Society, Culture and Politics of Eastern Europe Conference 12-13 Dec 2008 Diffusion across contested...

Society, Culture and Politics of Eastern Europe Conference 12-13 Dec 2008

Diffusion across contested institutional terrains: a study of family medicine-centred primary care reforms of European transition countries

Dr Yiannis Kyratsis DVM, MSc, DIC, MRCVS

12 December 2008

© Dr Yiannis Kyratsis Imperial College London

Triggering Research Questions

• Why disruptive events, such as the transformational change that occurred in the politico-economic and social contexts of former socialist countries, which had a direct impact on HC fields in some cases succeed or in others fail in triggering substantial institutional change?

• Are differences in institutional environments able to explain the dissimilar levels of success regarding the adoption of FM-centred PHC reforms in the five countries studied?


Levers

Financing

Organisational arrangements

Resource allocation

Intermediate Goals

Provision

Equity

Choice

Efficiency

Effectiveness

Goals

Health

Financial Risk Protection

User Satisfaction

Family Medicine Reforms:A Complex Health Innovation

Atun et al, 2005


Research Setting


Countries Overview

Estonia: (1.3m), USSR, Semashko model, THE: 5.1% of GDP (2002) Slovenia: (2m), Yugoslavia, Yug. Health Model (YHM), THE: 8.2% of

GDP (2002) BiH: (4m), Yugoslavia, YHM, THE: 9.2% of GDP (2002) Moldova: (3.6m - 4.2m including Transnistria ), USSR, Semashko

model, THE: 3.6% of GDP (2002) Serbia: (7.5m – 9.5m including Kosovo), Yugoslavia, YHM, THE 8.1%

Slovenia + Estonia: EU member states, Slovenia has the highest GDP per capita from all transition countries – In Slovenia population health status continued improving during transition

BiH + Moldova + Serbia: internal armed conflicts, ethnic divide –> 2 entities (BiH) de facto independent provinces (Moldova, Serbia) Moldova the poorest country in Europe: $353 GDP/capita (2000) – In Moldova population health status continued deteriorating during transition throughout the 1990s


Research Methodology

Building theory inductively from case study Research (Eisenhardt, 1989)

Research Design Multiple Case studies - Holistic, Pluralistic, Context sensitive method (Yin 2003)

- Replication Logic (Yin 2003)

Purposive sample of 280 key informants in 5 countries

- Multi-level, multi-stakeholder sample - Semi-structured interviews Primary data collection method - Statistics, Archival records, Legislation/Policy Docs Secondary data


An institutional theory account

• Innovations face “liability of illegitimacy” when introduced into a social context (Saunders and Tuschke, 2007)

• Innovations in order to gain momentum they need to be interpreted and theorised by purposeful actors (Greenwood et al, 2002)

• Innovations to be presented as appropriate Gain

Pragmatic, Moral, Cognitive Legitimacy (Suchman, 1995)

- Functionally / technically superior - Normative values - Shared cognitive-cultural prescriptions



1. Institutional environments as contested terrains (Lounsbury, 2007)

Actors Interests, agendas

Power base

Competition for Resources and Opportunities (Hoffman, 1999)

Institutional formation as a result of political struggle among actors (Seo & Creed, 2002)

2. Institutions as nested systems (Holm, 1995)



Theorisation Discursive strategy to enhance Legitimacy (Greenwood et al, 2002)

Abstract categorisations / models :

a) Specify an organisational failing/problem (Tolbert & Zucker, 1996)

b) Justify abandonment of old practice (Tolbert & Zucker, 1996)

c) Inform wider audiences about results of localised experiment related to the innovation (Hinnings et al, 2004)


Societal transformation in former European communist countries

Collectivist, communist/socialist, state bureaucratic, command & control system

More liberal system, political pluralism, market economy, “westernisation”

End of 1980s beginning of 1990s:


Health sector reforms in transition countries

Semashko model / Yugoslav HS- Heavily centralised, tax based, state owned, standardised, hospital and

polyclinic-centred, over-specialised, fragmented tripartite PHC, vertical programmes (Yugoslavia: less centralised, social insurance existed, strong PHC with extended network of DZs) specialist-led logic, equity

Bismarckian-like system- Mandatory social health insurance, more decentralised, public-private

mix, PHC-centred system based on FM/GP model generalist-led logic, efficiency (equity, responsiveness)


Semashko / Yugoslav Healthcare models Macro-culture

a) Specialist-led delivery model

b) Healthcare is a Public service

c) Centrally driven, prescriptive organising

“don’t trust private”, “real doctors are the specialists” , “risk aversion / passive attitude” “punitive culture”


