The project organization as a policy tool in implementing welfare reforms in the public sector

A policy ethnography study of a Singapore regional health system on its governance adaptations and associated challenges as a project organisation to implement Healthier Singapore

Objectives

Project organisations reflect a modern and non-bureaucratic form of organising public-sector activities, which promises innovation, entrepreneurship, and order and control to bring about change. This study seeks to investigate the project organisation Singapore Health Services (SingHealth) Region Health System (RHS)'s approach to implementing the Healthier Singapore (HSG) strategy, including models of governance and perceptions of RHS leads, identify the challenges facing the RHS, and to draw insights into the conditions necessary for using project organisation as a policy tool in policy implementation.

Study design

We adopted a policy ethnography approach to answering the research question.

Methods

The approach involved: (1) non-participant observation with fieldnotes taken during meetings, events, programme activities, and conferences concerning SingHealth and HSG implementation; (2) analysis of 52 organisational documents; and (3) interviews with 21 senior SingHealth leaders from the RHS Executive Committee, involved in envisioning and overseeing the production of RHS projects to align with the HSG strategy (March to September 2022).

Results

Evidence demonstrates the presence of multiple governance and interactive governance in HSG implementation, including legitimising the RHS as the project organisation; engaging the private corporations; incorporating the citizens; and working with non-governmental organisations. However, the RHS faced many challenges, ranging from governance, workforce, financing, IT infrastructure and care models, problem definition, primary care and legacy issues, knowledge management, and being pandemic-informed in its delivery.

Conclusion

The RHS will need to address these challenges through the necessary constitutive, directive, and operational actions, and interactive governance to enhance its institutional capacity to implement the HSG Strategy.

Collaboration for drug prevention: Is it possible in a "siloed" governmental structure?

PURPOSE

Norwegian municipalities report that drug misuse is the most important public health challenge. The municipalities play a unique role in drug prevention aimed at youth, since young people rely on several services in their daily lives that are organized by different municipal departments. However, the municipal structure is described as siloed, and the policy areas as differentiated. This situation has led to a need for integration between different policy sectors to prevent drug use and promote health. The following study explores how policymakers describe the structures for integration within local government in practice with regard to drug prevention aimed at youth, contributing to the ongoing debate on collaboration and integration in response to public health challenges.

METHODS

A single case study design was used to investigate the accounts of policymakers from different municipal departments in a Norwegian municipality following Axelsson and Axelsson's conceptual scheme of integration.

FINDINGS

Collaboration between departments was viewed as important to successfully address drug prevention; however, the policymakers recognized problems with integration. The participants described confusion regarding ownership between the departments and a perceived lack of a mandate for collaboration.

CONCLUSIONS

The findings and discussion illustrate that integration of drug prevention in a siloed structure relies on departments appreciating their respective roles in drug prevention and advisers experiencing a mandate to manage the siloes that exist in the organization. By gaining a better understanding of the siloed structures, we can provide valuable information needed to navigate them.

A Discursive Sensemaking Perspective on Project-Based Work in Public Healthcare

This study investigates project participants’ sensemaking of lived work experiences during periods of organizational change within Finnish public healthcare. It introduces a discursive sensemaking perspective to investigate lived experiences, that is, reflexive practitioners’ situational thinking. Drawing upon 17 interviews, the study identifies diverse repertoires through which the lived experiences are considered meaningful. These are repertoires of: (1) transformation, (2) realism, (3) politics, (4) individuality, (5) reflexivity, and (6) senselessness. The results show that project-based work in public healthcare differs from project participants’ expectations because projects are perceived to increase rather than decrease bureaucracy and include unsustainable working conditions that have to be endured.

Strategies to facilitate implementation and sustainability of large system transformations: a case study of a national program for improving quality of care for elderly people

BACKGROUND

Large-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies.

METHODS

A longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries.

RESULTS

This study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care.

CONCLUSIONS

There is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability.