International Health Care Management: Volume 5

We hope this research volume will change the way scholars and managers think about health care management in two fundamental ways. First, we want to challenge the superficial separations between national and international health care management. To dissolve these distinctions, the “not-invented-here” or “who cares about a Belgian, Indian, or Thai medical center,” or “that won’t work in our policy system” attitudes must change. Second, we want scholars and managers to learn how to transfer innovative ideas and management practices across cultures and around policy barriers. Cultural, language, and policy differences present formidable barriers, but we believe lessons about managing human resources, informatics, quality, services, and strategies in health care organizations can be transferred.

To underscore the significance of international health care management, we focus on three themes: the problem of global blindness; global health care challenges and opportunities; and learning from international health care management. The problem of global blindness highlights how health care managers’ inattentional blindness to competitors’ operational performance and market strategies lead to avoidable and expensive failures. To address global challenges and opportunities, health care organizations are employing two different strategies: (1) building and marketing a world-class health care facility internationally, and (2) organizing and integrating multinational health care operations. The first strategy exploits the medical-tourism market. The second strategy requires either multinational health care networks or transnational health care organizations. One of the lessons to be learned from international health care management is that an organization can create a meta-national competitive advantage. Another lesson is that by examining best practices from around the world, health care organizations can obtain new insights and become more innovative within their home markets. A corollary and third lesson is that while health care organizations can learn a great deal from examining international best clinical practices, sometimes the most important management lessons are lost in clinical translations. The fourth and last lesson is that worst cases – serious international management failures – offer perhaps the most valuable insights into the role of culture, complexity, and leadership for health care organizations.

The incipient HIV/AIDS epidemic in Chile poses challenges for responsiveness of the Chilean national health care system, Fondo Nacional de Salud (FONASA) (National Health Funds), especially given the sociocultural forces for inertia in FONASA. Thus, the issue is what is the nature of the forces for change. A grounded theory approach was applied to interview data from two qualitative studies, one with HIV/AIDS advocates and activists as interviewees and the other with Chilean low-income women. The stories of their experiences with and perceptions of FONASA revealed major issues facing FONASA, including quality of care and ethics. Ways in which these issues are being addressed by the activists result in constructed environmental dynamism. A conceptual model of the forces for change was developed including actors, strategies, and targets of change that constitutes organizational environmental dynamism. The construct of environmental dynamism has international applicability, particularly to governmental health systems, which are influenced by strong sociocultural forces.

This chapter draws on a study conducted in the mid 1990s to compare management differences between three different groups of South African hospitals, in order to understand how these differences might have affected hospital functioning. The groups were public hospitals; contractor hospitals publicly funded but privately managed; and private hospitals owned and run by private companies. Public sector structures made effective management difficult and were highly centralized, with hospital managers enjoying little autonomy. In contrast, contractor and private groups emphasised efficient management and cost containment. These differences appeared to be reflected in cost and quality differences between the groups. The findings suggest that in the context of a country such as South Africa, with a relatively well-developed private sector, there is potential for the government to profit from the management expertise in the private sector by identifying lessons for its own management structures, and by contracting-out service management.

Globalization of health care services is becoming an alternative or complementary strategy for some U.S. health care organizations due to increased competition, a stagnant health care market, and nationally imposed cost constraints in the U.S. Additionally, entrepreneurial U.S. firms may see globalization as an opportunity to promote their services in new countries with increasing demand for advanced technological services. If an ambitious American health care firm decides to globalize its product or service lines, what might be some of the primary strategies it would use to enter an international market? To investigate this question, this chapter considers the strategies of two American firms that have entered the Beijing and Shanghai markets since 2000. We conducted numerous telephone conversations and interviews with executives of these firms in an attempt to understand their market entry and early development strategies. These firms’ market entry strategies range from “greenfield” operations, where the hospital does little to change its corporate and managerial style from what it uses domestically, to a “glocalization” strategy, where the firm is quite sensitive to fitting into the Chinese culture and being accepted by the Chinese government. The strategic challenges for international hospital organization developments in China are many, but the potential rewards from becoming among the leading firms in a large nation with an expanding economy are tremendous. What we learn from the experiences of enterprising American hospital firms in Chinese may well portend the future for international developments by many other American-based health organizations.

Integrated health care delivery (IHCD), as a major issue of managed care, was considered the panacea to rising health care costs. In theory it would simultaneously provide high-quality and continuous care. However, owing to the backlash of managed care at the turn of the century many health care providers today refrain from using further integrative activities. Based on transaction cost economics, this chapter investigates why IHCD is deemed appropriate in certain circumstances and why it failed in the past. It explores the new understanding of IHCD, which focuses on actual integration through virtual integration instead of aggregation of health care entities. Current success factors of virtually integrated hybrid structures, which have been evaluated in a long-term case study conducted in the San Francisco Bay Area from July 2001 to September 2002, will elucidate the further development of IHCD and the implications for other industrialized countries, such as Germany.

