Health care management in Finland: an analysis of the wickedness of selected reforms.Abstract
Questions regarding health care management are interesting, not least because of the nature of health care organizations. Professional expertise is high in these organizations, especially when considering medical and administrative knowledge. Nonetheless, health care management is said to have serious problems, not only in Finland, but also in other Western countries. Why is this? One reason may be the fact that health care management problems are simplified. The concept of "wicked Wicked may refer to:
Health care management has been under discussion in Western European countries for quite some time. Many researchers have noticed the complexity of health care organizations and systems (e.g. Kernick 2004). The complexity of health care systems, therefore, relies on health care management. For this reason, it is both surprising and disturbing to see how ambiguous, disorganized dis·or·gan·ize
tr.v. dis·or·gan·ized, dis·or·gan·iz·ing, dis·or·gan·iz·es
To destroy the organization, systematic arrangement, or unity of. , and messy mess·y
adj. mess·i·er, mess·i·est
1. Disorderly and dirty: a messy bedroom.
2. Exhibiting or demonstrating carelessness: messy reasoning. the health care management practices in different organizations can be. Added to this is the fact that it is quite a prevalent phenomenon. It seems that the whole complexity of the management problem in health care has not been identified well enough. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , the clarity of health care policies, organizational structures, and decision-making practices become complicated when applied to real situations. In practice, health care systems and organizations wrestle with problems that are wide-ranging and difficult. That is why the concept of "wicked problems" is useful, because it helps to explain and describe the social and structural complexity involved in health care management. This article concentrates on two different issues. Firstly, the principles and characteristics that make health care management a wicked problem The concept of "wicked problems" was originally proposed by Horst Rittel (a pioneering theorist of design and planning, and late professor at the University of California, Berkeley) and M. Webber  in a seminal treatise for social planning. are discussed. Secondly, the wickedness Wickedness
See also Evil, Villainy.
Admah and Zeboyim
cities destroyed by God for citizens’ sinfulness. [O.T.: Deuteronomy 19:23]
honored false gods, usurped others’ land; byword for baseness. [O.T. of the selected health care reforms is examined.
The Concept of Wicked Problem
The term "wicked problem" originates from the field of social policy research. A well-known description of the concept is found in a classic planning theory article from Rittel and Webber (1973). They formulate formulate /for·mu·late/ (for´mu-lat)
1. to state in the form of a formula.
2. to prepare in accordance with a prescribed or specified method. wicked problems as follows:
The search for scientific bases for confronting problems of social policy is bound to fail, because of the nature of these problems. They are "wicked" problems, whereas science has developed to deal with "tame" problems. Policy problems cannot be definitively described. Moreover, in a pluralistic plu·ral·is·tic
1. Of or relating to social or philosophical pluralism.
2. Having multiple aspects or parts: "the idea that intelligence is a pluralistic quality that ... society there is nothing like the undisputable public good; there is no objective definition of equity; policies that respond to social problems cannot be meaningfully correct or false; and it makes no sense to talk about "optimal solutions" of social problems unless severe qualifications are imposed first. Even worse, there are no "solutions" in the sense of definitive and objective answers (Rittel and Webber 1973: 155).
Clarke and Stewart (2003: 274) also emphasize the basic wickedness of most problems to be ones "for which there is no obvious or easily found solution." This definition clearly addresses the dichotomy di·chot·o·my
n. pl. di·chot·o·mies
1. Division into two usually contradictory parts or opinions: "the dichotomy of the one and the many" Louis Auchincloss. of problems in organizations. Some of the problems are tame, but many are wicked. Health care organizations are not an exception. That is why it is necessary to separate wicked problems from tame ones.
When analyzing health care management as a wicked problem it is interesting to examine how the characteristics of wicked problems explain the difficulties of health care management. In the literature, the concept of wicked problem has three elemental elemental
emanating from or pertaining to elements.
see elemental diet. characteristics. These are: circularity, stakeholder stakeholder n. a person having in his/her possession (holding) money or property in which he/she has no interest, right or title, awaiting the outcome of a dispute between two or more claimants to the money or property. involvement, and investment in problem-solving processes.
