The governance of primary care quasi-markets: a case study of the Stockholm region in Sweden

BACKGROUND: In the latter part of the 20th century, several European countries introduced quasi-markets in their public healthcare systems. The introduction of quasi-markets is designed to give patients a choice of the service provider that meets their needs, among competing providers, including, in some cases, privately owned providers. In quasi-markets, as “money follows the patient”, often in the form of fee-for-service payments, providers have an incentive to increase technical efficiency (to generate higher surpluses from the payment they receive) and service quality (to attract more patients and therefore generate more revenues), in comparison to a traditional planned resource allocation structure. Whether these improvements in efficiency and quality occur in practice, however, depends on the “rules of the game” in the market: what we in this thesis label the quasi-market’s governance system. The thesis aims to provide an analysis of a specific quasi-market — the primary care quasi-market in Stockholm, Sweden — from the perspectives of key stakeholders who work in or are affected by the relevant governance arrangements. The focus is on how the governance system operates and performs, with specific reference to the achievement of fair competition among providers with different ownership characteristics and the attainment of quality of care for patients. METHODS: A literature review was conducted to identify the existing base of knowledge to which the thesis aims to contribute. The main body of the thesis consists of an embedded case study that analyses how the regional authorities in Stockholm seek to exert influence on primary care providers, publicly and privately owned, and how, in the perception of key stakeholders, the mechanisms deployed impact on the achievement of fair competition and service quality. Key informants included those with the formal authority to govern (e.g. officials/employees of the region’s Health Committee and Health Care Office) alongside those who are subject to the resulting governance arrangements (the accredited service providers). Data was generated from 39 semi-structured interviews with senior professionals in relevant organisations, undertaken between February and November 2018. In addition, a documentary analysis of nine strategic/policy documents was carried out to further understanding of the governance system, and its impacts on the main outcomes of interest (competition/quality), with triangulation across sources. RESULTS: The results were organised to address the three key objectives of the thesis, as follows: (i) What mechanisms are used to govern the quasi-market and how do these influence the incentive environment in which primary care providers operate? According to the key informants interviewed, a range of specific mechanisms have been employed by public authorities to exert performance pressure on accredited providers. These include the payment mechanism, market entry/exit criteria, performance monitoring, the use of knowledge management, and a range of sanctions. Of these mechanisms, many informants perceived the payment mechanism to have the greatest impact on incentives. However, they also perceived the effect of this to be moderated by other variables. Primary care providers tended to perceive their actions as being shaped by the actions of different principals — e.g. public authorities, organisation owners, and their professional ethics — resulting in different (and sometimes competing) pressures. When reflecting on the resulting complexity of performance pressures, care providers tended to emphasise the pre-eminence of their values and professional ethics in determining their actions. Care providers also expressed frustration with those who set the rules of the game in the market because of limited opportunities for policy dialogue, and often found command and control-style directions from public authorities to be unhelpful and, in their view, contrary to the advancement of the patient/public interest. (ii) How do stakeholders perceive the impact of the governance system on the achievement of competition across providers in a context of diverse ownership characteristics? The “rules on paper” (manifested in a standardised contract and an associated rulebook) are designed to ensure that all providers — public and private — operate within the same market conditions, i.e. to ensure that there is fair competition. Yet, according to key stakeholders, the rules in practice lead to a situation in which providers with different ownership characteristics (a) serve different segments of the market (with publicly owned providers serving as providers of last resort) and (b) operate in different market conditions. Providers with small private owners perceived market conditions to be unfair to them, while public authorities expressed concern over the performance of providers with small private owners. Indeed, the results highlight the extent to which ownership matters in quasi-markets. This is not simply a matter of public versus private, but also the types of private ownership. In particular, larger private owners (often private-equity companies), for whom short-term profit maximisation is a key goal, are perceived to more often pursue profit maximisation strategies that could be inimical to patient welfare, such as unnecessary referral of patients to associated business units in secondary care facilities. These findings highlight the importance of considering ownership characteristics, and particularly the nature and scale of the owner, as determinants of providers’ behaviour in the primary care quasi-market and thus an important variable for governance systems to recognise and regulate. (iii) How do stakeholders perceive the impact of the governance system on the quality of primary care services? Service providers tended to be sceptical that the outcomes from primary care services are appropriately measured by public authorities. There is a widespread perception among managers of provider organisations that public authorities focus on the “wrong things” — especially those things that are easy to measure (e.g. rapid access to care), as opposed to factors that are less easily measured but are more important from a quality perspective (e.g. continuity of care). In addition, in the absence of robust data on outcomes, public officials tended to perceive the governance of quality to be weak, and highly dependent on trust — in other words, a reliance on providers not engaging in opportunistic behaviours to maximise surpluses/profits at the expense of patient welfare. CONCLUSION: This thesis provides critical insights into the governance of primary care quasi-markets and the challenges involved. Key challenges include: (i) the creation of appropriate incentive structures in the context of multiple (and sometimes competing) accountability relationships; (ii) the complexities and risks of establishing and maintaining fair competition in the context of diverse ownership characteristics; and (iii) establishing accurate measures of service quality and the limitations and risks of reliance on trust. In future reform efforts (in Sweden and elsewhere), health policymakers who wish to achieve the benefits of choice and competition can learn from the Stockholm experience to generate a more granular understanding of the costs and risks involved, and how to mitigate them in practice, noting the additional challenges in governing to achieve public interest objectives in the context of widespread ownership of large for-profit providers

