Tim Tenbensel

Multiple modes of governance

The emergence of one or more alternatives to hierarchical and market mechanisms has been one of the most prominent themes of public management literature over the past decade. The intellectual sources of this analysis are diverse and the proliferation of labels for the third mode (networks, professionalism, egalitarianism, communitarianism) generates some confusion. This article outlines and compares and contrasts the range of theoretical approaches to defining the third (and fourth) mode. On the basis of this comparison, I argue that there are two important alternative modes to hierarchies and markets that need to be distinguished from each other, namely provider-based governance and community governance. The modes of governance heuristic will be most useful when the focus of analysis is shifted away from the achievement of governance and co-ordination to attempts to steer public management. This requires that we pay attention to the types of power and knowledge that are necessary to support different governance mechanisms. Finally, I suggest the metaphor of a card game involving suits provides a useful way of re-labelling the four modes. This metaphor can be applied to help think about how multiple modes are used by those who attempt to steer.

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

BackgroundIn May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?Methods/designThe study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.DiscussionAt the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

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

UNLABELLED Health governance internationally has become more complex, with both hierarchical and network modes of governance explicitly represented within single public systems. OBJECTIVE To understand the implementation of new modes and mechanisms of governance under New Zealand health reforms and to assess these in the context of international trends. Research methods sought data from key groups participating in governance policy and implementation. Methods included surveys of board members (N=144, 66% response rate), interviews with chairs (N=14) and chief executives (N=20), and interviews with national policy makers/officials (N=19) and non-government providers and local stakeholders (N=10). Data were collected over two time periods (2001/2002; 2003/2004). Analysis integrated the findings of both qualitative and quantitative methods under themes related to modes and mechanisms of governance. Results indicate that a hierarchical mode of governance was implemented quickly, with mechanisms to ensure political accountability to the government. Over the implementation period the scope of decision-making at different levels required clarification and mechanisms for accountability required adjustment. Non-government provider networks emerged only slowly whereas a network of statutory health organisations established itself quickly. CONCLUSION The successful implementation of a mix of governance modes in New Zealand 2001-2004 was characterised by clear government policy, flexibility of approach and the appearance of an unintended network. In New Zealand there is less tendency than in some other some other small countries/jurisdictions towards centralisation, with local elections and community engagement policies providing an element of local participation, and accountability to the centre enhanced through political rather than bureaucratic mechanisms.

A successful mix of hierarchy and collaboration?: Interpreting the 2001 reform of the governance of the New Zealand public health system

This article analyses the relationship between different modes of accountability in New Zealands publicly funded health sector since 2001. It adopts a ‘multiple modes of governance’ framework, drawing on the findings of an evaluation of health system restructuring conducted between 2001 and 2005. In broad terms, governance of the health system has moved from a combination of hierarchy and market to a mixture of hierarchy and collaboration. This article assesses the degrees to which hierarchical and collaborative accountability regimes have clashed with or complemented each other. We also identify areas in which none of these modes of accountability operate.

How Not to Kill the Golden Goose: Reconceptualizing accountability environments of third-sector organizations

For third-sector organizations (TSOs) that deliver publicly funded health and community services, accountability practices are predominantly shaped by the imperatives of government funders. However, the ensuing public management accountability regimes can undermine TSO responsiveness to communities, align poorly with imperatives of professional staff, create high transaction costs and threaten TSO sustainability. Public management literature lacks an adequate framework for conceptualizing TSO accountability. We outline a conceptual framework – the ‘triskele’ – for analysing accountability tensions experienced by TSOs that could assist funders and other stakeholders with the difficult task of designing more workable and meaningful accountability regimes for all stakeholders.

Decentralizing resource allocation: early experiences with district health boards in New Zealand.

Objectives In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the governments stated objectives are likely to be achieved. Methods Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. Results The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decisionmaking has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. Conclusions Decentralized decisionmaking is starting to make some inroads towards achieving some of the governments objectives with respect to resource allocation and purchasing.

Indigenous Peoples’ Health Care: New approaches to contracting and accountability at the public administration frontier

Abstract This article analyses reforms to contracting and accountability for indigenous primary health care organizations in Canada, New Zealand, and Australia. The reforms are presented as comparative case studies, the common reform features identified and their implications analysed. The reforms share important characteristics. Each proceeds from implicit recognition that indigenous organizations are ‘co-principals’ rather than simply agents in their relationship with government funders and regulators. There is a common tendency towards more relational forms of contracting; and tentative attempts to reconceptualize accountability. These ‘frontier’ cases have broad implications for social service contracting.

How do Governments Steer Health Policy? A Comparison of Canadian and New Zealand Approaches to Cost Control and Primary Health Care Reform

Abstract This paper compares the ways in which governments in Canada and New Zealand have attempted to pursue reforms in two major health policy arenas – cost control and primary health care – in the period 1992–2005. The framework for comparison is drawn from the “modes of governance” literature that deals with hierarchies, markets, provider-based networks and communities as means of steering policy. Recent literature has argued that governments are increasingly mixing and matching different modes of governance. This comparison shows that governance versatility applies in New Zealand, but not Canada, and this is primarily attributable to the differences in health policy institutions.

Health reform in New Zealand: short-term gain but long-term pain?

Following a period of quite radical structural reform during the 1990s, health reform in New Zealand is now more incremental and often ‘under the radar’ of public scrutiny and debate. However, many changes have been made to the roles and functions of key agencies and this could have a profound effect on the direction and performance of the public health system. In particular, the objective of reform at the national level has shifted away from improving population health and reducing health disparities towards improving the performance of service providers. This article describes some of the reforms that have been introduced in recent years and discusses some implications of these changes. We argue that policy settings that are concerned only with getting the right services to the right people at the right time are inherently short-sighted if they fail to tackle the long-term causes of increasing demand for future health services.

International Human Rights Conventions and Australian Political Debates: Issues Raised by the 'Toonen Case'

In April 1994, the United Nations Human Rights Committee communicated its view to the Australian Government that Tasmanian anti-gay laws were inconsistent with Australias international human rights obligations. Issues of Australias human rights protection, treaty accession and Commonwealth-State relations, each of which have traditionally been characterised by major partisan differences, were brought to the fore of political debate. While the HRC decision at first appeared to give the coalition much scope to advance its arguments, subsequent developments highlighted considerable weaknesses in the rhetorical strategies of conservatives, and the difficulty of using the Tasmanian laws as a federalist cause ce le bre. In the long term, ironically, the coalition may well have weakened the efficacy of sovereignty-based arguments in Australian political debate.