Circularity means that wicked problems cannot be definitively formulated for·mu·late
tr.v. for·mu·lat·ed, for·mu·lat·ing, for·mu·lates
a. To state as or reduce to a formula.
b. To express in systematic terms or concepts.
c. , and that each attempt to create a solution changes the understanding of the problem. According to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. Rittel & Webber (1973: 161) "the information needed to understand the problem depends upon one's idea for solving it." Thus, since it is quite difficult to define the problem exactly, it is also difficult to determine when it is actually resolved. To solve a wicked problem is a complicated situation: usually there are many alternative solutions. All potential alternatives may be useful, but some are better than others. The difficulty is that we never know whether the chosen solution is good enough when compared to the stakeholders' needs. Different stakeholders Stakeholders
All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. can even compete with one another to confirm their views as a basis for problem solving problem solving
Process involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. .
In the context of Finnish health care management reforms, it can be proposed that the reforms fulfill ful·fill also ful·fil
tr.v. ful·filled, ful·fill·ing, ful·fills also ful·fils
1. To bring into actuality; effect: fulfilled their promises.
2. many of the elements of circularity. The reforms implemented in the health care sector follow each other, and new reforms are created based on the elements of the previous reforms. Actually, the implemented reforms do not often resolve the targeted health care problems. One reason for this is that the reforms have been implemented without understanding the problem at hand well enough. Another reason may be the fact that there are symptoms of problems that have not been taken into consideration when creating the reform for a certain problem. (Vartiainen 2005).
An interesting idea in the wicked problem approach is stakeholder involvement. Clarke & Stewart (2003: 275) put this as follows: "the wicked issues are likely only to be resolved by a style of governing gov·ern
v. gov·erned, gov·ern·ing, gov·erns
1. To make and administer the public policy and affairs of; exercise sovereign authority in.
2. which learns from people and works with people." When adapted to health care management, the statement could mean that resolving the wicked problems of health care depends on establishing a participatory management Participatory management is the practice of empowering employees to participate in organizational decision making. This practice grew out of the human relations movement in the 1920s, and is based on some of the principles discovered by scholars doing research in management and framework: a framework that emphasizes holistic Holistic
A practice of medicine that focuses on the whole patient, and addresses the social, emotional, and spiritual needs of a patient as well as their physical treatment.
Mentioned in: Aromatherapy, Stress Reduction, Traditional Chinese Medicine thinking and the capacity to co-operate with other organizations, professionals, and stakeholders (Vartiainen 2003, 2004).
Stakeholder participation in the health care service system can be fulfilled ful·fill also ful·fil
tr.v. ful·filled, ful·fill·ing, ful·fills also ful·fils
1. To bring into actuality; effect: fulfilled their promises.
2. through democratic decision making. This means, for example, that patients have the right to be involved in decisions about their treatment. This statement is widely known in health care systems as a patient's autonomy. This "right" can, however, develop into a wicked problem because of the strong hierarchical A structure made up of different levels like a company organization chart. The higher levels have control or precedence over the lower levels. Hierarchical structures are a one-to-many relationship; each item having one or more items below it. and partly authoritative culture in health care organizations. The authoritative culture does not encourage stakeholders to participate in the decision-making processes well enough. (Conklin & Weil 2003).
It was stated earlier that wicked problems should be separated from tame problems. The difference between wicked and tame problems is the process of solution. Tame problems can be solved via traditional methods and processes. There is always some guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. or formula that helps you to solve a tame problem. Conklin & Weil (2003: 2) call these solutions "waterfalls This is a list of worldwide waterfalls. Africa
An attendant in a hospital. and linear process, working from the problem to the solution."
This kind of problem solving does not function in the context of wicked problems. Instead, the problem-solving processes of complex organizations require non-linear methods. The non-linear method works through order to chaos and self-organised complexity. The method also stresses that the non-linear problem-solving process gives the possibility to analyze the problem-solving process again and again. The decision maker can move between the different stages of the problem-solving process and check the different situations in the process again, if necessary. (Article on Wicked Problems 2003; Rihani 2002).
