Governance, Government, and the Search for New Provider Models

Document Type : Debate

Authors

1 Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA

2 AllDMHealth, Seville, Spain

Abstract

A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcome.

Highlights

Commentaries Published on this Paper

  • Risks and Opportunities of Reforms Putting Primary Care in the Driver’s Seat; Comment on “Governance, Government, and the Search for New Provider Models”

          Abstract | PDF

  • Governance: Blending Bureaucratic Rules with Day to Day Operational Realities; Comment on “Governance, Government, and the Search for New Provider Models”

          Abstract | PDF

  • New Provider Models for Sweden and Spain: Public, Private or Non-profit?; Comment on “Governance, Government, and the Search for New Provider Models”

          Abstract | PDF

  • Governance in Health – The Need for Exchange and Evidence; Comment on “Governance, Government, and the Search for New Provider Models”

          Abstract | PDF

  • Governance Must Dive Into Organizations to Make a Real Difference; Comment on “Governance, Government, and the Search for New Provider Models”

          Abstract | PDF

 

Authors’ Response to the Commentaries

  • Provider Governance; A Basic Blackbox Seldom Looked at Properly: A Response to Recent Commentaries

          Abstract | PDF

Keywords

Main Subjects

References

  1. Saltman RB, Duran A, Dubois HFW, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011.
  2. Hood C. A public management for all seasons. Public Adm. 1991;69(1):3-19. doi:10.1111/j.1467-9299.1991.tb00779.x
  3. Gingrich JR. Making Markets in the Welfare State: The Politics of Varying Market Reforms. Cambridge, UK: Cambridge University Press; 2011.
  4. Saltman RB, Cahn Z. Re-structuring health systems for an era of prolonged austerity. BMJ 2013;346:f3972. doi:10.1136/bmj.f3972
  5. Thomson S, Figueras J, Evetovits T, et al. Economic crisis, health systems, and health in Europe: Impact and implications for policy. Brussels: European Observatory on Health Systems and Policies; 2014.
  6. Duran A, Jeurissen P, Saltman R. Uncomfortable Realities: Making Real Change Inside Real Institutions in a Consolidating Hospital Sector. BMC Health Serv Res. Special Issue ‘Medicine and Management in European Hospitals’, Kirkpatrick I, Kuhlmann E, Hartley K, Lega F, eds. In press.
  7. Duran A, Saltman R. Governing public hospitals. In: Blank R, Kuhlmann E, Bourgeault IL, Wendt C, eds. International Handbook of Healthcare Policy and Governance. Basingstoke, UK: Palgrave MacMillan; 2015:443-461.
  8. Coulter A. Engaging Patients in Health Care. Maidenhead, UK: Open University Press; 2011.
  9. Winblad U, Ringard A. Meeting rising public expectations: The changing roles of patients and citizens. In: Magnussen J, Vrangback K, SaltmanRB, eds. Nordic Health Care Systems: Recent Reforms and Current Policy Challenges. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2009:126-150.
  10. Saltman RB, von Otter C. Planned Markets and Public Competition: Strategic Reform in Northern European Health Systems. “State of Health” Series. Buckingham, UK: Open University Press; 1992.
  11. Saltman RB, Busse R. Balancing regulation and entrepreneurialism in Europe’s health sector: theory and practice. In: Saltman RB, Busse R, Mossialos E, eds. Regulating Entrepreneurial Behavior in European Health Care Systems. European Observatory on Health Care Systems series. Buckingham, UK: Open University Press; 2002:3-52.
  12. Alvarez A, Duran A. Hospital governance in Spain. In: Saltman, RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:241-260.
  13. Chinitz D. Hospital Governance in Israel. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:163-178.
  14. Edwards N. England. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:113-140.
  15. Habitch T, Habitch J, Jesse M. Hospital Governance in Estonia. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:141-162.
  16. Roubal T, Hrobon P. Czech Republic. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:99-112.
  17. Magnussen J. Norway. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011: 201-216.
  18. Hagen TP, Vrangbaek K. The changing political governance structures of Nordic health care systems. In: Magnussen J, Vrangback K, Saltman RB, eds. Nordic Health Care Systems: Recent Reforms and Current Policy Challenges. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2009:107-125.
  19. Vrangbaek K. The political process of restructuring Nordic health care systems. In: Magnussen J, Vrangback K, Saltman RB, eds. Nordic Health Care Systems: Recent Reforms and Current Policy Challenges. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2009:53-77.