Health care organizations function in multidimensional environments, and their organizational cultures are complex and demanding. Expectations for health care services are high: patients want the most effective and newest possible treatments, politicians demand accountable service production, and health care professionals require motivating and challenging work environments. All these goals and objectives, for example, can be at the root of wicked problems in health care management. Thus, this chapter aims to explore the wickedness of health care management through an analysis of Finnish and Swedish health care reforms. The aim of these reforms is to solve the problems encountered in health care systems and organizations. The concept of a ‘wicked issue’ can shortly be described as a problem that is difficult to identify and solve. The reasoning behind using the concept of wicked issue as a method for analysis here is the hypothesis that the concept helps to explain and understand the social complexity involved in health care management.

Recent invasions, coups, civil wars, and ethnic crusades have caused many individuals and families around the world to flee their homelands for fear of their own safety. The exodus of refugees to foreign nations causes a strain on those nations’ health care systems and resources. With the assistance of outside organizations, these countries can develop a health care management system for refugees that provides for both their immediate survival and long-term health stability, while preserving critical national resources. This chapter reviews the refugee problem and presents the short-term tactics and long-term strategies undertaken by seven very different national governments to care for the refugees that cross their borders. A model of a sound health care management system is used to incorporate the best practices of each country into a framework for approaching this multi-billion dollar issue.

For health services researchers and health services management educators, chronicling the unfolding of a country's implementation of national health insurance (NHI) is once in a lifetime opportunity. Rarely, do researchers have the opportunity to observe the macro and micro changes associated with turning a country's health care delivery system 180 degrees. Accordingly, we report on the first decade of Taiwan's changing delivery system and selected adaptations of health care management, providers and patients.

We present a description and analysis of the current reforms in the French system of “assurance maladie”, or its health insurance system, particularly as they bear on quality at the hospital level. The measurement and management of quality play a significant role in the reform, thus providing a particularly timely example for health care policy makers, researchers, and managers. We discovered several lessons from the French experience. First, the issue of workload influenced thinking about how best to build a given indicator, and led to careful evaluation of the added value of additional data collection. In some cases the indicators are actually more of a screen or filter than an actual assessment of quality, with particularly high or low values signaling the need for further investigation rather than serving as assessments per se. Second, the development and implementation of quality indicators (QIs) demand the involvement of professionals in the process. Third, process indicators seemed to be more useful than outcome indicators. Fourth, expectations for quality management should be aligned with feasibility and with the reality of measurement system. For example, the workload is closely tied to the state of the hospital data collection systems (indicators selection). Lastly, the twin objectives of quality improvement and accountability do not necessarily mesh easily or well.

We outline the design and development of a diagnostic tool for use in health care organisations to assist in benchmarking the management of human resources. Key areas of focus were the way in which employees perceived their work roles, work loads, satisfaction with their work life and their views of clients, peers, front line supervisors and senior management. Using a cross-section of metropolitan and regional health services, the study used focus groups and large-scale survey research to capture data on these employee perceptions. Principal component analysis identified a series of ‘factors’ associated with the key elements found within human resource management (HRM) frameworks. The diagnostic tool we developed offers a way of measuring employees’ perceptions of their work environment and offers managers within large health care service organisations a potentially useful tool for benchmarking human resources.

The rising of chronic illness and the continuous aging of the global population requires a re-organization of health care systems based on relations and exchange of information to address patient needs in the community. The re-organization of health care systems involves interconnected changes and the development of integrated health care information systems and novel eHealth services. In Crete, the Foundation for Research and Technology-Hellas has developed HYGEIAnet, a Regional Health Information Network (RHIN) to contribute to the re-organization of health care systems and information sharing. We present HYGEIAnet, some of the most critical and novel eHealth services developed and deployed, discuss the impact of an RHIN on health care processes, and explore innovative models and services for health delivery and the coordination of care. We then critically discuss lessons learned regarding the effective management of change to overcome organizational and cultural issues in such large-scale initiatives. The paper concludes with policy and practice recommendations for managing change processes in health care organizations.

A common observation is that both single- and multi-payer health care systems will achieve lower overall costs if they use primary care gatekeeping. Questioning this common wisdom, we focus on the health care access system, that is, the way in which patients gain access to health care. Gatekeeping, the use of primary care providers to control access to more specialized physician and hospital services, has come under intense scrutiny in the United States and in Europe. The few international comparative studies that have focused on the issues of quality of care, cost containment, and patient satisfaction find weak or no support for common assumptions about gatekeeping. Hence, we examine the institutional environments in seven countries in order to: (a) define and categorize health care access systems; (b) identify the components of a health care access system; (c) explore the notion of a strategic fit between health care financing systems and access system configurations; and (d) propose that the health care access system is a key determinant of process-level cost efficiency. Drawing upon institutional and governance theories, we posit that the structure and organization of an access system is determined by how it addresses six essential questions: Who is covered? Which services are included? What are the points of access? How much time elapses before access? What are the ways of selecting among points of access? and Are services and their quality the same for everyone? This analytical framework reveals that national health care access systems vary the most in their points of access, access times, and selection mechanisms. These findings and our explanations imply that access systems are one of the only tools for demand management, that any lasting change to an access system typically is implemented over an extended time period, and that managers of health care organizations often have limited freedom to define governance structures and shape health care service production systems.