It is conceivable con·ceive
v. con·ceived, con·ceiv·ing, con·ceives
1. To become pregnant with (offspring).
2. that partial and linear thinking dominates in most Finnish health care organizations. The organizations are still quite hierarchical and the authority of the leading professionals (especially doctors) as well as leading administrators and politicians is high. This fact complicates the resolution of wicked problems. A strong authoritative culture in an organization may effect problem solving so that wicked problems are treated as tame problems (Roberts 2000). This means that some powerful stakeholders are chosen to conduct a linear and partial problem-solving process: to define, analyse an·a·lyse
v. Chiefly British
Variant of analyze.
analyse or US -lyze
[-lysing, -lysed] or -lyzing, and solve the problem. Because of the wickedness of the problem, the implemented solution does not work very well (Vartiainen 2005).
Health Care Organizations in Finland
The Ministry of Social Affairs and Health is mostly responsible for health care policy at the national level. The Ministry of Social Affairs and Health, together with several agencies and institutions, defines and prepares all health care reforms, makes proposals for legislation, evaluates their implementation, and assists the government in decision-making. In the municipalities, the municipal council, the executive board, and committees are the main decision-making bodies in the health care sector. These bodies work in a position of trust, and are politically accountable to all members of the municipality. The actual decisionmaking process varies among municipalities. However, during recent years, there has been a significant trend towards decentralization de·cen·tral·ize
v. de·cen·tral·ized, de·cen·tral·iz·ing, de·cen·tral·iz·es
1. To distribute the administrative functions or powers of (a central authority) among several local authorities. . This means that municipal councils have allocated their power to different committees and leading officials (Jarvelin 2002).
The municipalities have the main responsibility to provide health care services in Finland. This means that health services health services Managed care The benefits covered under a health contract are financed primarily with public monies. In 2001, approximately 43 percent of total health care costs were financed by the municipalities, roughly 17 percent by the state, 16 percent by the National Health Insurance, and the remaining 24 percent with private sources. (Stakes 2003).
Between national and municipal decision making, there are also five provinces that have an official role in the Finnish health care system. The provincial state offices are administrative bodies which promote the objectives of the national and regional administrations in their area. Every provincial state office has many departments, one of which is the social and health department.
Health care service provision is taken care of in the 20 hospital districts, with each district having several hospitals. Every hospital district provides specialized spe·cial·ize
v. spe·cial·ized, spe·cial·iz·ing, spe·cial·iz·es
1. To pursue a special activity, occupation, or field of study.
2. medical care and coordinates the specialized public care in its area. Primary health care is implemented through health centers. A health center is an organization that provides primary curative curative /cur·a·tive/ (kur´ah-tiv) tending to overcome disease and promote recovery.
1. Serving or tending to cure.
2. , preventive, and public health services in its own area. The health center system was established in 1972. At the moment, there are approximately 270 health centers in Finland, and all of them are owned by one or by several municipalities (Jarvelin 2002).
There are certain overall reform trends in Finnish public sector management that have affected the whole health care system. These reforms are ones that have been under discussion and development largely in the public sector both internationally and nationally. Therefore, the main reforms applied in health care organizations are prevalent trends that have been developed in a wider management context. The central point in the dominant management reforms is their cyclical cyclical
Of or relating to a variable, such as housing starts, car sales, or the price of a certain stock, that is subject to regular or irregular up-and-down movements. nature and fast changing political and practical idealism Practical idealism is a term whose earliest recorded use was by Mahatma Gandhi (Gandhi Marg 2002). It describes a philosophy which holds it to be an ethical imperative to implement ideals of virtue or good. . This, by definition, is what makes health care management complex and multidimensional. Exhibit 1 describes the management reforms and their characteristics that are most important from the point of view of this article. The management reforms analyzed an·a·lyze
tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es
1. To examine methodically by separating into parts and studying their interrelations.
2. Chemistry To make a chemical analysis of.
3. in the article are: New Public Management, Quality Management, Decentralization, and Patient Orientation.
Exhibit 1 also gives some examples that describe the wickedness of health care reforms and their implementation. These examples are discussed in detail in the discussion of each individual reform.
Exhibit 1. Health Care Management Reforms in Finland Change New Public Management Quality Management Administrative- Managerialism More for less Focus on professional policy paradigm expertise Key objectives Management by results Quality assurance Efficiency Accountability Evaluation Implementation Changes in service Strengthening of (e.g.) production processes knowledge Changes in the state subsidy process Real examples of Inadequate management Quality management has wicked problems skills and imperfect been seen as a tool forin health management tools prevent the tame problems. care reform implementation of NPM ideas. E.g., too partial management This leads to circular reform quality standards processes. do not steer assurance well enough. Change Decentralization Patient Orientation Administrative- Structural and Patient-focused policy paradigm functional changes management Key objectives Coordination Strengthening of Co-operation patients' status and rights Implementation Reducing state Guarantee for care (e.g.) regulation Real examples of Health care development Hierarchical and wicked problems reforms succeed only professionally oriented in health care partly, which can lead management neglects the reform management to circular development stakeholder and patient processes involvement.
