Foreword ^☆

Worldwide forces have changed the nature of social organization everywhere, in an epidemic of cultural rationalization. The direction of the change is always toward more formal organization, with more rules and roles, more formalization, and more articulated rationalization. The change occurs in all sorts of countries: even the most unlikely places now experience rapid organizational expansion. It occurs in all the fields or sectors of social life: governmental structures shift from bureaucratic forms to modern managerial organizations, and so do traditional firms. Most strikingly, a whole array of more traditional social structures come to take the forms of modern organization in now called the “non-profit sector.” So schools, charities, recreational associations, churches, religious orders, and many social movements now become organizations, with all the trappings. So do universities and health care institutions – the focus of the studies here.

Managers appear, and take the lead in building the new world. They plan and create strategies. They erect elaborate information and control systems. They track and record resources: human and material. They engage in the rituals of formalized and explicit “decision-making,” including explicit structures for participation.

In one way or another, whole new structures appear, relating what was once a simpler enterprise to an expanding array of “stakeholders.” A large human resources department is created, with programs for supporting human rights and participation. Relations with the physical and social environment are codified. Some of these take legalized forms: much social control that was once neglected or left to informal arrangements is now conducted under explicit hard- or soft-law controls from local or national or even supra-national public or professional authorities. Similarly, organization arises to meet the new demands for transparency and accountability: monetary accounting, but also other sorts of statistical information, expand. In the for-profit world, corporate social responsibility becomes an important institution and ideology, and the newly expanding multi-nationals take on many expanded structures to come to terms with it.

Understanding why all this happens in so many social arenas and so many places in the world is an important task. It is aided by our awareness that the whole social movement toward more formalized organization takes its upward trajectory principally in a very specific time period: it occurs rapidly through most of the post-World-War-II time period, and explodes in the neoliberal decades since the 1980s. Further, it is clearly aided by the broadly liberal forces of the whole period, and the dramatic neoliberal crusade more recently. The old authoritative nation-state, often linked to a corporatist social structure, did not look good in 1945, and looked even worse in the Cold War. The decline in its authority (though not its scale), combined with an enormous rise in awareness of supra-national interdependence, led to bursts of liberal ideology celebrating the value and capability of the sub-units of society rather than the central state structures – rights-bearing individuals and the organizations they create.

In many social sectors – industry, for example – the new ideology could play out in fairly straightforward ways. Production and exchange could in fact be organized in great multi-national firms, operating on a worldwide scale. In the same way, activities formerly directly managed by the state could be spun out to for-profit and non-profit organizations. Whether or not the new world was more efficient or effective than the old one is a legitimate question, but the new order does in fact operate.

The problem arises when the attempt to organize reaches out into social sectors producing activities difficult to standardize, measure, and control. These include the domains of the traditional professionals – corporate bodies with roots in the medieval university: the Church and its theologians and priests; the legal order; and most importantly, the doctor, and the professors in the core knowledge system. Here, the new system of rationalized organization runs up against two related realities. First, there is great uncertainty and invisibility in the core work of the domain: what do salvation, education, and health mean, and how can they be produced, and if produced, measured? Second, these domains are already managed by the professions and thus carry much autonomous authority. This authority is embodied in professional occupations with their own corporate status and their own charisma (reflected in medieval saints and modern Nobel laureates).

In this book, Rómulo Pinheiro and his colleagues have assembled a valuable set of studies of what happens when the era of managerialist organizations, infused with the powers and responsibilities of organizational actorhood, confronts the recalcitrance both of the professionals and of the realities with which they deal. The researchers focus on the health system with its hospitals and doctors, and on the system of higher education with its professors and researchers. The cases come mainly from Europe, though the issues are clearly worldwide.

The studies show the wide variety of outcomes that result from the collision between rationalizing and standardizing schemes and the realities faced in hospitals and universities. Higher education and the health system differ. This is partly because in much of the medical care system there is a fairly clear bottom line in terms of health, efforts to organizationally control and standardize can reach further down: there is high agreement on whether a patient is dead or not, and mortality can thus be counted. Further, there are in many cases fairly clear technologies that can be employed and managed. The definitions involved may be socially constructed and maintained, but they are often visible, clear, and measurable. There is much less consensus on whether or not a graduate in history is well educated, or on how to produce a well-educated one. The social constructions involved vary within universities and across them.

