Actor, Resource Dependence And Institutional Change

A profound institutional change movement named "autonomy reform" has been taking place in health service delivery in China since the reform and opening up. To a certain extent, "market-oriented" institutional environment for public hospitals has been constructed by market methods and competition mechanism. Meanwhile, government departments at all levels have gradually reduced direct "administrative intervention" to those health service producers. Undoubtedly, economic incentives, policy guide and innovation demonstration have been essential tools for local reform practice. All these become distinct characteristics of the gradual reform in health service delivery in China. It is regrettable that many problems haven’t been solved, although the public hospital reform has made certain achievements. There is a baffling phenomenon that many public hospitals, especially the large public hospitals in cities, haven’t achieved significant success to improve organizational efficiency, but continue to expand and develop in the course of institutional change. This phenomenon has not been explained adequately still by the mainstream researches on public hospitals and health services in China which use popular theories of health economics and health policy science. Why those inefficient organizations could survive for a long time? Furthermore, how the institutional change affects the behavior and performance of healthcare organizations? This study tries to construct a analytical framework in perspective of resource dependence, and respond to the research questions by case study of management system reform of H hospital.Chapter Ⅰ is an introduction of the thesis. This chapter presents the research background, research issues, research objectives, research methods and paths, and so on.Chapter Ⅱ provides a review of relevant research literatures about the relationship between institutional change and healthcare organizations. These literatures are classified according to two research approaches:"institutional structure" and "institutional process". The former focuses on regulative elements of institution, pays attention to design of "structure" and its external influence on organizations, more emphasis on assessment of results and instrumental rationality. This research approach is always seen in the early and the mainstream literatures. The latter pays more attention to normative and cultural cognitive elements of institution, not only receives institution as exogenous variable, but also as an endogenous process. Action of organization, interaction and relationship between the actors (organizations), and their impact on institutional implementation are paid more attention. This kind of research approach could not be seen often in Chinese scholars’ literatures, although it has increasingly become a trend that scholars do research in this approach since the late twentieth century. In order to explain the phenomenon of institutional change of health services delivery more effectively, we have to identify and select several effective analytical tools, make intensive study on the practice of healthcare organizations, and construct proper logic of interpretation. This chapter also puts forward the possible directions of research on public hospitals and health services delivery in China.Chapter Ⅲ puts forward the analytical framework of this study. In order to give a systematic analysis from "organizational field" to "organizations", this study is mainly based on analytical approach and methods of "institutional process", and moderately uses analytical methods of "institutional structure". The diverse reform practice of health service delivery is still failed to be explained adequately by rational choice model and institutional isomorphism model, although these theoretical tools have certain effectiveness for analyzing the action logic of healthcare organizations and change mechanism of health service delivery. This thesis attempts to introduce a theoretical perspective of resource dependence, reference to other theoretical achievements, and construct an analytical framework of endogenous institutional change. Interactive power and dynamic equilibrium of resource dependence constitute the basic assumptions of the analytical framework. Starting from the relationship between organization and institution, this thesis interprets the institutional roles of healthcare organizations. Moreover, it provides a series of indicators for observation of the two dimensions of organizational performance:effectiveness and efficiency.Chapter IV interprets the process of management system reform of H hospital, which became an affiliated hospital of university from a staff hospital. The results show that, a field level of resource dependence pattern of "segmentation of vertical and horizontal relationships" was gradually formed under the influence of regulation and normalization of the management and governance system. In the process of management system reform of H hospital, action of individual organization was always deeply connected with the resource dependence pattern. The influence of legitimacy isomorphism from institutional environment and organizational action of rational choice to maintain stability and seek greater development is based on the relationship of resource dependence between organizations. As a necessary condition to the institutional change, H hospital had to consider the relationship with environment, do negotiations and coordination with different organizations in the field by using its relative power, mobilized other actors to join the action group of institutional change. In the process of this reform practice, factors of resource dependence shaped the potential motive of the organization, restrained the decision making of the organization, and guided the process of interaction between organizations.Chapter V further discusses institutional change continuously caused by the management system reform of H hospital. In order to meet the requirements of new institutional roles, H hospital did necessary adjustment in strategy and tactics, and gradually established a new relation of resource dependence with the college of traditional Chinese medicine, government departments, and other organizations. By reshaping institutional roles, H hospital gained boundary expansion of organizational effectiveness. It achieved "great leap forward" development in functional cultivation of clinical teaching, scientific research and discipline construction of combine traditional Chinese and western medicine, and expansion of sphere of business and foreign exchange. However, the organizational efficiency was not significantly promoted by the management system reform and other series of measures, according to the analysis of technical efficiency and allocative efficiency of H hospital during the ten years after the management system reform. The results also show that, the field level of resource dependence pattern has not been fundamentally changed. Compared with many peer hospitals, H hospital has a certain weakness still in capacity of acquisition and allocation of resources, such as talent, capital, technology, and so on. H hospital has been increasingly incorporated into an ever strengthening resource dependence pattern of "segmentation of vertical and horizontal relationships".Chapter VI is the theoretical summary and reflection on the case study. The case illustrates an endogenous process of institutional diffusion and institutional implementation which was affected by factors of resource dependence. This kind of endogenous institutional change reflects the changing of resource dependence pattern: from "vertical relationships" to "segmentation of vertical and horizontal relationships". Three essential interrelated characteristics of the institutional change is put forward: (1) dynamic equilibrium of resource dependence is the basic motive force of institutional change; (2) exchange of legitimacy resources is a necessary condition for institutional change; (3) the relative position of organization in the field influence the direction of institutional change. Although H hospital played a positive role in fighting for resources and selecting and implementing reform plans with the help of "institutional empowerment", and achieved greater development, it encountered efficiency predicament which was originated from inherent contradiction of the endogenous institutional change. The subjective motive of actors to improve organizational performance was insufficient, because the ever strengthening resource dependence pattern of "segmentation of vertical and horizontal relationships" actually reinforced their dependence on development model of "endogenous growth". In addition, flawed symbiosis relationships between actors hindered the healthcare organizations to improve performance, so the objective conditions for actors to improve the organizational performance ware restricted. These led to "expanded and fuzzy social functional requirements", "weak accountability system", "low degree of market entry", "implementation difficulties of residual claim", and so on. Therefore, economic incentives and policy guide and innovation demonstration could not provide sufficient conditions for effective reform of public hospitals and health service delivery. The key lies in coordinating the power and interests relationship between actors, creating conditions for actors to play autonomy effectively, and properly guiding actors’ participation in reorganization and integration of social resources. Undoubtedly, it is crucial to gradually break the original pattern of resources allocation, form an open market order, and redefine roles of governments in this process.Chapter VII is the conclusion of this thesis. This chapter also expounds a self-criticism of the methodology and methods of the study, and makes a prospect on theory and practice in future.