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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 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