Diffusion of FM Practice: Scale of adoption of institutional innovation

0

20

40

60

80

100

% population covered by FM

Serbia

Bosnia &Herzegovina

Moldova

Slovenia

Estonia


Change Outcome

Estonia Slovenia BosniaHerzegovina

Moldova Serbia

Spread across the system

Significant spread but still contestation over reforms elements (private FM practice)

Debated and some spread with small pockets of high advancement(RS: Laktasi, FBiH: Tuzla)

Contested with significant time lag to spread

Non spread


Change Outcome / Process

Estonia Slovenia BiH Moldova Serbia

Rapid, radical, transformational change

“Transform”

Incremental, developmental change

“Build on - gradualist”

Incremental transformational change

“Transform & Build on”

Inertia followed by rapid radical change

“Cautious – Extensive but not in-depth change”

Non adoption / No real change

“Reject – Keep/adjust the old”


Structural Characteristics of PHC reforms:Organisational arrangements

Dimensions of Change

Estonia Slovenia Bosnia &Herzegovina

Moldova Serbia

Organisational Form

Family physician

Personal Doctor: 1) FP2)Paediatric. 3)Gynaecol.

Family Medicine Team

(FPs-FNs)

Family physician(General Practice)

Chosen Doctor:

1) GP2)Paediatric.3)Gynaecol.4)Occup. Med. 5) Dentist

Service Delivery structure

FM independentprivate practices

Public PHC Centres (75%)

FM independent private practices (25%)

DZs (FBiH)

DZs/Ambulant (RS)

Polyclinics – Family Medicine Health Centres

PHC Centres (DZs)


Structural Characteristics of PHC reforms:Organisational arrangements



Degree of autonomy

High Limited for FPs in public PHC centres (75%)

High for private FPs (25%)

Limited Limited Limited

Ownership status

Private Private

Public (PHC centres)

Public Public Public

User Choice Yes Yes Yes Yes Yes


Structural Characteristics of PHC reforms:Financing



Introduction of Social Health Insurance (Year)

1991: Sickness Funds 2001: EHIF

1992: HIIS

Pre-existing

1997: FBiH 1999: RSPre-existing

(1998)2004: NHIC

1991 2005: RIHIPre-existing

Payment System for FPs/GPs

Weighted per capita-FFS-practice allowance

FPs working in Public PHC Centres: Fixed Salaries

Private FPs:Weighted per capita-FFS (health prevention)-PRP (w/t, pr, rf)

Non pilot: Salaried employment

Pilots: Weighted per capita - FFS health prevention (RS)- Bonus accredited FM teams (RS)

Simple Per Capita- Quality Indicators bonuses

Salaried employment

Per capita (piloting)

Public Health Expenditure allocated to PHC

14% 20% 40% 35% 20%


Structural Characteristics of PHC reforms:Provision


Estonia Slovenia Bosnia &Herzegovina

Moldova Serbia

Unified Provision of care irrespective of age, gender and type of disease of patients

Yes No No No No

Expanded Scope of Service for FPs(compared to the role of PHC FP/GP in the preceding health model)

YesConsiderable Secondary – primary care shift

YesConsiderableSecondary – primary care shift

YesModerate to Considerable Secondary – primary care shift

Yes Moderate change

No


Professional Development in FM


Estonia Slovenia Bosnia &

Herzegovina

Moldova Serbia

Initiation of Reforms

Academics- MedicalProfession

Medical profession

State Administration

Internat. Aid Orgs

Internat. Aid Orgs

State Administration

Intern. Aid Orgs

FM Association

1991

(Strong Active)

1992(GP:1966)

(Strong Active)

2000(GP:1960s)

(Limited Role)

2000

(Limited Role)

N/a(GP:1960s)

N/a

FM Department

1992 (Tartu)

1995 (L)

2003 (Mar)

1998 (Tuzla)

1999 (Ms,BL)

2005 (S, E-S)

1998 N/a


Professional Development in FM



Herzegovina

Moldova Serbia

Percentage of practising FPs who are specialists in FM (by 2007)

15% 53.4%

40.5% 24% 55% (GPs)

Jurisdictional exclusivity for FPs on adult care

Yes A legal requirement since 2003

Yes A legal requirement since 2000 (2007)

No No No

FM specialty officially recognised(Year)

