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

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

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  1. 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

  2. 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?

  3. 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

  4. Research Setting

  5. 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

  6. 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

  7. 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

  8. 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)

  9. 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)

  10. 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”

  11. 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)

  12. 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”

  13. Diffusion of FM Practice: Scale of adoption of institutional innovation

  14. Change Outcome

  15. Change Outcome / Process

  16. Structural Characteristics of PHC reforms:Organisational arrangements

  17. Structural Characteristics of PHC reforms:Organisational arrangements

  18. Structural Characteristics of PHC reforms:Financing

  19. Structural Characteristics of PHC reforms:Provision

  20. Professional Development in FM

  21. Professional Development in FM

  22. 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

  23. Theorising

  24. Counter-theorising

  25. Institutional practice: acting

  26. Institutional practice: counter-acting

  27. 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

  28. Thank you!! Thank you!! Ioannis.kyratsis@imperial.ac.uk

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