New Public Management
The premises of New Public Management have represented the main cutting edge of Finnish health care reforms since the 1980s. These ideas have mostly been implemented through efficiency and accountability.
The efficiency and accountability discussions have focused on questions that emphasize high costs and low productivity in health care organizations. The reasons for the strengthening of the efficiency and accountability paradigms are both political and practical. Politically, the concepts of managerialism In the field of administration, observers can characterise as managerialism those systems where they perceive a preponderance or excess of managerial techniques, solutions and personnel. are also interesting in the field of health care management. In many political circles, the health care sector is seen as a too expensive and ineffective system. One practical reason for the implementation of reforms, which can be put under the wide umbrella of New Public Management doctrine, was the strong economic depression at the beginning of the 1990s. Also, the discussion concerning co-operation between different health care organizations was strongly criticized. The lack of co-operation led to coordination problems. This was made concrete, for example, so that the patients were treated unnecessarily in hospitals instead of health care centers or nursing homes. (Jarvelin 2002).
One example of New Public Management reforms implemented in Finnish health care is the changes made in the resource allocation resource allocation Managed care The constellation of activities and decisions which form the basis for prioritizing health care needs system. Finnish health care organizations are traditionally financed by the state and municipalities. Until the beginning of the 1990s, the financing of public health care was based on the resources and total expenditures. In 1993, the resource allocation systems were changed on the basis of state subsidies reform. and reforms that focused on the purchaser-provider split. In these reforms, health care service provision and financing were separated from each other.
In practice, the Finnish state subsidy subsidy, financial assistance granted by a government or philanthropic foundation to a person or association for the purpose of promoting an enterprise considered beneficial to the public welfare. reform in 1993 reduced state regulation of health care provision. The main changes of the reform were focused on the financing of health care. From 1993 to 1997, state subsidies were calculated on the basis of the age structure of the population, morbidity morbidity /mor·bid·i·ty/ (mor-bid´it-e)
1. a diseased condition or state.
2. the incidence or prevalence of a disease or of all diseases in a population.
n. , population density, and land area. In 1997, the subsidy system was changed, and at the moment the following criteria are used: the number of inhabitants
The game is based loosely on the concepts from SameGame. , age structure, and morbidity. There are also additional criteria for remote areas and archipelago Archipelago (ärkĭpĕl`əgō) [Ital., from Gr.=chief sea], ancient name of the Aegean Sea, later applied to the numerous islands it contains. The word now designates any cluster of islands. municipalities. The changes were remarkable because the former state subsidy system was based on actual costs, and also on the principle that more wealthy municipalities got fewer subsidies than poor municipalities. After the 1993 and 1997 reforms the state could not specify the level of Finnish health care expenditures any longer, but the portion to be financed to municipalities. The effects of the state subsidy reform were strong; the share of state financing diminished di·min·ish
v. di·min·ished, di·min·ish·ing, di·min·ish·es
a. To make smaller or less or to cause to appear so.
b. from 40 percent to 20 percent during ten years. (Vartiainen 2004; Linnakko 2005: 318; Vuori 2005).
In Finland the purchaser-provider split has aimed at the improvement of health care efficiency and mechanisms with which the state tries to direct the implementation of the model in practice. The purchaser-provider split has not changed health care systems structurally. In practice, the reform has mostly developed health care managers who have contracting skills needed in quasi [Latin, Almost as it were; as if; analogous to.] In the legal sense, the term denotes that one subject has certain characteristics in common with another subject but that intrinsic and material differences exist between them. markets. However, the Finnish model has not very strongly aimed at competition for market shares, unlike many other European countries.
What characteristics of wickedness are seen in the NPM NPM National Poetry Month
NPM National Postal Museum
NPM New Public Management
NPM National Association of Pastoral Musicians (Silver Spring, Maryland)
NPM Network Processor Module
NPM National Project Manager reforms implemented in Finnish health care systems and organizations? The most significant characteristic in these cases is circularity. It can be stated that inadequate health care management skills and imperfect imperfect: see tense. management tools have, at least partly, prevented the implementation of NPM ideas.
