| In late twentieth century America, institutionalized public health practices such as running immunization clinics, testing for sexually transmitted infections, and managing prenatal programs are being contested as threats to the legitimacy of public health as a social institution. The research conducted for this study examines how one state public health system attempted to address this challenge and in the process, reestablish public health as a vital and integral institutional force within the larger health care system. As such, this study attempts to understand the complex dynamics involved in institutional change, focusing specifically on the roles that individual organizations play as both enablers and barriers to institutionalization. Operating under the assumptions that institutionalization is the result of the dialectic between organizations and institutional constituents, and that organizational behavior is both interpretative and strategic, this dialectic renders the process of institutionalization partial, contingent, and fluid.; Utilizing an embedded case study design, this study examines how local health jurisdictions in the state of Washington strategically respond to the state's attempts to re-institutionalized core public health functions that signify specific sets of norms and values. Three factors were found to influence this institutionalization process. First, the loosely coupled arrangement that characterizes the relationship between the state Department of Health and the state's 34 local health jurisdictions enables local health jurisdictions to retain distinctive local organizational forms that may resist institutional change. Second, the cognitive geographies of local public health officials strategically influence local response to institutional change. And third, how local health jurisdictions enact state and local environments influences their degree of resistance or conformity to institutional processes. Given the marginality of public health as a health protection institution embedded within the wider domain of health care during an era shaped by managerial and corporate logics, how to achieve and maintain institutional legitimacy becomes important if public health is to remain a relevant social institution. |
