The impossible split? A study of the creation of a market actor.
During the last fifteen years, several studies have focused on public sector management models called New Public Management (NPM). The term, however, has no clear definition. NPM may be broadly defined as a movement towards management models within the public sector that are more similar to markets and private businesses. Empirical studies have shown that these models have not worked as intended. The market inspired management models have failed to meet expectations and scholars from various disciplines, including public administration, economics, sociology and business administration, have tried to provide an explanation. The theoretical field that covers the NPM reforms may be characterized as fragmented and there is no obvious starting point for new research (Ferlie et al 1996).
Researchers prefer to refer to the market solutions as quasi-markets in order to distinguish them from the concept of the ideal market (Bartlett and Le Grand 1993). The term quasi indicates that they differ from other markets. Quasi-markets have to be regulated in a specific way because of their connection to the public sector. Opinions differ with regard to exactly what aspects should be regulated, but there is some agreement. Several researchers (for example, Potter 1988; Propper 1993; Bartlett and le Grand 1993) have suggested important areas that should be regulated and supervised because the actors who provide the services are not part of the public administration. For example, Propper (1993) points out the importance of regulating prices, quality, and actors' access to the market as well as information. Researchers have also emphasized equity as well as the importance of ensuring that the actors not only take the best pieces, a behavior that is sometimes referred to as cream skimming. In this article, however, we focus on a different aspect of the regulation process: the regulation that is required for creating market actors, which is a less common approach. We will therefore also be able to provide new insights into the reasons for why quasi-markets sometimes fail.
We use sociological theories about markets to explain market models' lack of success. Our research follows a relatively new direction within sociological research that focuses on markets in general. Sociological studies of markets have hitherto, in many regards, only criticized neo-classical economics. They have not managed to present an alternative theory. The theoretical framework used in this article constitutes an exception. It builds on Callon's (1998) and Luhmann's (1995) theories of how markets are created. They view markets as being created through regulations rather than seeing them as the outcome of deregulation. In order for an exchange situation to develop into an ideal market characterized by perfect competition, a set of conditions must be fulfilled. These components are required because they reduce uncertainty, which is a prerequisite for every market transaction. Factors that help to reduce uncertainty include, well-known roles (such as the "economic man"), well-defined goods and services and information about alternatives. This paper's theoretical focus is on how all these components, or rules, are established and maintained. Sociological research has shown that these conditions are not fulfilled naturally, but have to be created and maintained.
Experiences from Quasi-markets
The analysis is founded on findings from a health care organization sector that uses an NPM control model, which distinctly aims to resemble a market: the purchaser-provider split. The purchaser-provider split has been a very popular way of organizing health care activities in many countries. When the model was introduced it was, among other things, expected to increase efficiency through business-like competition and contractual management (Locock 2000, Siverbo 2004). For the purchaser-provider split to work, the role of the actors within the health care organization has to be reconfigured. They must stop acting according to the principles of a hierarchy and begin to function according to market logic.
Earlier studies indicate that the purchaser-provider split in practice not live up to the ideal of competition and contractual management (Walsh 1995, Hughes et al. 1997, Propper and Bartlett 1997, Barker et al. 1997, Flynn and Williams 1997, Locock 2000, Siverbo 2004). The purchasers have not always paid attention to differences in price between different providers or to other market signals (Ellwood 1997), and they have tended to stick to one provider in spite of obvious reasons for change (Fischbacher and Francis 1998, Laing and Cotton 1995). The purchasers have been reluctant to refer patients to providers, with whom they had not had any prior contact and about whom they know little (Ellwood 1997). Some providers have been skeptical to the idea of being managed by contracts and especially by purchasers who they believe lack the necessary competence and knowledge to place the orders (Siverbo 2004). To avoid protests from local politicians and other actors, purchasers have considered certain factors like local employment issues (Walsh et al 1997). The range of alternatives, however, has hitherto been limited. Small purchasers, in particular, have experienced difficulties to actually influence the provider (Fischbacher and Francis 1998). On the other hand, some providers have felt that they are in the hands of one purchaser (Akehurst and Ferguson 1993, Walsh 1995). Both monopoly and monopsony have thus prevented competition (Ellwood 1996). In England, however, researchers observed that small purchasers managed to use the competition between providers to negotiate a better outcome (shorter waiting time) for their patients (Flynn and Williams, 1997, Walsh et al. 1997).
