Transcript Health Systems, Policy and Financing Module

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
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
Family Medicine Reforms:
A Complex Health Innovation
Levers
Organisational
arrangements
Intermediate Goals
Goals
Equity
Health
Financing
Resource
allocation
Provision
Efficiency
Effectiveness
Choice
Financial Risk
Protection
User
Satisfaction
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
End of 1980s beginning of 1990s:
 Collectivist, communist/socialist, state
bureaucratic, command & control system
 More liberal system, political pluralism,
market economy, “westernisation”
© 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 model
b) Healthcare is a Public service
c) 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
100
Serbia
80
Bosnia &
Herzegovina
Moldova
60
40
Slovenia
20
Estonia
0
% population covered by FM
© Dr Yiannis Kyratsis Imperial College London
Change Outcome
Estonia
Slovenia
Spread
across the
system
Significant
spread but
still
contestation
over reforms
elements
Bosnia
Herzegovina
Debated and
some spread
with small
pockets of
high
advancement
(private FM
practice)
(RS: Laktasi,
FBiH: Tuzla)
© Dr Yiannis Kyratsis Imperial College London
Moldova
Serbia
Contested
with
significant
time lag to
spread
Non spread
Change Outcome / Process
Estonia
Slovenia
BiH
Moldova
Serbia
Rapid, radical,
Incremental,
transformational developmental
change
change
Incremental
Inertia
transformational followed by
change
rapid radical
change
Non adoption /
No real change
“Transform”
“Transform &
Build on”
“Reject –
Keep/adjust the
old”
“Build on gradualist”
© Dr Yiannis Kyratsis Imperial College London
“Cautious –
Extensive
but not indepth
change”
Structural Characteristics of PHC reforms:
Organisational arrangements
Dimensions of Estonia
Change
Organisational
Form
Family
physician
Slovenia
Bosnia &
Moldova
Herzegovina
Serbia
Personal
Doctor:
Family
Medicine
Team
Family
physician
(General
Practice)
Chosen
Doctor:
Polyclinics –
Family
Medicine
Health
Centres
PHC Centres
(DZs)
1) FP
2)Paediatric.
3)Gynaecol.
Service
Delivery
structure
(FPs-FNs)
FM
Public PHC
DZs (FBiH)
independent Centres (75%)
private
practices
FM
DZs/Ambulant
independent
(RS)
private
practices
(25%)
© Dr Yiannis Kyratsis Imperial College London
1) GP
2)Paediatric.
3)Gynaecol.
4)Occup. Med.
5) Dentist
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%)
Limited
Limited
Limited
Public
Public
Public
Yes
Yes
Yes
High for
private FPs
(25%)
Ownership
status
Private
User Choice Yes
Private
Public (PHC
centres)
Yes
© Dr Yiannis Kyratsis Imperial College London
Structural Characteristics of PHC reforms:
Financing
Dimensions
of Change
Estonia
Introduction of
1991:
Social Health
Sickness
Insurance (Year) Funds
2001: EHIF
Payment
Weighted per
System for
capita
FPs/GPs
-FFS
-practice
allowance
Public Health
Expenditure
14%
allocated to PHC
Slovenia
BiH
Moldova
Serbia
1992: HIIS
1997: FBiH
1999: RS
Pre-existing
(1998)
2004: NHIC
1991
2005: RIHI
Pre-existing
Pre-existing
FPs working in
Public PHC
Centres: Fixed
Salaries
Private FPs:
Weighted per
capita
-FFS (health
prevention)
-PRP (w/t, pr, rf)
20%
Non pilot: Salaried
employment
Simple Per
Capita
- Quality
Pilots:
Indicators
Weighted per capita bonuses
- FFS health
prevention (RS)
- Bonus accredited
FM teams (RS)
Salaried
employment
40%
20%
© Dr Yiannis Kyratsis Imperial College London
35%
Per capita
(piloting)
Structural Characteristics of PHC reforms:
Provision
Dimensions of
Change
Estonia
Unified Provision Yes
of care
irrespective of
age, gender and
type of disease
of patients
Expanded Scope
of Service for
FPs
(compared to the
role of PHC
FP/GP in the
preceding health
model)
Yes
Considerable
Secondary –
primary care
shift
Slovenia
Bosnia &
Herzegovina
Moldova
Serbia
No
No
No
No
Yes
Considerabl
e
Secondary –
primary care
shift
Yes
Yes
Moderate to
Moderate
change
Considerable
Secondary –
primary care shift
© Dr Yiannis Kyratsis Imperial College London
No
Professional Development in FM
Dimensions
of Change
Estonia
Slovenia
Bosnia &
Herzegovina
Initiation of
Reforms
Academics
- Medical
Profession
Medical
profession
State
Internat. Aid
Administration Orgs
FM
Association
FM
Department
Moldova
Internat. Aid
Orgs
State
Administration
2000
Serbia
Intern. Aid
Orgs
1991
1992
(GP:1966)
2000
(GP:1960s)
(Strong
Active)
(Strong
Active)
(Limited Role) (Limited Role) N/a
1992
(Tartu)
1995 (L)
2003 (Mar)
1998 (Tuzla)
1999 (Ms,BL)
2005 (S, E-S)
© Dr Yiannis Kyratsis Imperial College London
1998
N/a
(GP:1960s)
N/a
Professional Development in FM
Dimensions
of Change
Estonia
Slovenia
Bosnia &
Herzegovina
Moldova
Serbia
Percentage of
practising FPs
who are
specialists in
FM (by 2007)
Jurisdictional
exclusivity for
FPs on adult
care
15%
53.4%
40.5%
24%
55% (GPs)
Yes
A legal
requirement
since 2003
No
No
No
FM specialty
officially
recognised
(Year)
1993
Yes
A legal
requirement
since 2000
(2007)
1994
2000
1997
No
© Dr Yiannis Kyratsis Imperial College London
Prevailing societal sentiment
Nationalist / Traditionalist  Proud of Yugoslav past,
“Nostalgia for the previous system + Desire to re-join Europe”
Mixed picture: Nostalgia for Yugoslav model / Wish to break
away from the Socialist and Serbian dominated system
Mixed picture: Nostalgia for Soviet system (looking to “east”
“Russia”) / Break away from the Soviet past (looking to
“west”, “Europe”)
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
© Dr Yiannis Kyratsis Imperial College London
Theorising
Framing of
FM Reforms
Estonia
Slovenia
Bosnia
Herzegovina
Moldova
By the FM
Profession
and 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/co
mmunitycentred 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
Estonia
FM Reforms
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”
Slovenia
Bosnia
Herzegovina
Moldova
“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
Counter
Acting
Estonia
Slovenia
Bosnia &
Herzegovina
Moldova
Narrow
specialists
(Medical
Chamber)
“mobilise
political power”
“undermine
moral
legitimacy of
FM:
misinformation”
“promoting antiprivatisation
agenda”
“control postgraduate
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
© Dr Yiannis Kyratsis Imperial College London
Thank you!!
Thank you!!
[email protected]
© Dr Yiannis Kyratsis Imperial College London