A framework for e-government implementation at a national level

This study attempts to explore and investigate empirically how an e-government system can be implemented at a national level; the key issues that might restrict its implementation; and how these issues could be treated in practice. Following a comprehensive review of the relevant literature, an initial conceptual framework for e-government implementation is formulated The framework is then applied in a real world case study to support further data collection and to establish an exhaustive view of the e-government implementation process at a national level. The case study examines the development of an e-government implementation in Qatar and involved 26 semi-structured interviews, 10 observations, 10 electronic reports, analysis of around 50 documents, and numerous newspaper articles and press releases. The interviewees included senior officials from the e-government steering committee, the e-government project team and various government ministries. The documentations included all the key documents relating the e-government project. Based on the data collected the initial framework is then revised by using the interpretive case study approach, which depends on an iterative research cycle where triangulated data are extracted The study then combined the evidence from the literature with the case study data to narrow the gap between e-government implementation theory and practice. As a result, a comprehensive framework including detailed measurements to differentiate four development stages is created. This framework classifies the key issues that might restrict e-government implementation into two main categories, organisational and technological issues, and uses other issues as the development measurements. The framework can be used as a tool to determine the road ahead for implementing an e-government system at a national level and to identify the main practices, processes, possible goals, progress indicators and key conditions to move from one stage to another. It can be claimed that this study has made a novel contribution to the area of e-government and has expanded the boundaries of knowledge, especially for governments that are seeking to implement an egovernment system at a national level

Global and regional sourcing of ICT-enabled business services: upgrading of China, Hong Kong and Singapore along the global value chain

Offshoring, as part of globalisation, first started decades ago with manufacturing processes disintegrated along the global value chain and dramatically redistributed to low-cost regions. The next global shift of work involving ICT-enabled business services has arisen since the 1990s, especially featuring the success of India’s supplier role. The possibilities for the Global South to move up the value ladder are well demonstrated by the achievements of the newly industrialised economies in East Asia in the first shift and of India in the second. In the services sector, however, potential for upgrading is conditioned by quality-based elements, such as trust, culture and language, which vary both between producing and market areas. Flows are increasingly multi-directional, requiring attention to the neglected issue of demands from fast-growing Southern economies. So how do locations and firms in the Global South attempt to upgrade in the regime of rising services offshoring? The Indian experience especially in serving Anglophone markets in the Global North has been widely documented – but not that of East Asian economies, with their distinct characteristics and strong historic, ethnic and cultural ties with each other. This study examines the upgrading possibilities and constraints of China, Hong Kong and Singapore along the global services chain. For cross-case analysis, it focuses on three specific sets of services, including information technology, finance and accounting, and customer contact services. The concepts of global value chain, competitive advantage and capabilities are applied to reconstruct the phenomenon of services offshoring from both the demand and supply perspectives in the selected locations, and synthesise the dynamics between locational characteristics and firm strategies. A series of distinct upgrading strategies are identified, involving mixes of manufacturisation, knowledge-intensification and deepening relational capabilities to exploit both regional advantages of language/cultural proximity and established global links

