Field-level change in post- Soviet contexts: evolving institutional logics in primary healthcare restructuring

Field-level change in post- Soviet contexts: evolving institutional logics in primary healthcare restructuring Federica Secci MSc, PhD Candidate CERGAS, Bocconi University 24 September 2010

About me

Key message: how does change unfold? Our current understanding: The process of change occurs through shifts in sets of belief systems (logics) My view: perpetual motion of change The process of change occurs through grafting and evolution of belief systems (logics) Logics are not monolithic, but they evolve (toolkits) Logics and fields are layered, stratified

Agenda 1. Theoretical framework 2. Research question and contributions 3. Methodology 4. Empirical settings 5. Findings 6. Contributions of the study 7. Future research agenda Imperial College Business School

Agenda 1. Theoretical framework 2. Research question and contributions 3. Methodology 4. Empirical settings 5. Findings 6. Contributions of the study 7. Future research agenda

Institutional theory approach to study change Core constructs: Why are organizations similar? They become isomorphic to institutions (Meyer & Rowan 1977, DiMaggio & Powell 1983) To acquire legitimacy (Suchman 1995) Within a given sector, field (Scott 1994, DiMaggio 1983) Why do organization differ and change? The environment is complex (Greenwood et al. 2010) There are multiple logics (Friedland & Alford 1991) There is embedded agency (Holm 1995, Seo & Creed 2002)

How does institutional theory see change? Change as: Theorization of new institutions (Greenwood, Suddaby & Hinings 2002) Delegitimation of old institutions (Oliver 1992) Shift in the dominant logic (Thornton & Ocasio 1999; Scott et al. 2000; Lounsbury 2007; Greenwood et al. 2008) Translation of institutions (Sahlin-Andersson 1996) How do logics relate to each other? (Reay & Suddaby 2009; Greenwood et al. 2010) Are old beliefs and practices really abandoned? Does change only occur through shifts in logics?

2. Research question and contributions Research question: How does field-level change unfold? How do logics evolve, generating a more or less homogeneous configuration and stratification of the field? Contributions: Evolution of institutional logics Field and actor stratification Grafting process Intellectual leaders as theorizing agents

Why Estonia and Lithuania? Imperial College Business School

3. Methodology: standpoint and approach Standpoint and approach: Interpretive and constructivist research Inductive theory generation Naturalistic methodology (qualitative research) Strategy and methods: Comparative case study design (instrumentality) Theoretical sampling and constant comparison (Berger and Luckmann 1967; Denzin and Lincoln 2000; Glaser & Strauss 1967; Langley 1999; Lincoln and Guba 1985; Morgan and Smircich 1980; Strauss & Corbin 1990; Pope and Mays 2000; Stake 2000)

Estonia & Lithuania: background information Similar but different: Size and population (Lithuania is bigger) Ethnical composition (Lithuania is more homogeneous) Language (Estonian is Finno-Ugric, Lithuanian Indo- European) Religion (Estonians are atheist, Lithuanians Catholic) Past history (Estonia fell under Germany and Sweden, Lithuania under Poland) Economic indicators (GDP, health expenditure) Health outcomes (life expectancy)

Focus on healthcare: pre-reform (Semashko) However: Poor health outcomes and responsiveness Resource constraints Desire of Westernization

Focus on healthcare: the current system

Professional logics in primary care Elements Specialist-led (Semashko) Generalist-led (GP) Public insurance and Economic system Central planning contracting system External: doctor as gatewayto-treatment coordinator-of-care Internal: doctor as Sources of identity Sources of legitimacy Referrals; Patient lists; Specialization of care Comprehensive care Sources of authority Head of polyclinic Individual doctors; patients Basis of mission Increase referrals Manage patients lists Basis of attention Basic medical treatment; Expanded medical (and Increase service demand managerial) responsibilities Basis of strategy Growth of polyclinic activity Provision of comprehensive and resources care within a practice Logic of investment Budget-based Activity-based Governance Accountability for patient lists Hierarchy and direct control mechanism and for practice management