The review indicates that the market frame, which is a precondition for the market model, was hard to establish fully. For example, purchasers violate their role description when they consider local employment issues. Other factors, however, also indicate that the model had had some of the intended effects when purchasers were small and there were several providers from which to choose. The purchaser-provider model might thus work if the purchasers can choose from several providers. However, in the following section we point at another explanation.
In the following section we describe our theoretical perspective followed by the methodology. We then proceed to present our empirical material, which is a case study of a purchaser within the Swedish health care sector. Finally, we conclude with a discussion and conclusions.
One important issue in sociological market theory has been to deal with the very nature of the market actor. One of the findings is that the idea of the "economic man" is over-simplified (Beckert 1996). According to these theories, economics is built on fragile theoretical grounds and researchers have instead, introduced the idea of a more complex individual nature. Lately, other scholars of sociology have argued that there are inherent problems with the notion that while humans are more complex than the idea of the "economic man" they strikingly often act accordingly. The solution hitherto has been to detach the concept of economic man from human nature and place it instead in the social world as a role that individuals play (Luhmann 1995, Callon 1998). The role is a created social construct and not a natural phenomenon. We, therefore, do not view the purchaser-provider as a deregulation, but as a re-regulation.
The paper is founded on Luhmann's (1995) systems theory which is built on the idea that social systems exist because they reduce complexity. Complexity is reduced because their structures reduce the number of alternative opportunities. The structures' building blocks are the expectations that are tied to various situations, which creates contingency. For example, when people enter a store, they know how they are expected to act and so does the clerk. When the individuals enter a store for the first time abroad, however, the situation might not be as simple. For example, is bargaining acceptable or not? Efficiency is increased by reducing the number of alternative actions, which would otherwise always be infinite. This, however, also highlights the importance of selections and questions that become central to the organizing process. Which factors should or should not be taken into consideration? When some issues are highlighted others are left unattended. Social systems are autonomous when they are characterized by a high degree of contingency, which means that there is little room for interpretations of the situations.
Framing the Quasi-market Actors
The process by which the boundaries may be defined by using the terms framing and overflow (Kastberg 2005). The concepts were originally introduced by Callon (1998), who was inspired by the discussion about externalities within economics. The term framing means that actors strive to create a structural arrangement that facilitates the efficient exchange of goods and services. Framing thus concerns creating structures that benefit exchange and which aim to reduce uncertainty (Callon 1998). Reducing complexity and uncertainty is a precondition for an efficient exchange process. The frame is, therefore, the boundaries around an exchange situation and it consists of the factors that are considered in the calculations. Externalities are examples of overflows. They are effects from an exchange which are not taken into consideration. Overflows are sometimes taken into account, which means that they are framed and constitute part of a calculation.
The process of creating a purchaser-provider model framing involves creating new actors who act according to prescribed roles. The model has to include purchasers and providers and each has to consider only their own interests. Competition is another component that has to be established. There must be several providers and contracts, which stipulate the conditions. This, in turn, means that the services that are included in the exchange have to be defined.
We believe that the actors have to be reconfigured in order for the purchaser-provider model to be successful. They must transition from acting as if they were parts of a hierarchy to function according to market logic. Both the purchaser and the provider have to become an "economic man". A central part of our hypothesis is that this transformation contains a built-in problem because politicians still have to consider the problems of both purchasers and providers. We use the terms framing and overflow to analyze the processes.
Our argument is based on a case study of a small purchaser unit that was created within a large Swedish public health care organization. Swedish county councils are responsible for most of the country's health care. The unit's mission was to reduce waiting times for the county council's patients (the following section will provide a more detailed description). As noted in the beginning of the article, small purchasers seem to function better as market actors than their larger counterparts. The purchasing unit in this study thus constitutes a "most likely case" and if this quasi-market setting is not successful, it should be a topic of some concern for quasi-market designers. Our case provides us with an opportunity to evaluate whether satisfactory (initial) conditions are enough to make quasi-markets function.
Twenty-two individuals were interviewed for this study including the purchaser unit's personnel (manager, staff and medical advisers), provider personnel (physicians and administrators) and politicians and civil servants at the central level. When selecting respondents we aimed to include individuals with different experiences of the purchasers operations and who could help to provide comprehensive picture of the activities. The interviews, which were taped, took approximately one hour. The interviews constitute the paper's main empirical data, but we also studied various documents and financial data as background material that allowed the interviews to be deeper and more focused.
