The Coordination of European Public Hospital Systems : Interests, Cultures and Resistance

'A clear, thorough, comparative work. Dan offers the reader a careful, nuanced analysis, structured by partly competing, partly complementary theoretical perspectives. His exploration of the similarities and differences between western and eastern European cases is particularly interesting.' - Christopher Pollitt, Emeritus Professor, Public Governance Institute, KU Leuven, Belgium 'A comparative book that looks into the impact of New Public Management reforms on the coordination of organizations in one of the key targets of reforms: public hospital systems. It offers a rich empirical account of reform trends and coordination challenges in public hospitals in Estonia, Romania and Norway.' - Trui Steen, Associate Professor, Public Governance Institute, KU Leuven, Belgium 'This is an important contribution to the study of how administrative reforms in the hospital sector in different countries have affected national coordination. The book raises research questions which are important both from a theoretical and a practical point of view. It gives a very good overview of health systems and hospital administration in three European countries which deserve attention by both academics and policy-makers globally.' - Per Lægreid, Professor, Department of Administration and Organisation Theory, University of Bergen, Norway This book engages theoretically and empirically with the unprecedented wave of public management reforms in public hospitals in Europe in the past 25 years. It provides a useful overview of these reforms and studies the way in which they have influenced the ability of national policy-making institutions to co-ordinate the system of public hospitals as a whole. Using a comparative structure, as well as original empirical data collected by the author, the book examines case studies on which little has so far been published for an international audience in English. Sorin Dan has worked as Policy Analyst at the OECD on public governance reform with countries such as Lithuania, Romania and Slovak Republic as well as the OECD more generally. He was previously a Doctoral Researcher at the Public Governance Institute, KU Leuven, Belgium where he completed his doctoral thesis. While in Leuven he was part of the COCOPS project team, a major EU-funded international research project. His work on public administration and healthcare reform has appeared in different international journals. Acknowledgments 6 Contents 8 LIST OF FIGURES 9 LIST OF TABLES 10 Chapter 1: Introduction 11 Research Questions 14 Structure of the Book 17 Bibliography 17 Chapter 2: Public Management Reform and Coordination 18 Autonomy Reform 21 Decentralization Reform 23 NPM and Healthcare Reform 25 Theorizing Coordination 32 Governance and Coordination 34 Organizations, Institutions and Coordination 36 Culture and Coordination 38 Principal-Agent Theory and Coordination 40 Coordination: Conceptual and Analytical Approaches 43 Bibliography 50 Chapter 3: Theoretical Framework 58 “Hospital System Culture” 58 Principal-Agent Theory 63 Bibliography 65 Chapter 4: Research Design 67 Case Selection 67 Methods of Primary Data Collection 69 Preliminary Interviews 70 Program of Semi-Structured Interviews 71 Methods of Secondary Data Collection 73 Addressing Specific Theoretical and Practical Issues 75 The Concept of Coordination 75 Defining Coordination Problems 76 Thinking in Before and After Terms 77 Perception versus Evidence 77 Access, Cultural Differences and Language 78 Bibliography 80 Chapter 5: Coordination of Public Hospitals in Estonia 82 Overview of Healthcare Policies and Hospital Trends (1991–2013) 82 The Reform Model: Hospital Management Autonomy and Political Decentralization 86 1991–2000 87 2000–2014 89 Hospital Master Plan 2015 90 Self-Governed Hospitals and Political Decentralization 91 Do Self-Governed Hospitals Compete or Collaborate? 98 Mechanisms and Instruments of Coordination 108 Cases and Problems of Coordination 111 Coordination of Medical Personnel: A Problem of Contradiction 111 Coordination of the Hospital Network 113 Duplication: A Coordination Problem or an Administrative Glitch? 115 Coordination of Expensive Medical Equipment in the Face of Divergence: The Case of East Tallinn Central Hospital 117 Explaining Coordination 119 Positive and Negative Incentives 120 Information Asymmetry and Imperfect Monitoring 123 Conflicting Interests and the Hospital System Culture: Where Politics, the Elite Medical Profession and Management Meet 128 Bibliography 135 Chapter 6: Coordination of Public Hospitals in Romania 137 Overview of Healthcare Policies (1991–2014) 137 Public Hospital “Rationalization” 141 Decentralization and Autonomy of Hospital Management 146 Decentralization Reform 146 Autonomy of Hospital Management 153 Mechanisms and Instruments of Coordination 158 Cases and Problems of Coordination 162 Coordination of Financial Resources: A Problem of Contradiction 162 Centralizing Public Procurement 167 Explaining Coordination 170 Positive and Negative Incentives 170 Information Asymmetry and Imperfect Monitoring 173 Conflicting Interests and Goals and the Hospital System Culture 176 Bibliography 182 Chapter 7: Coordination of Public Hospitals in Norway 185 Overview of Healthcare Policies (1984–2014) 185 The 2002 Hospital Reform 186 Mechanisms and Instruments of Coordination 194 Autonomy of Hospital Management 197 Cases and Problems of Coordination 202 Coordination of the Hospital Network 203 Coordination of Process versus Coordination of Quality 207 Explaining Coordination 210 Conflicting Interests and Goals 212 The Elite Medical Profession 216 Bibliography 222 Chapter 8: Discussion and Conclusions 224 Organizational Reform and Coordination in Public Hospitals 224 Explaining Coordination: Conflicting Interests and Goals and Hospital System Culture 235 Implications for Practice 244 Bibliography 246 Appendix 248 I. Interview Questionnaire: Central Healthcare Institutions (English Version) 248 II. Interview Questionnaire: Hospitals (English Version) 250 III. Interview Questionnaire: Central Healthcare Institutions (Romanian Version) 251 IV. Interview Questionnaire: Hospitals (Romanian Version) 254 V. Program of Interviews: Estonia 255 VI. Program of Interviews: Romania 256 VII. Program of interviews: Norway 258 Index 259 Front Matter....Pages i-xi Introduction....Pages 1-7 Public Management Reform and Coordination....Pages 9-48 Theoretical Framework....Pages 49-57 Research Design....Pages 59-73 Coordination of Public Hospitals in Estonia....Pages 75-129 Coordination of Public Hospitals in Romania....Pages 131-178 Coordination of Public Hospitals in Norway....Pages 179-217 Discussion and Conclusions....Pages 219-242 Back Matter....Pages 243-261 Annotation This text engages theoretically and empirically with the unprecedented wave of public management reforms in public hospitals in Europe in the past 25 years. It provides a useful overview of these reforms and studies the way in which they have influenced the ability of national policy-making institutions to co-ordinate the system of public hospitals as a whole