The Need for Change in Swedish Health Care Organizations
The health care sector in Sweden has had two major problems to deal with during the last decade. The first is long waiting lists at hospitals, and the second is recurrent deficits in operating statements. On one hand there is a need for increased treatment and more surgeries, and on the other it is increasingly difficult to finance the operations. For some of the health care entities, the financial development has resulted in an equity ratio close to zero and a rather weak financial position.
In Sweden the county councils are responsible for the major part of the health care services. The regions and the councils can be regarded as large health care organizations governed by directly elected politicians. The constitution states that these organizations are autonomous; thereby the politicians (and managers) have the opportunity to make, and responsibility for making, necessary changes. But the regions and councils are not independent of the State. The government controls some of their financial resources and the National Board of Health and Welfare some of their operations.
If change is not initiated and implemented by the actors in the organizations' subunits, the responsible politicians and managers have to engineer it. Political decisions about priorities and cutbacks seem to be necessary, but for this to happen two conditions must be fulfilled. The first is that politicians and top managers that are responsible for producing the foundations for the decisions are aware of the problem. Lack of awareness can of course cause an unwanted status quo. The second is that they must have the strength to implement measures. It is not hard to imagine that there can be resistance against top-level decisions in health care organizations. Politicians and managers must be able to control the implementation process. This reasoning means that there are three situations where necessary measures will not be taken:
When politicians and managers lack awareness of the problem-in spite of implementation strength.
When politicians and managers lack the strength to implement measures-in spite of awareness of the problem.
When politicians and managers lack both awareness and strength.
Our overall research question is, Which are the constraints to implementing change? Our contribution to an already well-investigated question is a consequence of the way we illuminate the described phenomenon and our theoretical perspective.
Purpose, Case, and Method
The purpose of this article is to explain why necessary change has not occurred in Swedish health care organizations. The analysis is based on an institutional perspective and is limited to intra-organizational impediments to change. More specifically we are investigating whether the lack of change can be explained by lack of awareness of the problem, lack of strength to engineer change, or both in the executive health care organization management.
In order to answer the question, three case studies have been carried out. Case studies are appropriate when a phenomenon needs to be investigated in depth, and our judgment is that there was need for deep understanding of the development in a few health care organizations rather than shallow understanding of several.
For our case studies we wanted three health care organizations that fitted well in the general description of the problems in the health care organization sector. We found that Dalarna, Gavleborg, and Vastmanland matched this criterion. They had all faced a period of more than ten years of financial stress and long waiting lists for surgeries and treatments. There was (and had been for some time) need for change, but change had not occurred. The three counties are geographically located in the middle of Sweden and have approximately a quarter of a million inhabitants each. The most striking difference between them is that the surface of Dalarna is five times larger than that of Vastmanland and twice as large as that of Gavleborg. The dominating city in Dalarna is Falun; in Vastmanland, Vasteras; and in Gavleborg, Gavle.
The procedure in the case studies was to interview leading politicians and civil servants. A total thirty interviews were carried out, ten in each organization. Five of the interviewees in each organization were leading politicians, and five were key civil servants. All of the politicians interviewed were part of the executive health care organization management. The civil servants were primarily active centrally, although some administrative directors were also interviewed. The interviews took between one and two hours. Before the analysis they were transcribed word for word.
The aim of the interviews was to try to find out the politicians' and civil servants' view of certain distinguishing features in their organization. The aim was also to provide an impression of each organization's historical development, current situation, and how they look upon the future. Thereby we formed a basis for comparisons and explanations of the course of development and the significance of institutions.
The interviewees were given two important questions. One concerned ingrained attitudes and the other, threats and opportunities for each health care organization. By studying, reviewing, and coding these questions, an impression of the distinguishing features of each council has been provided, in addition to which a sharply focused picture of ways in which the actors in the three county councils perceive anticipated threats and opportunities has been created. Descriptions of distinguishing features are to be seen in relation to perceptions of health care organizations' threats and opportunities. What are the distinguishing features? What similarities and differences are there between the health care organizations? What is the significance of the distinguishing features for perceptions of adaptation and change? Can tendencies for adaptation and change be identified? What are the preconditions for adaptation and change? In which way do existing institutions impede change? What is the connection and how can it be explained? A speculation on this concludes the article.
We are here primarily interested in' the intra-organizational constraints to necessary change, but that of course does not mean that there are no constraints in the organizations' environment. One obvious example is legislation.
Theoretical Point of Departure
To explain and understand an organization's course of development and the prevailing situation, informal rules and intra-organizational values must be accounted for and included in the analysis (Atkinson and Oleson 1996). Individuals' notions of what the informal rules and values are greatly influence their decisions and actions. A clear set of preconstructed notions facilitates individuals' decision making and actions. When combined, the preconstructed notions provide a framework. The clearer and more delimited this framework is, and the more restricted it is in terms of scope, the easier it is for the individual to make choices between different alternatives, since the number of possible alternatives is reduced.
The preconstructed notions exist alongside formal rules, management principles, and organizational models. The notions, rules, principles, and models are examples of institutions, since they constrain, enable, and guide behavior, are durable, and cannot be selected individually by each member of the organization (which is the definition given by Nooteboom 2002). Institutions function as behavioral constraints; information providers; determinants of how people organize, select, and interpret information; and determinants of individuals' objectives (Dequech 2002).
For individuals, therefore, institutions facilitate decision making and the implementation of new activities. The issue, however, is which decisions are made and which activities are implemented--and how these affect the developmental trend. The institutions are a result of a continuous process. They are based on historical development and previous circumstances. Another way of expressing how the process reveals itself is the formation of future institutions in prevailing conditions at present. It therefore follows--in accordance with fundamental arguments asserted by Thorstein Veblen, the founder of institutionalism--that institutions can never fully adapt to the current situation without a certain degree of retardation. Institutions provide knowledge of reality that is more or less false in relation to how reality actually is constructed. A consequence of this observation and insight is that...