  20. World Health Organization (WHO). World Health Report 2000: Health Systems: Improving Performance. Geneva: WHO; 2000.
  21. Rhodes RAW. The new governance: governing without government. Polit Stud (Oxf). 1996;44(4):652-667. doi:10.1111/j.1467-9248.1996.tb01747.x
  22. Stoker G. Public-private partnerships and urban governance. In: Pierre J, ed. Public-Private Partnerships in Europe and the United States. London: MacMillan; 1997:34-51.
  23. van Doeveren V. Re-thinking the meaning of governance and good governance. Paper presented at: Governing good and governing well: the first global dialogue on ethical and effective governance; 28-30 May, 2009; Amsterdam.
  24. Duran A, Dubois HFW, Saltman RB. The evolving roles of hospitals and recent concepts of public sector governance. In: Saltman RB, Duran A, Dubois HWF, eds. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Systems and Policies; 2011:15-34.
  25. LeGrand J, Bartlett W, eds. Quasi-markets and Social Policy. London: Macmillan; 1993.
  26. Saltman RB, Vrangbaek K, Lehto J, Winblad U. Consolidating national authority in Nordic health systems. Eurohealth. 2012;18(3):21-25.
  27. Saltman RB, Teperi J. Health reform in Finland: Current proposals and unresolved challenges. Health Economics Policy and Law. 2016; forthcoming.
  28. Rhodes RA. Understanding Governance: Policy Networks, Governance, Reflexivity and Accountability. Buckingham, UK: Open University Press; 1997.
  29. Osborne D, Gaebler T. Re-inventing Government. Reading, MA: Addison-Wesley; 1992.
  30. Kettl D. Sharing Power. Washington, DC: Brookings Institution; 1993.
  31. Saltman RB, Dubois HFW. The historical and social base of social health insurance systems. In: Saltman RB, Busse R, Figueras J. Social Health Insurance Systems in Western Europe. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2004:21-32.
  32. Mutuals Taskforce. Public Service Mutuals: The Next Steps. London: Department of Health; 2014.
  33. De Roo AA. Contracting and solidarity: Market-oriented changes in Dutch health insurance schemes. In: Saltman RB, von Otter C, eds. Implementing Planned Markets in Health Care: Balancing Social and Economic Responsibility. “State of Health” Series. Buckingham, UK: Open University Press; 1995: 45-64.
  34. Anell A. Choice and privatization in Swedish primary care. Health Economics, Policy and Law. 2011;6 (4):549-569. doi:10.1017/s1744133110000216
  35. Anell A, Glenngard AH, Merkur S. Sweden: Health System Review. Brussels: European Observatory on Health Systems and Policies; 2012.
  36. Scott F. A History of Sweden. Minneapolis: University of Minnesota Press; 1957.
  37. Serner U. Swedish Primary Health Care. In: Heidenheimer A, Elvander N, eds. The Shaping of the Swedish Health System. New York: St. Martin’s Press; 1980.
  38. Saltman RB. Health care in Sweden. In: Saltman RB, ed. International Handbook of Health Care Systems. Westport, CT: Greenwood Press; 1988:285-294.
  39. Kringos D, Boerma W, Bourgueil Y, et al. The strength of primary care in Europe: an international comparative study. Br J Gen Pract. 2013. doi:10.3399/bjgp13X674422
  40. Anell A. The public-private pendulum – Patient choice and equity in Sweden. N Engl J Med. 2015;372(1):1-4. doi:10.1056/nejmp1411430
  41. Saltman RB, von Otter C. Re-vitalizing public health care systems: a proposal for public competition in Sweden. Health Policy. 1987;7(1):21-40. doi:10.1016/0168-8510(87)90043-1
  42. Krasnik A, Paulsen B. Reforming primary health care. In: Magnussen J, Vrangback K, Saltman RB, eds. Nordic Health Care Systems: Recent Reforms and Current Policy Challenges. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2009:233-254.
  43. Harrison M, Calltorp J. The re-orientation of market-oriented reforms in Swedish health-care. Health Policy. 2000;50(3):219-240. doi:10.1016/s0168-8510(99)00060-3
  44. Swedish Competition Authority. Uppföljning av vårdval i primärvården – Valfrihet, mångfald och etableringsförutsättningar. Slutrapport (Study of privatization and choice in primary care. Final report). Stockholm: Konkurrensverket; 2010.
  45. Andersson-Back M, Calltorp J, Saltman RB. Privatization in Swedish health care. Working paper, Swedish Forum on Health Policy, Stockholm; 2013.
  46. Vårdanalys. Let the right one in — what impact have reforms in the pharmaceutical market, in primary care, and regarding the waiting-time guarantee had on patient access? Rapport 2014:3 [In Swedish].
  47. Kringos D, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood). 2013;32(4):686-694. doi:10.1377/hlthaff.2012.1242
  48. Bendz A. Providing welfare: The importance of public or private actors in welfare state regimes. In: 69th annual national conference, Midwest Political Science Association; Chicago; 2011.
