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Between substance and governance.

Helen Dickinson1, Jon Pierre

  • 1Associate Professor Public Governance, Melbourne School of Government, University of Melbourne, Melbourne, Australia.

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Summary

Health system reforms often fail because they neglect governance. Focusing only on substantive changes, without addressing how organizations are governed, leads to stalled progress and ineffectiveness.

Keywords:
Change managementGovernancePolicyPolitical analysis

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Area of Science:

  • Health policy analysis
  • Public administration
  • Healthcare management

Background:

  • Developed countries have implemented numerous health system reforms over decades.
  • Despite significant investment, health systems continue to face persistent challenges.
  • Standard explanations like demographics and disease profiles do not fully account for reform failures.

Purpose of the Study:

  • To identify two key reasons for the limited success of health system reforms.
  • To argue that governance issues are central to reform effectiveness.
  • To propose a more comprehensive approach to health system transformation.

Main Methods:

  • Literature-based commentary.
  • Analysis of reform processes and their outcomes.
  • Conceptual exploration of reform meanings and intentions.

Main Results:

  • Health care reform and governance reform are intertwined; their interaction has distorted both.
  • Reform can be ritualistic rather than a plan for specific change, with limited success.
  • Focusing on substantive healthcare aspects while ignoring governance leads to reform failure.

Conclusions:

  • Substantive reform without governance reassessment is likely to fail.
  • Governance is often obstructed by internal interest groups, causing paralysis.
  • Comprehensive reform requires addressing both substantive and governance aspects of public organizations.