A Case Study of a Small Purchaser
The Small Purchaser
The Small Purchaser (SP) in our study is a part of Vastra Gotalandsregionen (VG)'s county council. The SP was introduced because the politicians had concluded that waiting times had become unacceptably long. The politicians at the county council board had decided that a patient with a referral should be guaranteed not to have to wait more than nine months for treatment. The guarantee included seven categories of diagnoses; including orthopedics, obstetrics, hearing aids and cataract. The county council itself was organized as a purchaser-provider organization and introducing the SP may thus, to some extent, be considered as an attempt to fix the problems of the purchaser-provider model by using a similar method. The SP was commissioned to take care of the so called guarantee patients and link them to a provider who could provide treatment. They were allowed a budget and the authority to turn to any provider that could supply the treatment in question. Hospitals within the county councils own production organization and other providers of health care were to compete for the contracts.
The SP consisted of one manager, five civil servants and an administrator. Three physicians were available for consultation on an as needed basis. The SP had a budget of 5 million Euro, which were earmarked for the guarantee patients. Three million Euro were immediately diverted from the SP and placed into ordinary county council operations which left the SP with about 2 million Euro. Over the course of the year, the budget was reduced additionally and by the end of the first year, the SP had spent 1.7 million Euro. The budget for 2003 was 2.5 million euro, which after the cutbacks, was reduced to 1.5 million euro.
The Mission and Activities
The SP's main mission was to help the guarantee patients to get treated. It was to help the guarantee patients to find providers and negotiate contracts. The goal at the outset of the operations was that once the patients had come to the SP they should not have to wait for more than six weeks. Some of the respondents described this mission as a pilot or a guide.
Their second mission was to provide information. The SP was supposed to inform, not only the patients of their rights, but also the politicians and civil servants within the region about the waiting times. The SP also had to examine all the waiting lists within the county council's own operations. Every hospital within the county had its own routine with regard to managing the waiting lists. The SP was to centralize the waiting lists to keep track of the actual waiting times. The interviews showed that politicians and other officials within the county councils doubted that the hospitals managed their waiting lists correctly. Some of the respondents suspected that the hospital had an interest in keeping long waiting lists because they would constitute a powerful weapon in budget negotiations.
The SP staff also appeared to have added an additional task: They believed that they should detect problems and question the routines within the county council's health care operations. The politicians and civil servants confirmed that they had received a lot of relevant information from the SP. All the interviewed politicians, including members of the majority party, were positive toward the idea of the SP and the commission.
When a patient contacts the SP, the administrators first make sure that the patient in question is covered by the guarantee. They also check whether the patient has another diagnosis or complications that must be considered. The SP also checks the waiting time because it is unnecessary to help patients who would get treated sooner if they remained in line. When the SP was first established, the hospitals occasionally rushed the treatment for patients who had turned to the SP because they did not want to lose them.
After the initial discussion and examination of the patient's records, the SP proceeds to contact a provider. For certain diagnoses, such as cataracts, a provider is already under agreement, while new contracts have to be drawn up for other illnesses. The SP proceeds to schedule a treatment and the previous health care provider sends the patient's records to the new provider. The patient is then informed about the date and time of the treatment. Representatives of the providers said that the SP's clients had high priority.
One problem that was mentioned during the interviews was that in some areas there was a shortage of alternative providers. For example, one respondent mentioned that the personnel at the SP had tried to find an alternative foot surgeon, which had turned out to be almost impossible. Sometimes the SP had been able to schedule treatments in another county for patients who were willing to travel. The SP, however, appeared to attract more providers in the region. Some of the respondents were private providers who had begun to work in the region because of their contract with the SP.
The Contracting Procedure
Because the SP did not perform any medical procedures, they had to contract providers to help the guarantee patients. At the time of the study, however, the SP could no longer choose freely between all potential providers. Its mission to help the guarantee patients had been restricted. The SP's staff now had to check first for unused capacity within the county council's own provider organization before they were allowed to turn to an external provider. The reason for this restriction was that politicians believed that it would be unreasonable to use alternative providers while the county council's organization had excess capacity. Because the county council's health care organization is quite large, one hospital might have long waiting lists while another's might be very short. According to some respondents, one problem with the restriction was that it sent a signal to the county council's provider organizations that they did not have to compete.
Several respondents stated that the SP had managed to get reasonable deals and, in some cases, had even lowered prices. Of course, it is easier to negotiate a good deal when several providers compete for the contracts. The SP had also learned about differences in prices between both external contractors and the county council as well as between the county council and other county councils. One respondent mentioned that a neighboring county council charged 1,400 Euro for a cataract treatment while a private provider in Gothenburg performed the same procedure for 600 Euro.