  49. Blomqvist P, Rothstein B. Velfardsstatens nya ansikte (The New Face of the Welfare State). Stockholm: Agora; 2015.
  50. Saltman RB, von Otter C. Voice, choice, and the question of civil democracy in the Swedish welfare state. Economic and Industrial Democracy. 1989;10(2):195-209. doi:10.1177/0143831x89102004
  51. Boerma WGW, Rico A. The changing conditions for structural reform in primary care. In: Saltman RB, Rico A, Boerma W, eds. Primary Care in the Driver’s Seat? Organizational Reform in European Primary Care. Maidenhead, UK: Open University Press/McGraw-Hill Education; 2006:50-67.
  52. Durán A. Health system decentralization in Spain: a complex balance. Euro Observer. 2011;13(1):7-10.
  53. García Armesto S, Abadía B, Durán A, Bernal E. Health Systems in Transition - Spain: Health system review. Brussels: European Observatory on Health Systems and Policies; 2010:1–295.
  54. Preker AS, Harding A. Innovations in health service delivery: the corporatization of public hospitals. Washington, DC: World Bank; 2003.
  55. Belenes R. Un balance personal de 25 años de gestión sanitaria moderna en el Sistema Nacional de Salud (A personal balance of 25 years of modern health care management in the National Health System). Gaceta Sanitaria. 2003;17(2):150-156.
  56. Instituto para el Desarrollo e Integración de la Sanidad (IDIS), Sanidad Privada, Aportando Valor. Análisis de situación 2015. Madrid; 2015. https://www.fundacionidis.com/es/informes/sanidad-privada-aportando-valor-an%C3%A1lisis-de-situaci%C3%B3n-2015.
  57. Alvarez A, Duran A. Spain’s hospital autonomy: Muddling through the economic crisis. Eurohealth. 2013;19(1):8-11.
  58. Cortès-Franch I, González López-Valcárcel B. Crisis económico-financiera y salud en España. Evidencia y perspectivas. Informe SESPAS 2014 (The economic-financial crisis and health in Spain. Evidence and viewpoints. SESPAS Report 2014). Gac Sanit. 2014;28(S1):1-6
  59. Federación de Asociaciones para la Defensa de la Sanidad Pública (FADSP). Los Servicios Sanitarios de las CCAA. Informe 2015 (XII Informe). http://www.fadsp.org/index.php/sample-sites/manifiestos/1111-los-servicios-sanitarios-de-las-ccaa-informe-2015-xii-informe. Published September 2015.
  60. IASIST. Evaluación de Resultados de los Hospitales en España según su modelo de gestión. Barcelona: IASIST; 2012. http://www.iasist.com/files/Modelos_de_gestion.pdf.
  61. NHS Confederation. The search for low-cost integrated healthcare: The Alzira model – from the region of Valencia. Brussels: European Office; 2011.
  62. Cámara de Cuentas. Análisis comparativo de la actividad realizada por dos hospitales del sistema sanitario público de Andalucía: Hospital Virgen de Valme y Hospital Costa del Sol. Seville: Cámara de Cuentas. http://www.ccuentas.es/files/reports/complete/1332156441-oe-04-2009-def.pdf. published 2008.
  63. CSIT. Informe Comparativo Coste/Eficiencia de la Gestión Pública y la Gestión Privada de la Sanidad en la Comunidad de Madrid. http://www.actasanitaria.com/fileset/file__sobre_Informe_CSIT_57842.pdf. Published December 3, 2012.
  64. Coduras A, del Llano Señarís J, Raigada González F, et al. Gestión de tres procesos asistenciales según persona jurídica hospitalaria. Madrid: SEDISA; 2008.
  65. PricewaterhouseCoopers (PwC). Ten hot issues in the Spanish Health Sector for 2013 (Avoiding that economic crisis becomes a public health crisis). https://www.pwc.es/es/publicaciones/sector-publico/assets/diez-temas-candentes-sanidad-2013.pdf. Published 2013.
  66. Joint Commission. Health care at the crossroads: guiding principles for the development of the hospital of the future. http://www.jointcommission.org/guiding_principles_for_the_development_of_the_hospital_of_the_future_/. Published November 19, 2008.
  67. Nolte E, Pitchforth E, Miani C, Mc Hugh S. The changing hospital landscape. An exploration of international experiences. Rand Europe; 2014.
  68. Management Sciences for Health. An Urgent Call to Professionalize Leadership and Management in Health Care Worldwide, Occasional Papers No. 4. http://projects.msh.org/projects/lms/Documents/upload/Professionalize_Leadership.pdf. Published 2006.
  69. Lehto J, Vrangbaek K, Winblad U. The reactions to macro-economic crises in Nordic health system policies: Denmark, Finland and Sweden, 1980-2013. Health Economics Policy and Law. 2014;10(1):61-81. doi:10.1017/S1744133114000243
  70. Rechel B, Wright S, Edwards N, Dowdeswell B, McKee M, eds. Investing in Hospitals of the Future. Maidenhead, UK: Open University Press/McGraw Hill Education; 2009.

Files

History

  • Receive Date: 29 June 2015
  • Revise Date: 03 November 2015
  • Accept Date: 29 October 2015
  • First Publish Date: 01 January 2016

Share

How to cite

Statistics