One example is the Management by Results reforms, which were launched in Finnish health care organizations at the end of the 1980s. In this reform, more economic responsibility was given to clinical profit centers, and the clinical managers held both economical and medical power and responsibilities in their organizations.
However, the difficulties in applications of Management by Results ideas were a problem already in the beginning of the 1990's. One of the most serious problems was the fact that big special health care units that could have budgets of 20 million euros, for example, were managed mostly with medical, not economic, management skills. Also, the fact that most clinical doctors worked as part-time managers weakened their possibilities to go into the economical issues as a part of their management position. Many of the doctors in management positions were also unwilling to engage their time and efforts in administrative questions. (Linnakko 2005). This, for one, led to the circularity phenomena, which means that new reforms aimed at the accountability and efficiency have followed each other, and only some of them have had the capacity to really change Finnish health care management systems.
From the beginning of the 1990s, Finnish health care administration has launched many new reforms that focused on the improvement of professional expertise in every sector of health care. These reforms are connected to the ideas of Total Quality Management and Continuous Quality Improvement. The key objectives for the implementation of Quality Management ideas are to analyze and improve processes in health care organizations. The idea is simple: to cut down functions that seemed to be unnecessary, and to strengthen and improve functions that are necessary (Linnakko 2005: 323). The evidence of the results of these actions are, however, quite contradictory. It is still possible to notice that the lively discussion concerning Management by Results and Quality Management has led to the fact that Finnish health care organizations are now experienced, at least to some degree, in implementing different evaluation methods in their improvement work. The benchmarking model, for example, is in use both nationally and organizationally, not to speak of Balanced Scorecard Balanced Scorecard
A performance metric used in strategic management to identify and improve various internal functions and their resulting external outcomes. The balanced scorecard attempts to measure and provide feedback to organizations in order to assist in implementing applications.
One example of the reforms in Finnish health care is the guidelines guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. for quality assurance published in 1995 and 1999 by different national and local administrative organizations. The guidelines concentrate on the promotion of quality as a part of the daily work. They emphasize patient-orientation in service production, the use and strengthening of knowledge as a basic element of quality work, and evaluation as a part of development. On the grounds of these guidelines, quality assurance work has continued, and many separate service sectors and organizations have created their own special quality programs.
When analyzing the above-mentioned reform processes from the wicked issues point of view, it can be stated that the problem-solving processes in these cases have been quite traditional. This means that health care organizations have been simplifying their quality problems, and Quality Management has been seen as a tool for solving tame problems. As a consequence, organizations have been trying to solve their quality problems by creating, for example, quality standards that can only partly steer steer
castrated male cattle beast over a year of age. See also bullock, buller steer.
steer Medtalk verb the quality assurance and quality assessment processes. Conceptual difficulties have also weakened the application of quality standards. It has been difficult for health care organizations to understand what "standard" means as a concept. In addition it has been difficult to decide whether the standards should describe the minimum, maximum or middle range quality of health care. (Pollitt 1996, Lumijarvi 2005). That is why the created quality standards have mostly represented technical quality factors, not functional quality factors that are important for individual patients.
The rewarding point in the implementation of quality reforms has been the fact that the principles of Quality Management have emboldened em·bold·en
tr.v. em·bold·ened, em·bold·en·ing, em·bold·ens
To foster boldness or courage in; encourage. See Synonyms at encourage.
Adj. 1. most of the public health care organizations to analyze their processes. As a result, the quality reforms have opened up some of the critical aspects of the implementation processes in health care organizations. To find out and understand the critical elements of one's functional processes can lead organizations to move from linear problem-solving methods to non-linear methods. The non-linear method stresses that the problem-solving process gives managers a possibility to analyze the problem-solving process again and again. It follows, then, that more enlightened problem-solving processes can lead to more effective decisions and functions.
