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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. - PowerPoint PPT Presentation
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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, MRCVS12 December 2008
© Dr Yiannis Kyratsis Imperial College London
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?
© Dr Yiannis Kyratsis Imperial College London
Levers
Financing
Organisational arrangements
Resource allocation
Intermediate Goals
Provision
Equity
Choice
Efficiency
Effectiveness
Goals
Health
Financial Risk Protection
User Satisfaction
Family Medicine Reforms:A Complex Health Innovation
Atun et al, 2005
© Dr Yiannis Kyratsis Imperial College London
Research Setting
© Dr Yiannis Kyratsis Imperial College London
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
© Dr Yiannis Kyratsis Imperial College London
Research Methodology
Building theory inductively from case study Research (Eisenhardt, 1989)
Research Design Multiple Case studies - Holistic, Pluralistic, Context sensitive method (Yin 2003) - Replication Logic (Yin 2003)
Purposive sample of 280 key informants in 5 countries - Multi-level, multi-stakeholder sample - Semi-structured interviews Primary data collection method - Statistics, Archival records, Legislation/Policy Docs Secondary data
© Dr Yiannis Kyratsis Imperial College London
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 interpreted and theorised by purposeful actors (Greenwood et al, 2002)
• Innovations to be presented as appropriate Gain
Pragmatic, Moral, Cognitive Legitimacy (Suchman, 1995)
- Functionally / technically superior - Normative values - Shared cognitive-cultural prescriptions
© Dr Yiannis Kyratsis Imperial College London
An institutional theory account
1. 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)
© Dr Yiannis Kyratsis Imperial College London
An institutional theory account
Theorisation Discursive strategy to enhance Legitimacy (Greenwood et al, 2002)
Abstract categorisations / models :
a) Specify an organisational failing/problem (Tolbert & Zucker, 1996)
b) Justify abandonment of old practice (Tolbert & Zucker, 1996)
c) Inform wider audiences about results of localised experiment related to the innovation (Hinnings et al, 2004)
© Dr Yiannis Kyratsis Imperial College London
Societal transformation in former European communist countries
Collectivist, communist/socialist, state bureaucratic, command & control system
More liberal system, political pluralism, market economy, “westernisation”
End of 1980s beginning of 1990s:
© Dr Yiannis Kyratsis Imperial College London
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)
© Dr Yiannis Kyratsis Imperial College London
Semashko / Yugoslav Healthcare models Macro-culture
a) Specialist-led delivery modelb) Healthcare is a Public servicec) Centrally driven, prescriptive organising “don’t trust private”, “real doctors are the
specialists” , “risk aversion / passive attitude” “punitive culture”
© Dr Yiannis Kyratsis Imperial College London
Diffusion of FM Practice: Scale of adoption of institutional innovation
0
20
40
60
80
100
% population covered by FM
Serbia
Bosnia &HerzegovinaMoldova
Slovenia
Estonia
© Dr Yiannis Kyratsis Imperial College London
Change Outcome
Estonia Slovenia BosniaHerzegovina
Moldova Serbia
Spread across the system
Significant spread but still contestation over reforms elements (private FM practice)
Debated and some spread with small pockets of high advancement(RS: Laktasi, FBiH: Tuzla)
Contested with significant time lag to spread
Non spread
© Dr Yiannis Kyratsis Imperial College London
Change Outcome / Process
Estonia Slovenia BiH Moldova Serbia
Rapid, radical, transformational change
“Transform”
Incremental, developmental change
“Build on - gradualist”
Incremental transformational change
“Transform & Build on”
Inertia followed by rapid radical change
“Cautious – Extensive but not in-depth change”
Non adoption / No real change
“Reject – Keep/adjust the old”
© Dr Yiannis Kyratsis Imperial College London
Structural Characteristics of PHC reforms:Organisational arrangements
Dimensions of Change
Estonia Slovenia Bosnia &Herzegovina
Moldova Serbia
Organisational Form
Family physician
Personal Doctor: 1) FP2)Paediatric. 3)Gynaecol.