The SP had to conform to the LOU (competitive mandatory tender) when negotiating contracts. The personnel at the SP tried to follow the law, but sometimes they thought the law made it more difficult for them to be flexible and act quickly. One respondent admitted that the SP did not always follow the law. The manager of the SP mentioned that the financial uncertainty constituted a major problem with regard to signing the contracts. Political decisions caused financial conditions to change occasionally making it risky to be tied to a certain contractor. Another problem was that it was impossible to predict the number of patients who would need a particular medical treatment. Providers frequently wanted to know how many services they would be expected to provide before they signed the contract and it was difficult for them to sign without knowing exactly to what they agreed. The following quote illustrates how one respondent described the situation:
"Their financial situation has been uncertain which makes it difficult. When the money finally arrives there is a great hurry and competitive tendering takes to long."
Another respondent described a situation in which there has to be a balance between price and flexibility. When it comes to a common diagnosis such as cataract surgery, there were existing contracts with providers.
SP Challenged the Profession
At first, many of the hospitals and clinics were not very cooperative and were sometimes even resistant. One reason was that the SP's operations changed the hospitals' priorities. One example included the priorities at a clinic that treated cataracts. The patients were divided into three priority groups: high priority, low priority and no priority. The waiting times varied between the groups from about six months because patients of low priority did not get any treatment. Some of the respondents who worked at the hospitals saw no problem with this routine because the system was based on medical priority. The guarantee meant that patients of low priority would also be treated.
Several respondents described the situation as a conflict within the medical profession. When the SP's staff began their assigned work on the waiting lists they found that a waiting list at a clinic sometimes "belonged" to a specific physician. The waiting lists thus were not just local in the sense that they were connected and managed by each hospital or clinic, but the clinics also held separate waiting lists that were connected to individual physicians. The patients who were waiting in line at a specific hospital were supposed to wait their turn regardless of the waiting times at other hospitals. The SP challenged this view and believed that the waiting lists should be centralized. According to some of the respondents, the SP was subsequently regarded as a threat.
What was frightening was the fact that the clinics view the line of waiting patients as an assurance. If they do not have a line of patients waiting, their operations might be in danger. Therefore, the waiting list is perceived as an asset.
The resistance to centralizing waiting lists prevented the SP from accomplishing their mission. No centralization had occurred and one of the interviewed politicians said that it should be the next step.
SP makes it Harder to Save Money
During the interviews, the respondents discussed the fact that the SP had actually managed to cut waiting times and that the allocated resources were well used. The downside was that it made it harder for the county council to cut costs. If politicians decided on cutbacks at the county's hospitals, the SP would have to deal with longer lines later, because the treatment guarantee was still in place. Cutting back in one area leads to increased costs in another place in the same organization.
Another negative impact that was mentioned during the interviews was that solutions like the SP are short-sighted and have a negative impact on the long-term planning at the hospitals. One respondent viewed the SP as just one of a series of attempts to address the permanent problem of long waiting times. And this, like other attempts, would eventually be replaced with another idea of how to solve the problem. The respondent believed that resources should instead be allocated directly to operations at the hospitals and clinics.
The SP, however, also had to cut costs which forced them to prioritize by reducing the number of diagnoses that were included in the guarantee. The decision about prioritizing was not made by politicians, but was an entirely administrative decision made by the SP. Discussions about alternative ways of addressing the problem preceded the discussion. One suggestion had been not to prioritize between different groups of diagnoses, but to keep helping everybody until resources were depleted.
The study shows that the SP's framing process may be described as balancing the benefits of being an autonomous actor who behaves like "the economic man" and being part of the county council's organization which means considering factors other than pure self-interest. This balancing act produces endless overflows. First, the SP reduces complexity because it only has to consider its mission, which, however, creates a more complex situation for the county council. The politicians have to deal with problems like how to handle excess capacity. On the other hand, when the SP has to consider issues such as excess capacity within the county council, their situation becomes more complex. The terms framing, overflow and autonomy may help us to understand the processes. In summary, many aspects caused the overflows and loosened the frame.
The SP evolution over time indicates that it went from a high to a low level of autonomy. The SP's initially clear mission to help patients to get treatment as soon as possible had become blurred. One complicating factor was the restriction stipulating that it first had to turn to providers within the county council.