Decentralization activities in Finnish health care have actually been in use since the late 1980s. Administratively the aims of the decentralization reforms have been clear: the main target has been to accomplish structural and functional changes in the health care sector. However, the reforms have had different targets at the macro and micro levels. At the macro-level, these reforms focused on reducing detailed legislation and control and simplifying the planning processes of health care systems. State regulation changed from formal legislative regulation mechanisms to steering through information. However, the state has still maintained the possibility to reset municipalities' quantitative and qualitative objectives concerning health care services. At the micro-level, the reforms aimed at decentralization by giving more decisionmaking power to local authorities. It actually moved authority downwards to frontline front·line also front line
1. A front or boundary, especially one between military, political, or ideological positions.
2. Basketball See frontcourt.
3. Football The linemen of a team. managers and even to personnel. It also aimed at better coordination of the functions of primary and secondary care, and, in this way, gave attention to more effective health care production.
One example of macro-level decentralization is the 1993 reform which reduced state regulation of municipal health care organizations. Previously, this had been very dominant. After the 1993 reform, the municipalities' authority and responsibility to reorganize re·or·gan·ize
v. re·or·gan·ized, re·or·gan·iz·ing, re·or·gan·iz·es
To organize again or anew.
To undergo or effect changes in organization. and finance health care increased. Municipalities were still responsible for producing health care services, but the state did not specify how the service production had to be organized. At the moment, there are many different possibilities. The municipality can produce the services through their own organizations or together with other municipalities. It can also purchase health services from other municipalities or from private service producers. Thus, a well functioning service system comes before the manners of production.
In this article decentralization is understood as a phenomenon that transfers authority and power from high-level decision makers to lower level decision makers. In concrete terms, this means that Finnish high-level decision-making organizations (e.g., the Ministry of Social and Health) have launched new development reforms one after another to solve both structural and functional problems. Some examples of the wide-range decentralization reforms in health care are the delegation, de-concentration, and prioritization processes. The circularity phenomenon is strengthened by the fact that many of the Finnish welfare reforms as well as individual sub-projects have proved to be ineffective and unsuccessful. In addition we are currently lacking deep analysis of the Finnish health care reforms and their implementation and outcomes. The serious thing in this is that, in fact, we do not have enough understanding of the relationships that led to the unsuccessful processes. For this reason, this article claims an analysis that takes into consideration the wickedness and complexity of health care management problems and problem-solving processes.
Administratively, the reforms concerning patients' rights The legal interests of persons who submit to medical treatment.
For many years, common medical practice meant that physicians made decisions for their patients. This paternalistic view has gradually been supplanted by one promoting patient autonomy, whereby patients and have aimed at management systems that emphasize patients' participation and possibilities to effect their treatment. The law for patients' status and rights was introduced in 1993. The law was mainly targeted to improve patients' possibilities to get information about their treatment and medical documents. The autonomy or the right to determine one's own affairs, also in questions of health care, was strengthened.
The general principle, at the moment, is that patients cannot choose the hospital or the doctor. However, the newest reform--the Government Resolution on the Health 2015 public health programme (2001)--also stresses patients' rights and possibilities to choose. The reform decreases the differences between patients' access to care by introducing criteria for access to non-urgent treatments in the country. If health care institutions maintained by the local authority or federation of municipalities cannot fulfill the criteria, treatment must be procured from another service provider at no extra charge to the patient (MSAH 2002).
The reforms directed to improve access to care are closely connected to the other reforms mentioned above. Reforms aiming at improved access to care are linked to the projects dealing with effectiveness and efficiency, and to the structural changes of health care systems. The meaning of the term "access to care" is convergent. The term refers to interventions that are taken to secure patients' possibilities to get treatment.
Long waiting times for care have been a constant problem in Finnish health care. In the 1980s waiting times to health center doctors, for example, could be two to six weeks for non-urgent cases. Both patients and doctors were unsatisfied with the situation. The reform aiming at the "personal doctor system" was therefore launched during the late 1980s and early 1990s in many municipalities. The aim of the reform was to simplify patients' access to care so that they could enter their own doctor's reception within three days. The results of the project were quite good; waiting times were shortened and patient satisfaction in the services improved. The main problem with the system was that many small and poor municipalities could not implement the system at all. Also, the lack of doctors in many municipalities led to the situation where the personal doctor system could not work in practice. However, the results of the reform led to a further development; the new reform can be described with the concept "personal responsibility." The concept means that doctors and nurses form a team that has the responsibility for the care of persons living in a certain area. In practice the personal responsibility system is functioning inconstantly in·con·stant
1. Changing or varying, especially often and without discernible pattern or reason.
2. Fickle; faithless.
in·con in different parts of the country. (Jarvelin 2002).