Rethinking the risk matrix

So far risk has been mostly defined as the expected value of a loss, mathematically PL (being P the probability of an adverse event and L the loss incurred as a consequence of the adverse event). The so called risk matrix follows from such definition. This definition of risk is justified in a long term “managerial” perspective, in which it is conceivable to distribute the effects of an adverse event on a large number of subjects or a large number of recurrences. In other words, this definition is mostly justified on frequentist terms. Moreover, according to this definition, in two extreme situations (high-probability/low-consequence and low-probability/high-consequence), the estimated risk is low. This logic is against the principles of sustainability and continuous improvement, which should impose instead both a continuous search for lower probabilities of adverse events (higher and higher reliability) and a continuous search for lower impact of adverse events (in accordance with the fail-safe principle). In this work a different definition of risk is proposed, which stems from the idea of safeguard: (1Risk)=(1P)(1L). According to this definition, the risk levels can be considered low only when both the probability of the adverse event and the loss are small. Such perspective, in which the calculation of safeguard is privileged to the calculation of risk, would possibly avoid exposing the Society to catastrophic consequences, sometimes due to wrong or oversimplified use of probabilistic models. Therefore, it can be seen as the citizen’s perspective to the definition of risk

Combining SOA and BPM Technologies for Cross-System Process Automation

This paper summarizes the results of an industry case study that introduced a cross-system business process automation solution based on a combination of SOA and BPM standard technologies (i.e., BPMN, BPEL, WSDL). Besides discussing major weaknesses of the existing, custom-built, solution and comparing them against experiences with the developed prototype, the paper presents a course of action for transforming the current solution into the proposed solution. This includes a general approach, consisting of four distinct steps, as well as specific action items that are to be performed for every step. The discussion also covers language and tool support and challenges arising from the transformation

Knowledge transfer in website design:exploring the processes and benefits of design collaboration for non-creative Micros

This thesis explores the interaction between Micros (<10 employees) from non-creative sectors and website designers ("Creatives") that occurred when creating a website of a higher order than a basic template site. The research used Straussian Grounded Theory Method with a longitudinal design, in order to identify what knowledge transferred to the Micros during the collaboration, how it transferred, what factors affected the transfer and outcomes of the transfer including behavioural additionality. To identify whether the research could be extended beyond this, five other design areas were also examined, as well as five Small to Medium Enterprises (SMEs) engaged in website and branding projects. The findings were that, at the start of the design process, many Micros could not articulate their customer knowledge, and had poor marketing and visual language skills, knowledge core to web design, enabling targeted communication to customers through images. Despite these gaps, most Micros still tried to lead the process. To overcome this disjoint, the majority of the designers used a knowledge transfer strategy termed in this thesis as ‘Bi-Modal Knowledge Transfer’, where the Creative was aware of the transfer but the Micro was unaware, both for drawing out customer knowledge from the Micro and for transferring visual language skills to the Micro. Two models were developed to represent this process. Two models were also created to map changes in the knowledge landscapes of customer knowledge and visual language – the Knowledge Placement Model and the Visual Language Scale. The Knowledge Placement model was used to map the placement of customer knowledge within the consciousness, extending the known Automatic-Unconscious -Conscious model, adding two more locations – Peripheral Consciousness and Occasional Consciousness. Peripheral Consciousness is where potential knowledge is held, but not used. Occasional Consciousness is where potential knowledge is held but used only for specific tasks. The Visual Language Scale was created to measure visual language ability from visually responsive, where the participant only responds personally to visual symbols, to visually multi-lingual, where the participant can use visual symbols to communicate with multiple thought-worlds. With successful Bi-Modal Knowledge Transfer, the outcome included not only an effective website but also changes in the knowledge landscape for the Micros and ongoing behavioural changes, especially in marketing. These effects were not seen in the other design projects, and only in two of the SME projects. The key factors for this difference between SMEs and Micros appeared to be an expectation of knowledge by the Creatives and failure by the SMEs to transfer knowledge within the company

INTERACT 2015 Adjunct Proceedings. 15th IFIP TC.13 International Conference on Human-Computer Interaction 14-18 September 2015, Bamberg, Germany

INTERACT is among the world’s top conferences in Human-Computer Interaction. Starting with the first INTERACT conference in 1990, this conference series has been organised under the aegis of the Technical Committee 13 on Human-Computer Interaction of the UNESCO International Federation for Information Processing (IFIP). This committee aims at developing the science and technology of the interaction between humans and computing devices. The 15th IFIP TC.13 International Conference on Human-Computer Interaction - INTERACT 2015 took place from 14 to 18 September 2015 in Bamberg, Germany. The theme of INTERACT 2015 was "Connection.Tradition.Innovation". This volume presents the Adjunct Proceedings - it contains the position papers for the students of the Doctoral Consortium as well as the position papers of the participants of the various workshops