Another example was the reduction of the SP's budget. The fact that their patients were called guarantee patients indicated the organization's standing. A guarantee is a promise, a commitment. A tight budget that does not allow help to all guarantee patients, however, is a contradiction in terms. It contradicts the very idea of what a guarantee is all about. The SP was still forced to make the difficult decision with regard to what groups to prioritize. An alternative might be not to prioritize but to help patients until there is no more money. The financial problem with regard to guarantee solutions is, of course, not a new phenomenon. The problem has been noted in several studies and is sometimes expressed as an irreconcilable dichotomy (Siverbo 2004). On one hand, politicians and administrators within the health care sector face an almost endless demand. The problem of the overwhelming demand is also triggered by providers who have an interest in getting more resources for their organizations. On the other hand, there is the problem of scarce resources. This unsolvable problem which is a part of the SP's structure increased the complexity that the organization had to manage. The SP was reframed but the frame was less autonomous, i.e. more problems had to be considered. The budget may therefore be viewed as a source of overflow, which makes it more difficult for the market to function. Hierarchical principles are admitted instead.
Additional factors, however, complicated the SP's situation with regard to acting like an autonomous market actor. The county council is a political organization that is run by politicians which had a negative impact on the SP. Political institutions tend to be unstable (Noren 2003; Akerstrom Andersen 2000), which is obvious when it comes to factors such as objectives and priorities. The character of the political system stems from the fact that it constitutes an arena in which different interests and ideologies meet (Brunsson 1989). The uncertainty and unpredictability generated by political actors tend to make it harder for the market actors to make relevant calculations and they may thus resist entering into an exchange situation.
Our empirical material supports the effect of the political system. Evidence of the political connection was found in contracting and the SP was unable to sign long-term contracts because politicians continuously changed their resource allocation. The SP never knew when there would be additional cutbacks, thus making it difficult to sign long-term contracts. In addition, some people believed that the SP was just another novelty, which would disappear over time and that it would eventually be replaced with a new idea of how to handle the problems with waiting times.
Another source of overflow was the strength of the medical profession. The professionals successfully resisted certain issues including the centralization of waiting lists. The SP was unable to challenge the professions even with the support of the politicians. Centralizing the waiting lists would have constituted an important step toward creating a situation that was more similar to a market. Sociologic research that discusses market creation emphasizes the importance of developing transparent rules and disconnecting the provider from the customer (Callon 1998). Because the purchaser-provider model was fully implemented in the county council, it may come as a surprise that these issues had not been solved. However, knowing the strength of the professions involved (Mintzberg 1983) the outcome may not be completely unexpected. The professions loosened the frame around the market situation making them a source of overflow for the SP.
Concluding Remarks--Increased Complexity
What does our study tell us about creating a market actor and the surrounding processes? We believe that while the SP functioned like a market actor in the beginning, this function declined over time and it instead came to incorporate some of the surrounding hierarchy's problem.
We conclude that the SP, as an organizational solution, will have to confront several problems and make adjustments to its operations. Its problem often consists of balancing various aspects of reality. To establish an autonomous market actor and fulfill all the criteria of a guarantee model, the problem of increasing total costs has to be neglected. Considering costs complicates the model. The empirical study and our conclusions highlight the difficulties involved in creating an autonomous market actor and some of the inherent problems.
At the heart of the problem is the fact that the purchaser and the provider are parts of the same organization and are both managed by politicians who have to address problems of both parties. Even a small unit like the SP, which has a clear mission, is affected by belonging to the same organization as the county councils production organization.
The findings of this study agree with the conclusions made in the literature review in the beginning of this article. The study revealed the difficulties involved in the framing process. The underlying problem seems to consist of differentiating between the county council's internal organizations, which is a condition of the purchaser-provider model. Establishing the model on paper is one thing, but implementing it is quite another. Most of the county council's production organization remains the responsibility of politicians which means that gains in one area might easily become problems in another. If purchasers actually manage to negotiate better deals and lower costs, their results might backfire on politicians who have to deal with losses or cutbacks in the provider organization. The internal complexity seems to increase rather than decrease. We may conclude that as long as the provider and the purchasers belong to the same organization, the purchaser-provider split will not work.
Akehurst, R., & Ferguson, B. (1993). The purchasing authority. In M. F. Drummond, A. Maynard, & N. Wells (Eds.) Purchasing and providing cost-effective health care. Edinburgh: Churchill-Livingstone.