As stated above, the reforms emphasizing patient orientation and autonomy have been seen as an important element in Finnish health care development. Many of the projects have been successful, and the patients have, for example, better possibilities to effect their treatments and in some cases even choose their own doctors and service providers. However, the development of a patient's rights and autonomy is in many ways a wicked issue, mostly because different patients have different possibilities and skills to take part in the planning of their treatment. This fact is often forgotten when development projects and reforms are planned. The hierarchical and professionally oriented o·ri·ent
1. Orient The countries of Asia, especially of eastern Asia.
a. The luster characteristic of a pearl of high quality.
b. A pearl having exceptional luster.
3. management often neglects or does not have a very high opinion concerning stakeholder and patient involvement. Thus, reforms aiming at patient orientation have in many cases been created by authorities without stakeholder contribution.
Many of the health care management reforms have treated wicked problems as tame problems. Thus, the results of the reforms have not always been as expected. The reason for this can be the fact that both national and local decision makers as well as researchers and health care staff do not take the complexity of health care management as seriously as they should. This leads to the simplifying of problems as well as the reforms created to solve them.
It is also possible that health care problems are thought to be separate issues that can be solved through separate solutions. One example is the fact that many Finnish health care centres suffer from a lack of qualified doctors. Finnish authorities have made efforts to solve the problem by increasing the number of medical students in Finnish universities. The solution has not been successful. This means that there are other reasons behind this problem. These may be the high stress levels among health centre personnel, busy schedules, and few possibilities to concentrate on research and further education. The example shows that a problem that, on the surface, seems to be tame is actually wicked, and deep analysis is needed to understand the many-sided facets behind this single problem.
Exhibit 2 describes the characteristics of health care reforms from the point of view of the wicked problem concept. The table offers examples of the most obvious characteristics, not an overall picture of the reform areas. At the end of this chapter there are four different cases of the wicked concept, which may be able to help managers to analyze and perhaps even solve the wicked elements of health care management.
Exhibit 2. Wickedness of Finnish health care reforms Wickedness Changes in service Guidelines for quality production system assurance Circularity The execution of market Quality work in health care orientation mechanisms has has advanced gradually. taken more than ten years. The application of purchaser-provider split has proceeded step by step. Stakeholder Stakeholder Patient participation through involvement participation is feedback systems. marginal.Patients' fees are 5.8 percent from the total expenditures of public special care. Problem The marketing The definition of quality solving of public health standards. Constant care services has improvement. Quality been difficult. debugging. The efficiency of health care has not been treated as an ambiguous problem. Wickedness Reducing state Strengthening of patients' regulation rights Circularity Difficulties to make real The increasing of patients' structural and rights to choose their organizational changes. doctor and possibilities or hospital has, in practice, been slow. Stakeholder In theory, stronger In principle, the patient can involvement decision-making participate in the planning of power at the his or her own treatment. local level can better take into account patients' needs. Problem Weak national steering Traditional thinking still solving mechanisms call dominates, and slows down the for innovative development of patients' problem-solving participation. capabilities at the local level.
According to the circularity principle, problem-solving processes have the tendency to continue like a revolving door. This means that the reforms are following each other, and new reforms are created based on elements of the previous reforms. It may also happen that the implemented reforms do not resolve the targeted health care problems. This is mostly because the targeted problems are more multidimensional than the creators of the reforms have expected. For example, the reforms aiming at the structural and functional changes in health care systems have been, to some degree, alive for a long time. Still, the changes have been quite minor. The purchaser--provider split model has moved ahead step by step; in practice, the expectations addressed by the model have only been partially fulfilled. Lately, development work has mostly been directed towards the improvement of health care managers' contracting skills in quasi markets. It is also evident that the purchaser-provider split does not give any mechanisms that could help to cut health care expenditures.