Function Semashko Primary care Estonia Lithuania Financing State budget Mandatory insurance Mandatory insurance Service delivery Differences in the health systems functions Public employees in polyclinics Independent contractors (FDs) Independent contractors (FDs/GPs); salaried employees (GPs); public PHC teams Stewardship Hierarchy Accountability Accountability; hierarchy Ownership Local level Private FDs; municipality Municipality; private GPs Planning Central level Central and local level Central and local level Monitoring & evaluation Direct control Contracting; quality bonus Contracting; (quality bonus)

Findings There are several phases of the reform process and different key actors intellectual leaders as theorizing agents Institutional change occurs through logic grafting The change process unfolded differently in the two cases: Different modes of grafting Generated different field configurations

Phases of the reform and key actors State: Professionals:

5. Grafting as a process for field change Existing logic Grafting Revised logic Theorization Delegitimation Identity Translation Shift in logic Other contexts Legitimacy Translation to practice

Comparative analysis of the cases In what does the process differ in the two countries? The starting point for both countries was exactly the same, the Soviet model. The difference was that Estonia did a very clean-cut, comprehensive reform, and I think in Lithuania they just did a piecemeal they didn t really reform, but the new forms of provision emerged and they coexisted with the others, and you have a more plural system. (World Bank expert) Imperial College Business School

5. Findings: modes of logic grafting

5. Findings: field outcomes of logic grafting Evolving logics Dominance Complement Coexistence Complement Dominance Field configuration Field homogeneity Field heterogeneity Field homogeneity

Contributions to institutional theory Internal evolution of logics: flexibility and mutual tolerance Change as logic grafting Centrality and complementarity of the theorization and translation processes Field and actors stratification Intellectual leaders as theorizing agents Empirical settings

Institutional theory Perpetual motion of change: logics evolution through grafting AMR, AMJ Intellectual leaders as theorizing agents JMS, AMJ, OS (with Nelson Phillips, Imperial College, and Royston Greenwood, U of A) Conceptualization of logics and fields at multiple levels of analysis AMR (with Kari Jalonen, Helsinki University of Technology) Impact of institutional logics on gender differences within professional groups AMJ (with Roy Suddaby, U of A)

Healthcare management and policy Comparative analysis of reform processes (with Margus Lember, University of Tartu; Danguole Jankauskiene, Mykolas Romeris University) HP Intra-organizational processes and service integration (e.g. primary care and public health) (with Jarno Habicht, WHO Regional Office) HPP, AMJ Impact of IT diffusion in primary care on activity, performance and data quality Quality bonus payments for family doctors

Thank you f.secci07@imperial.ac.uk

Appendix on pt.3: list of key informants ESTONIA E-Health Department Estonian Family Doctors Association Estonian Health Insurance Fund Health Protection Inspectorate Healthcare Department of the City Government (Tallinn; Tartu) Labor Inspectorate Medicum Health Centre Ministry of Social Affairs (ex-minister of Social Affairs; current Health Secretariat; Public Health Department) National Institute for Health Development Practicing family doctors PRAXIS, Research Centre for Policy Studies Tallinn Tartu University (Department of Family Medicine; Department of Internal Medicine), The World Bank, country experts The World Health Organization, Regional Office LITHUANIA Center for Family Medicine, Vilnius University College of General Practitioners Department of Family Medicine, Kaunas University Faculty of Strategic Management and Policy, Mykolas Romeris University General Practitioners Association Health centers (Vilniuas universitetine Antakainio ligonine; Vilnius Centre Polyclinic) Health Economic Centre, Research Centre Vilnius Ministry of Health (Secretariat; Foreign Affairs Division; Health Policy Development Division) Practicing general practitioners State Patient Fund (Health Services Department; Insurance Development Department) Territorial Patient Funds The World Health Organization, primary care experts Vilnius City Government (Healthcare Division, Social Welfare Division)

Appendix on pt.5: inst. conditions for grafting Gradualness Tolerance Translatability Resultorientation