National contexts matter too, perhaps even more. Organizational and professional life function rather well together in Scandinavia, with long histories of cooperation. And ideas about markets and competition have long histories in the United Kingdom (and even stronger ones in the United States), so that organizational expansion is facilitated. In France or Germany, the history of resistance to organizational control and raw competition is stronger.

So the studies here quite successfully explore the many variations that they find: there is variation in the control efforts put forward in the wider environment, in the older structures come under these controls, and thus in the organizational patterns that result. But some core observations are very general, and describe the whole array of observations.

First, the contemporary binge of rationalization is to be found everywhere in the modern social environment. It seems that all health systems face it, as do all higher educational systems. The notions of the correct world-class university, or the medical system rooted in scientific best practices, are strong and worldwide. Local settings in all the cases under review in this book are under continuing inspection from expanding and rationalized standards of an essentially global character. The days when a local doctor can imagine conforming to the best standards of Danish medicine as set in a traditional medical community are gone. And every higher educational institution comes under pressure to conform to the imagined model of the “American research university.”

Second, as a result, everywhere the researchers look, they find increases in the elaboration of local organizational systems. Managers appear, and organizational staffs expand. Every university is pressed to become more of an organization, with more accountability, more decision-making, and more responsiveness to more environments. And every hospital comes under pressure to manage its business in light of standard measures and criteria: management becomes more and more important, and the traditions of autonomous medical authority decline. The old professionalism declines, and a new more managerial form rises.

Third, decoupling of one sort or another is endemic in the social fields under investigation here. The realities of the treatment of the patient, or the schooling of the students, or the difficulties and uncertainties of the research project, are everywhere in part buffered from the sweeping regulatory regimes of the organization and its environment. The old professionals, princes of their establishments, lose out to the managers; but the work of the new professionals adapted to the new world goes on with only limited scrutiny from the expanded organizational structures of the evolving environment. The researchers here evaluate the decoupling they observe in differing ways, but they all observe it.

As a result, fourth, the researchers here – reflecting the organizations they study – can (and need) give very little attention to what happens to the actual patients in these new health care systems, or what happens to the students in the reformed universities. In fact, neither the researchers nor the organizations they study are all that well informed on the matter. The social science of higher education, it turns out, studies the ever-expanding organizational and career systems involved, not the substance of teaching and research. And the social science of health care is a subfield of political science more than of medicine.

But to qualify this point, fifth, it is clear that health and health care, and education and research in the university, are incorporated in the growing organizational systems of education and health. They are incorporated, not in the traditional case-by-case way, but as statistics. The expanding organizational systems work, not with students and patients, but with data, and data are rapidly expanding throughout the world. One can criticize this as governmentality, or control “at a distance,” or one can defend it as ensuring the spread of equality and proper standards, but it is certainly a dominating trend.

Carvalho and Santiago capture the decoupled rationalization involved with a quote from a doctor:

To me what is more painful and takes more time is the huge number of documents we need to have to respond to management and administration. Sometimes things are a bit repetitive … it gives me the idea that managers who are in health still do not know much about health. Often … a document requested is the repetition of another and they end up not realizing where is the problem of the patient in the middle of those squares where there are only numbers ….

As a sixth and final generalization, it is important to understand, in reading the studies in this book, that the systems they analyze have undergone very rapid expansion over recent decades. We see expanding organization and (often decoupled) regulation, and expanded management of abstract and statistical sorts, but this goes on in association with massively expanded higher education and health care arrangements. In most of the countries here, higher education now captures a substantial majority of people in a cohort: this would have been unthinkable a few decades ago. Similarly, expanded medical systems touch the lives of many more people than would have been the case in earlier periods.

The editors and authors here have done the field a real service with detailed and empirically grounded analyses of what happens around the world when widespread standardizing rules impact inevitably messy local situations. They track a wide variety of outcomes – all of which seem to involve some sort of organizational expansion in local settings. And they provide ample evidence that these outcomes involve a great deal of decoupling. The researchers rarely find the straightforward implementation of sweeping rules and programs reflecting global ideas about virtuously standardized arrangements for education and health.