on concrete activities. In knowledge-intensive activities such as healthcare, it is common that professionals operating independently shut themselves off from central requirements that are not perceived as meaningful.…”

“…Expressed in terms of Saltman and Duran, well-functioning governance is formed at the macro level, but in the end what is crucial is how regulation and incentives are understood and manifested in daily work. 1 Capturing everyday practice is easier said than done, however. There is little research about what is happening in new primary care centers after the reform, and qualitative approaches aiming for thick descriptions are needed.…”

Provider Governance; A Basic Blackbox Seldom Looked at Properly: A Response to Recent Commentaries

“…The five commentaries on our initial article 1 provide valuable insights into the complex process of re-framing the relationships involved in provider side decision-making in the health sector. These commentaries help focus more closely on the elements involved in the proposed shifting of institutional level decision-making; ( i ) away from full and exclusive dependence on governmental and political bodies, at either/or both national and regional level, one of the critical elements in the definition of governance; so that ( ii ) the new center of gravity is one or another structural arrangement simultaneously more targeted on patients and performance, as well as having greater potential to innovate effectively in its patient care routines and procedures.…”