Viola Burau

Comparing health policy: An assessment of typologies of health systems

Abstract Typologies have been central to the comparative turn in public policy and this paper contributes to the debate by assessing the capacity of typologies of health systems to capture the institutional context of health care and to contribute to explaining health policies across countries. Using a recent comparative study of health policy and focusing on the concept of the health care state the paper suggests three things. First, the concept of the health care state holds as a set of ideal types. Second, as such the concept of the health care state provides a useful springboard for analyzing health policy, but one which needs to be complemented by more specific institutional explanations. Third, the concept of the health care state is less applicable to increasingly important, non-medical areas of health policy. Instead, different aspects of institutional context come into play and they can be combined as part of a looser “organizing framework”.

A manager in the minds of doctors: a comparison of new modes of control in European hospitals.

BackgroundHospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals.MethodsThe research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources.ResultsThe findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management.ConclusionsOur comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.

THE ‘HEALTHCARE STATE’ IN TRANSITION: National and international contexts of changing professional governance

ABSTRACT The building of a European nation challenges entrenched ties between the state and the professions. Yet, in relation to healthcare, European law is especially weak and professional power is particularly strong. Against this background, the present paper aims to map out the specific configurations of the changing governance of healthcare and the dynamics arising from intersecting contexts of change. We argue that the ‘healthcare state’ is strongly shaped by national regulatory frameworks, while the platform for the power of a self-regulatory medical profession is increasingly international in nature. Across countries managerialism and performance measures together with evidence-based medicine and clinical guidelines are meant to improve the accountability of professionals and the safety of the public. However, the new regulatory tools may also have the opposite effect and indeed serve as a means to reassert professional power; here, the heightened internationalization of healthcare even provides new opportunities. We use material from different countries gathered in a number of research projects to assess the changing governance of healthcare and its contexts. The paper concludes by highlighting the significance of both national regulatory frameworks and (international) professionalism.

Medicine and management in European healthcare systems: how do they matter in the control of clinical practice?

During recent years, management has brought tighter controls into all areas of clinical practice, responding mainly to financial shortages coupled with increasing public demand for quality and safety of care. Management is not simply expanding and creating new roles for non-clinical managers, but doctors, too, are charged with managerial responsibilities. Consequently, the boundaries between medicine and management are no longer sustainable and this, in turn, may have complex implications for control and leadership in clinical practice.

Institutions and non‐linear change in governance: Reforming the governance of medical performance in Europe

PURPOSE The paper aims to account for the substance of non-linear governance change by analysing the importance of sector-specific institutions and the pathways of governing they create. DESIGN/METHODOLOGY/APPROACH The analysis uses recent reforms of the governance of medical performance in four European countries as a case, adopting an inductively oriented approach to comparison. The governance of medical performance is a good case as it is both, closely related to redistributive policies, where the influence of institutions tends to be pertinent, and is subject to considerable policy pressures. FINDINGS The overall thrust of reforms is similar across countries, while there are important differences in relation to how individual forms of governance and the balance between different forms of governance are changing. More specifically, sector-specific institutions can account for the specific ways in which reforms redefine hierarchy and professional self-regulation and for the extent to which reforms strengthen hierarchy and affect the balance with other forms of governance. ORIGINALITY/VALUE The recent literature on governance mainly focuses on mapping out the substance of non-linear change, whereas the development of explanations of the substance of governance change is less systematic. In the present paper, therefore, it is suggested coupling the notion of non-linear change with an analysis of sector specific institutions inspired by the historical institutionalist tradition to better account for the substance of non-linear governance change. Further, the analysis offers interesting insights into the complexity of redrawing boundaries between the public and the private in health care.

Care coordination of multimorbidity: a scoping study

Background A key challenge in healthcare systems worldwide is the large number of patients who suffer from multimorbidity; despite this, most systems are organized within a single-disease framework. Objective The present study addresses two issues: the characteristics and preconditions of care coordination for patients with multimorbidity; and the factors that promote or inhibit care coordination at the levels of provider organizations and healthcare professionals. Design The analysis is based on a scoping study, which combines a systematic literature search with a qualitative thematic analysis. The search was conducted in November 2013 and included the PubMed, CINAHL, and Web of Science databases, as well as the Cochrane Library, websites of relevant organizations and a hand-search of reference lists. The analysis included studies with a wide range of designs, from industrialized countries, in English, German and the Scandinavian languages, which focused on both multimorbidity/comorbidity and coordination of integrated care. Results The analysis included 47 of the 226 identified studies. The central theme emerging was complexity. This related to both specific medical conditions of patients with multimorbidity (case complexity) and the organization of care delivery at the levels of provider organizations and healthcare professionals (care complexity). Conclusions In terms of how to approach care coordination, one approach is to reduce complexity and the other is to embrace complexity. Either way, future research must take a more explicit stance on complexity and also gain a better understanding of the role of professionals as a prerequisite for the development of new care coordination interventions.

Reforming medical governance in Europe. What is it about institutions

This article presents a cross-national analytical framework for understanding current attempts to reform medical governance - in particular, those by third parties to control the practice of medicine. The framework pays particular attention to the ways in which institutions shape policy reform. The article also outlines the main comparative findings of case studies of selected reforms and associated processes of negotiations in Denmark, Germany, Italy and the United Kingdom. These four countries were selected because they are characterised by theoretically interesting variations in the institutional contexts of medical governance. The analysis suggests that although all the four countries have pushed for more control over the way in which doctors practise medicine, in response to similar imperatives, each country differs in the path it has taken. More specifically, the instruments and techniques brought to bear in each case vary considerably and are directed by a countrys political institutions towards a unique path.

Universalism and the local organisation of elderly care

Purpose – The purpose of this paper is to discuss the concept of territorial equality as an indicator of universalism in locally provided care services for older people. The research question explored is how the local organisation of care services impacts on and either strengthens or weakens local universalism.Design/methodology/approach – The analysis is based on case studies in six municipalities in Finland, Norway and Sweden.Findings – The paper shows that three kinds of organisational characteristics are of relevance for local universalism: the explicitness in assignment criteria, the organisational strength of service guarantees and the degree of co‐payments. Local universalism is highly dependent on the specific organisational arrangements at the local level, but in interplay with national level regulations. Of the three investigated kinds of organisational conditions, the local impact is largest on access criteria and the organisational strength of service guarantees.Originality/value – Although, t...

Transforming health policy and services: Challenges for comparative research

Over the last 20 years or so the comparative study of health policy and services has become a well-established field of research. However, over this same period, health policy and services themselves have undergone significant transformations, and this has changed the business of comparison itself. Comparisons have become more diverse in terms of geographical and substantive scope, in the inclusion of practice in addition to policy, and at the level of analysis with greater interest for sub-national levels. This transformation results in a range of challenges related to ensuring comparability, to comparing beyond the nation-state and to finding appropriate data for comparison. Importantly, although the challenges are not necessarily greater now, they are different ones. Also, as this monograph issue demonstrates, the appeal of a comparative perspective remains strong as does the richness of insights offered.

Trajectories of Change in Danish Long Term Care Policies—Reproduction by Adaptation through Top-Down and Bottom-Up Reforms

The literature often sees universalism and local autonomy as the key tenets of Nordic care regimes (Burau et al. 2007); the former refers to substantive aspects of long term care policies , while the latter refers to procedural aspects. Against this background, the case of Denmark is interesting in two respects. Firstly, among the Nordic countries, long term care policies remain the most universal in terms of coverage, which is reflected in the level of public expenditure. Secondly, Denmark combines institutional change from below (nonlegislative change) with institutional change from above (legislative change).