Family Medicine Team
(FPs-FNs)
Family physician(General Practice)
Chosen Doctor:
1) GP2)Paediatric.3)Gynaecol.4)Occup. Med. 5) Dentist
Service Delivery structure
FM independentprivate practices
Public PHC Centres (75%)
FM independent private practices (25%)
DZs (FBiH)
DZs/Ambulant (RS)
Polyclinics – Family Medicine Health Centres
PHC Centres (DZs)
© Dr Yiannis Kyratsis Imperial College London
Structural Characteristics of PHC reforms:Organisational arrangements
Dimensions of Change
Estonia Slovenia BiH Moldova Serbia
Degree of autonomy
High Limited for FPs in public PHC centres (75%)
High for private FPs (25%)
Limited Limited Limited
Ownership status
Private Private
Public (PHC centres)
Public Public Public
User Choice Yes Yes Yes Yes Yes
© Dr Yiannis Kyratsis Imperial College London
Structural Characteristics of PHC reforms:Financing
Dimensions of Change
Estonia Slovenia BiH Moldova Serbia
Introduction of Social Health Insurance (Year)
1991: Sickness Funds 2001: EHIF
1992: HIIS
Pre-existing
1997: FBiH 1999: RSPre-existing
(1998)2004: NHIC
1991 2005: RIHIPre-existing
Payment System for FPs/GPs
Weighted per capita-FFS-practice allowance
FPs working in Public PHC Centres: Fixed Salaries
Private FPs:Weighted per capita-FFS (health prevention)-PRP (w/t, pr, rf)
Non pilot: Salaried employment
Pilots: Weighted per capita - FFS health prevention (RS)- Bonus accredited FM teams (RS)
Simple Per Capita- Quality Indicators bonuses
Salaried employment
Per capita (piloting)
Public Health Expenditure allocated to PHC
14% 20% 40% 35% 20%
© Dr Yiannis Kyratsis Imperial College London
Structural Characteristics of PHC reforms:Provision
Dimensions of Change
Estonia Slovenia Bosnia &Herzegovina
Moldova Serbia
Unified Provision of care irrespective of age, gender and type of disease of patients
Yes No No No No
Expanded Scope of Service for FPs(compared to the role of PHC FP/GP in the preceding health model)
YesConsiderable Secondary – primary care shift
YesConsiderableSecondary – primary care shift
YesModerate to Considerable Secondary – primary care shift
Yes Moderate change
No
© Dr Yiannis Kyratsis Imperial College London
Professional Development in FM
Dimensions of Change
Estonia Slovenia Bosnia &Herzegovina
Moldova Serbia
Initiation of Reforms
Academics- MedicalProfession
Medical profession
State Administration
Internat. Aid Orgs
Internat. Aid Orgs
State Administration
Intern. Aid Orgs
FM Association
1991
(Strong Active)
1992(GP:1966)
(Strong Active)
2000(GP:1960s)
(Limited Role)
2000
(Limited Role)
N/a(GP:1960s)
N/a
FM Department
1992 (Tartu)
1995 (L)2003 (Mar)
1998 (Tuzla)1999 (Ms,BL)2005 (S, E-S)
1998 N/a
© Dr Yiannis Kyratsis Imperial College London
Professional Development in FM
Dimensions of Change
Estonia Slovenia Bosnia &Herzegovina
Moldova Serbia
Percentage of practising FPs who are specialists in FM (by 2007)
15% 53.4%
40.5% 24% 55% (GPs)
Jurisdictional exclusivity for FPs on adult care
Yes A legal requirement since 2003
Yes A legal requirement since 2000 (2007)
No No No
FM specialty officially recognised(Year)
1993 1994 2000 1997 No
© Dr Yiannis Kyratsis Imperial College London
Prevailing societal sentiment
Mixed picture: Nostalgia for Yugoslav model / Wish to break away from the Socialist and Serbian dominated system
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
Mixed picture: Nostalgia for Soviet system (looking to “east” “Russia”) / Break away from the Soviet past (looking to “west”, “Europe”)
Nationalist / Traditionalist Proud of Yugoslav past, “Nostalgia for the previous system + Desire to re-join Europe”
© Dr Yiannis Kyratsis Imperial College London
Theorising Framing of FM Reforms
Estonia Slovenia BosniaHerzegovina
Moldova
By the FM Professionand other supportive actors
“European”“Western”“Nordic”“entrepreneurial”“human friendly”“dissociation from soviet past”“efficient”“patient-centred”“family focus”“private”“independent”“choice”“revolutionary”
“European”“private”“efficient”“rediscovering pre-Yugoslav Slovenian past”“responsive”“modern”“continuity of care”“evolutionary, building on the past”
“efficient”“choice”“family focus”“user-friendly”“holistic care”“contextual/community-centred model”“improved access to care”“modern”“European”“preventive”“named doctor”
“efficient”“family oriented model”“personal care – named doctor”“rational”“part of societal change”“holistic model”“preventive”
© Dr Yiannis Kyratsis Imperial College London
Counter-theorising
Framing of FM Reforms
Estonia Slovenia BosniaHerzegovina
Moldova
By the narrow specialists opposing the reforms -DZs directors- heads of polyclinics
“risk to children’s health”“model only for the poor”“individualistic”“poor quality”“suitable only for rural areas”“good for FM advocates but bad for patients”
“low quality for children and women”“elementary health”“how something named general claim to be specialist”
“cheap”“poor quality”“imposed”“basic model compared to state of art PHC centres in Yugoslav model”“conditional necessity”“backward”“downgrading women & children’s care”
“Western construct”“American”“ineffective model compared to advanced soviet system”“imposed by the West”“top-down”“basic care”“incompetent FPs”“poor quality/training of FPs”
© Dr Yiannis Kyratsis Imperial College London
Institutional practice: acting Acting Estonia Slovenia BiH Moldova
Change of regulatory rules, incentives, practical connections for the innovative practice-FM community-State officials - External actors
“institutional forgetting”“advocacy, political lobbying”“external networks”“educating, training”“collective action”“dissociating moral foundations of pre-existing practice”“constructing a distinct professional identity”“Symbolic action”
“external networks”“advocacy and political suasion”“educating, training, researching”“constructing a new professional identity”“Symbolic action”
“International organisations moral, financial, technical and political support”“training” “constructing a distinct professional identity for FM”“experimentation”“researching in FM”“demonstration sites”“foreign universities support/network”
“International organisations financial, technical and political support”“political lobbying”
© Dr Yiannis Kyratsis Imperial College London
Institutional practice: counter-acting
CounterActing
Estonia Slovenia Bosnia &Herzegovina
Moldova
Narrow specialists(Medical Chamber)
“mobilise political power”“undermine moral legitimacy of FM: misinformation”
“promoting anti-privatisation agenda”“control post-graduate education and undermine professional development of FM”“political lobbying”“mobilising local communities” “lobbying hospitals”
“mythologizing the past to influence state administration”“mobilising local governments” “misinformation”“emphasise image gap bw FPs and specialists”
“restrict organisational autonomy of FM under the jurisdiction of rayon hospital director (2003)”“control education and training of FM” “overstressing competence inefficiencies of FPs”
© Dr Yiannis Kyratsis Imperial College London
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