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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.
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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
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 IntermediateGoals Goals Organisational arrangements Equity Health Efficiency Financing Financial Risk Protection Resource allocation Effectiveness User Satisfaction Provision Choice Family Medicine Reforms:AComplexHealthInnovation Atun et al, 2005
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 inductivelyfrom case study Research (Eisenhardt, 1989) • Research Design Multiple Case studies - Holistic, Pluralistic, Context sensitive method (Yin 2003) - Replication Logic (Yin 2003) • Purposive sample of280 key informants in5 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 interpretedandtheorisedby purposeful actors (Greenwood et al, 2002) • Innovations to be presented as appropriate Gain Pragmatic, Moral, CognitiveLegitimacy(Suchman, 1995) - Functionally / technically superior - Normative values - Shared cognitive-cultural prescriptions
An institutional theory account • 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)
An institutional theory account Theorisation Discursive strategy to enhance Legitimacy (Greenwood et al, 2002) Abstract categorisations / models : • Specify an organisational failing/problem (Tolbert & Zucker, 1996) • Justify abandonment of old practice (Tolbert & Zucker, 1996) • Inform wider audiences about results of localised experiment related to the innovation (Hinnings et al, 2004)
Societal transformation in former European communist countries End of 1980s beginning of 1990s: • Collectivist, communist/socialist, state bureaucratic, command & control system • More liberal system, political pluralism, market economy, “westernisation”
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 • Specialist-led delivery model • Healthcare is a Public service • 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
Structural Characteristics of PHC reforms:Organisational arrangements
Structural Characteristics of PHC reforms:Organisational arrangements
Prevailing societal sentiment Nationalist / Traditionalist Proud of Yugoslav past, “Nostalgia for the previous system + Desire to re-join Europe” Mixed picture: Nostalgia for Yugoslav model / Wish to break away from the Socialist and Serbian dominated system Mixed picture: Nostalgia for Soviet system (looking to “east” “Russia”) /Break away from the Soviet past (looking to “west”, “Europe”) 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
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 you!! Ioannis.kyratsis@imperial.ac.uk