Akerstrom Andersen, N. (2000). Public markets--Political firms. Acta Sociologica, 43(1), 42-61.
Barker, K. M., Chalkley, M., Malcomson, J. M., & Montgomery, J. (1997). Contracting in National Health Service: Legal and economic issues. In R., Flynn, G., & Williams (Eds.) Contracting for health. quasi-markets and the National Health Service. Oxford: Oxford University Press.
Bartlett, W., & Le Grand, J. (1993). Introduction. In W. Bartlett, & J. Le Grand (Eds.) Quasi market and social policy. London: Macmillan.
Beckert, J. (1996). What is sociological about economic sociology? Uncertainty and the embeddedness of economic action. Theory and Society, 25(6), 803-840.
Brunsson, N. (1989). The organization of hypocrisy. Talk, decisions and actions in organizations. Chichester: Wiley.
Callon, M. (1998). An essay on framing and overflowing. Economic externalities revisited by sociology. In M. Callon (Ed.) The law of the markets. Oxford: Blackwell.
Ellwood, S. (1996). Pricing services in the UK national health service. Financial Accountability & Management, 12(4), 281-301.
Ellwood, S. (1997). The response of fundholding family doctors to price signals. Financial Accountability & Management, 13(4), 345-365.
Ferlie, E., Ashburner, L., Fitzgerald, L., & Pettigrew, A. (1996). The new public management in action. Oxford: Oxford University Press.
Fischbacher, M., & Francis, A. (1998). Purchaser provider relationships and innovation: A case study of GP purchasing in Glasgow. Financial Accountability & Management, 14(4), 281-298.
Flynn, R., & Williams, G. (1997). Contracting for health. In R. Flynn, & G. Williams (Eds.) Contracting for health. Quasi-Markets and the national health service. Oxford: Oxford University Press.
Hughes, D., McHale, J. V., & Griffiths, L. (1997). Settling contract disputes in the national health service: formal and informal pathways. In R. Flynn, & G. Williams (Eds.) Contracting for health. Quasi-Markets and the national health service. Oxford: Oxford University Press.
Kastberg, G. (2005). Kundvalsmodeller. En studie av marknadsskapare och skapade marknader. PhD thesis, School of Public Administration, Gothenburg.
Laing, A., & Cotton, S. (1995). Towards an understanding of health care purchasing: The purchasing behaviour of general practice fundholders. Journal of Marketing Management, 11(6), 583-600.
Locock, L. (2000). The changing nature of rationing in the UK national health service. Public Administration, 1(78), 91-109.
Luhmann, N. (1995). Social systems. Stanford: Stanford University Press.
Mintzberg, H. (1983). Structure in fives. Designing effective orgnisations. Engelwood Cliffs: Prentice-Hall.
Noren, L. (2003). Valfrihet till varje pris. Om design av kundvalsmarknader inom skola and omsorg. Kungalv: Bokforlaget BAS.
Potter, J. (1988). Consumerism and the public sector: how well does the coat fit. Public Administration, 66, 149-164 (summer).
Propper, C. (1993). Quasi market regulation. In W. Bartett, & J. Le Grand (Eds.) Quasi-markets and social policy. London: Macmillan.
Propper, C., & Bartlett, W. (1997). The impact of competition on the behaviour of national health service trust. In R. Flynn, & G. Williams (Eds.) Contracting for health. Quasi-Markets and the National Health Service. Oxford: Oxford University Press.
Siverbo, S. (2004). The purchaser-provider split in principle and practice: Experiences from Sweden. Financial Accountability & Management, 20(4), 401-420.
Walsh, K. (1995). Public services and market mechanisms. Competition, contracting and the new public management. London: Macmillan.
Walsh, K., Deakin, N., Smith, P., Spurgeon, P., & Thomas, N. (1997). Contracting for change. Contracts in health, social care and other local government services. Oxford: Oxford University Press.
Published online: 12 December 2007
[c] International Atlantic Economic Society 2007
G. Kastberg ([mailing address]) * S. Siverbo
School of Public Administration, Goteborg University, Gothenburg, Sweden
|Printer friendly Cite/link Email Feedback|
|Author:||Kastberg, Gustaf; Siverbo, Sven|
|Publication:||International Advances in Economic Research|
|Date:||Feb 1, 2008|
|Previous Article:||The moderator effect of communication in marketing channels of distribution; the case of car's industry in Canada.|
|Next Article:||Modelling exogenous variables in human capital formation through a heteroscedastic stochastic frontier.|