Governance Structures and Political Processes in a Public System: Lessons from Quebec

Abstract

Debates about the form and nature of changes in the management of public systems have for some time now been articulated under the theme of governance. All definitions of governance are related to the problems of securing convergence among a diversity of actors and organizations, of redistributing power in an organizational or social field characterized by a high level of heterogeneity and of gaining sufficient legitimacy to act in the name of the collectivity. This paper concentrates on the dynamics involved in the emergence of new governing capabilities in public systems. More precisely we study the implementation of regionalization policies in the health care field (in this case of Canada) conceived as one major attempt to renew the governance structures in a large public system.Our study draws on the comparative analysis of empirical regulation in three health regions as contrasted with three ideal type models of governance in regionalized systems. The first model is inspired by an economic approach to organizational behaviour and focuses on mandate-giving, execution and control. The second model is based on a political interpretation of behaviours and focuses on negotiation processes between actors. Finally, the third model is based on the theory of deliberation as well as the institutional school of policy analysis and focuses on direct public participation in public affairs. Evidence for this article is primarily derived from interviews with key informants and documentary analysis.Our analysis shows that none of the three models is sufficient in itself to grant regional structures the authority and legitimacy they need to create added value in terms of regulation that could ensure their survival. Regional Boards are thus forced by environmental constraints to conceive and implement original mixes of these models. The two predominant logics in regional action are inspired by the first two models although the last one also has an influence. Overall, our study also suggests that the implementation of new sources of governing authorities in a public system is rather fragile because of dependence on existing institutions. Clearly, the attempt to modify the dynamics of governance in a given system must be conceived as a political exercise and not just as a technical problem consisting of the rational adjustment of policy instruments.

Implementing new modes of governance in the New Zealand health system: An empirical study

“…Central policy and guidelines underpin government desire for consistency of access and services, as in other countries [11,14], and is maintained by mechanisms such as national policies, appointments to DHBs (particularly of chairs) and a range of accountability provisions. As elsewhere [12,17,18] there is some tension between national and local decision-making and accountability, with officials of larger DHBs tending to see central policy and reporting requirements as constraining their autonomy, whereas smaller DHBs were seen as having limited capability to comply with requirements. Over the research period there was no increase in central powers, but a more explicit exercise of these and an increasing appreciation at DHB level of the limitations of DHB autonomy and the importance of managing any perceived tension between national and local priorities.…”

“…For example, local boards may not be authorised to make key decisions such as setting physician fees or determining drug availability [15], but may engage in local functions such as needs assessment. While accountability mechanisms involve central directives and upwards reporting, complications nevertheless arise from competing expectations from central and local sources [9,16,17], especially if an intermediary agency intervenes between central authority and local organisations [18]. Also, variations may occur from place to place in either service provision [19] or quality, for example, the extent to which health technology assessment guidance is taken up in more centralised or decentralised systems [20,21].…”

Governance, Health Policy Implementation and the Added Value of Regionalization

“…As a conceptual tool, an ideal type is useful for comprehending the reality of a given situation, relationship or organization. Denis et al (1998) and Contandriopoulos et al (2004) identify three models of collective action. The technocratic model involves obedience to a central government, which sets policies, delegates and controls.…”

On the Nature and Strategies of Organized Interests in Health Care Policy Making

“…This work also rests on knowledge of the health care field and institutions developed in previous work (Contandriopoulos, 2004;Contandriopoulos, Denis, & Langley, 2001, 2004aContandriopoulos, Denis, & Langley, & Valette, 2004b, 2005.…”