The characteristics of the circularity principle are also seen in the reforms aiming at structural changes in the health care sector. For example, the aim of more effective co-operation between hospital districts could have been more successful. It seems that solutions aiming at better co-operation between hospital districts have in some cases been treated as a tame problem. Co-operation is not a question of mutual statements concerning treatments and other health-related issues, but very much a question of political interests. For example, the question of political interest is very relevant if the aim is to get the hospitals which use Swedish as the dominant language to co-operate with hospitals whose dominant language is Finnish. In these cases the practical solutions have been obvious even if they have been treated as tame problems. Instead, the political decision-making processes have changed practical solutions to a wicked problem within the party politics process. As a consequence of this, many of the practical solutions planned in the particular hospitals have been cancelled.
Stakeholder participation mechanisms can be emphasized through quality evaluations and patient-oriented measurements. In Finland there have been several reforms aiming at the improvement of patients' status and autonomy in health care service processes. These reforms are connected to the discussion of general interest concerning customer satisfaction and participation in public services Public services is a term usually used to mean services provided by government to its citizens, either directly (through the public sector) or by financing private provision of services. . As a result of these reforms it can be stated that these challenging targets have not been fully met. Perhaps the implementation means have been too traditional. The changing of health care acts or national public health programs have not been sufficient alone. Significant changes in patient participation also require attitudinal changes among patients and health care staff.
The problem-solving processes in health care seem to be linear in many cases. They have also treated health care problems as tame problems. For example, the generally-known requirement for more effective health care services has been treated as a tame problem. This has meant that efficiency has mostly been treated as a question of inputs and outputs. However, the profound analyses concerning health care organizations ask us to treat health care efficiency as an ambiguous question. This means that the problem-solving process has to recognize the contexts and situations obvious to health care efficiency.
To summarize sum·ma·rize
intr. & tr.v. sum·ma·rized, sum·ma·riz·ing, sum·ma·riz·es
To make a summary or make a summary of.
sum , the context of health care management is more multi-dimensional than the solutions and reforms created to solve the problems that management have acknowledged. That is why the results of these reforms have succeeded only partly. The introduction of new reforms straight after the previous reforms have finished has also confused the improvement of health care management. In the future, deep analysis concerning the context of health care problems is needed.
How, then, can the concept of wickedness help managers to better understand and analyze complex health care management issues? The discussion concerning wicked issues gives some relevant answers to the question.
Firstly, when health care management problems are viewed through wicked issue ideas, managers have more possibilities to identify and distinguish wicked problems from tame problems. This, in turn, helps managers to allocate resources to the problem-solving processes that cannot be resolved via traditional problem-solving processes. In health care management, it is easy to find solutions to tame problems, and the solutions are accepted among different stakeholders. However, it is difficult to come to a consensus about wicked problems: the stakeholders may even disagree on what the problem is. For example, different stakeholders may have totally different opinions about "why the health care center is suffering from the lack of doctors."
Secondly, by viewing health care problems through the lens of wickedness, the managers have better possibilities to be acquainted with to be possessed of personal knowledge of; to be cognizant of; to be more or less familiar with; to be on terms of social intercourse with.
See also: Acquaint the problem at hand. Wicked problems often arise when organizations operate in a turbulent and complex environment. It is quite impossible to understand the problem if you do not know the context of the problem. For example, it is difficult to create a reform that aims at more effective health care delivery if you do not know how the professional structures (policy, decision-making process, resources, etc.) of the system function.
Thirdly, the wicked issues concept can help managers to select the applicable problem-solving process. Wicked issues can be solved better with adaptive rather than empirical methods. The adaptive process contains discussions with different stakeholders, many-sided analyses of data, and innovative thinking. The process introduces and rejects solutions, analyzes the data again and again, and tries to find the solution that can be accepted among the different stakeholders. This, in turn, makes the decision-making processes and the implementation of health care development more effective.
Fourthly, because of the complexity of health care management, managers must have the means to consider possible alternatives to solve the problem. Wicked issues thinking can help in this. Thus, the managers often have to admit that definitive solutions to wicked problems cannot be found. Instead, you have to find a "best one." The main idea is that the created solution should function (give results) even in a complex and conflicting environment. It may, for example, be difficult to implement a new management ideology in a health care organization without the support of powerful stakeholders (politicians, doctors, personnel, etc.).
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Pirkko Vartiainen, Professor, Social and Health Administration, University of Vaasa It has four faculties: Business Studies, Humanities, Public Administration and Technology. The university has 425 personnel from which teaching staff 180 and professors 44. Around 5000 students are currently studying in various degree programs at the university.