1993 1994 2000 1997 No


Prevailing societal sentiment

Mixed picture: Nostalgia for Yugoslav model / Wish to break away from the Socialist and Serbian dominated system

Pro-European, pro-western, not negative memory of Yugoslav model “bridge” between “west” central Europe and “east” Slavic nations in former Yugoslavia

Pro-European, pro-western, Nordic people, previous model imposed by Soviet communists “forget the past” Russian population affiliated with Soviet Semashko model

Mixed picture: Nostalgia for Soviet system (looking to “east” “Russia”) / Break away from the Soviet past (looking to “west”, “Europe”)

Nationalist / Traditionalist Proud of Yugoslav past, “Nostalgia for the previous system + Desire to re-join Europe”


Theorising

Framing of FM Reforms

Estonia Slovenia BosniaHerzegovina

Moldova

By the FM Profession

and other supportive actors

“European”

“Western”

“Nordic”

“entrepreneurial”

“human friendly”

“dissociation from soviet past”

“efficient”

“patient-centred”

“family focus”

“private”

“independent”

“choice”

“revolutionary”

“European”

“private”

“efficient”

“rediscovering pre-Yugoslav Slovenian past”

“responsive”

“modern”

“continuity of care”

“evolutionary, building on the past”

“efficient”

“choice”

“family focus”

“user-friendly”

“holistic care”

“contextual/community-centred model”

“improved access to care”

“modern”

“European”

“preventive”

“named doctor”

“efficient”

“family oriented model”

“personal care – named doctor”

“rational”

“part of societal change”

“holistic model”

“preventive”


Counter-theorising

Framing of FM Reforms

Estonia Slovenia Bosnia

Herzegovina

Moldova

By the narrow specialists opposing the reforms

-DZs directors

- heads of polyclinics

“risk to children’s health”

“model only for the poor”

“individualistic”

“poor quality”

“suitable only for rural areas”

“good for FM advocates but bad for patients”

“low quality for children and women”

“elementary health”

“how something named general claim to be specialist”

“cheap”

“poor quality”

“imposed”

“basic model compared to state of art PHC centres in Yugoslav model”

“conditional necessity”

“backward”

“downgrading women & children’s care”

“Western construct”

“American”

“ineffective model compared to advanced soviet system”

“imposed by the West”

“top-down”

“basic care”

“incompetent FPs”

“poor quality/training of FPs”


Institutional practice: acting

Acting Estonia Slovenia BiH Moldova

Change of regulatory rules, incentives, practical connections for the innovative practice

-FM community

-State officials

- External actors

“institutional forgetting”

“advocacy, political lobbying”

“external networks”

“educating, training”

“collective action”

“dissociating moral foundations of pre-existing practice”

“constructing a distinct professional identity”

“Symbolic action”

“external networks”

“advocacy and political suasion”

“educating, training, researching”

“constructing a new professional identity”

“Symbolic action”

“International organisations moral, financial, technical and political support”

“training” “constructing a distinct professional identity for FM”

“experimentation”

“researching in FM”

“demonstration sites”

“foreign universities support/network”

“International organisations financial, technical and political support”

“political lobbying”


Institutional practice: counter-acting

Counter

Acting


Herzegovina

Moldova

Narrow specialists

(Medical Chamber)

“mobilise political power”

“undermine moral legitimacy of FM: misinformation”

“promoting anti-privatisation agenda”

“control post-graduate education and undermine professional development of FM”

“political lobbying”

“mobilising local communities”

“lobbying hospitals”

“mythologizing the past to influence state administration”

“mobilising local governments”

“misinformation”

“emphasise image gap bw FPs and specialists”

“restrict organisational autonomy of FM under the jurisdiction of rayon hospital director (2003)”

“control education and training of FM”

“overstressing competence inefficiencies of FPs”


Some key observations

• Pursuing PHC field level and societal legitimacy for the novel institutional arrangement has been a precondition for adoption

• Theorising and strategic framing as discursive strategies for legitimating the institutional innovation

• Counter-theorising as resistance strategy• Key actors respond to change in dissimilar ways,

depending upon the mapping out of their interests and power balance in the novel institutional context

• Innovation interaction with institutional and health systems contexts mediated spread

• Change outcome partly conditioned by practices and collective action of FM professional associations – legitimation via professional appropriateness


Thank you!!

Thank [email protected]

Society, Culture and Politics of Eastern Europe Conference 12-13 Dec 2008 Diffusion across contested...

Documents

Transcript of Society, Culture and Politics of Eastern Europe Conference 12-13 Dec 2008 Diffusion across contested...