Governance & Strategy
Week 1
Lecture 1 – From government to governance
Learning goals:
1a) describe the concept of governance.
1b) describe the concept of networks in governance theory.
1c) describe a shift from government to governance and the hollowing out of the state
1d) analyze the interaction between institutional context and healthcare governance, through micro,
meso, and macro level lenses.
Movie about the future of elderly in Denmark
- Denmark is international frontrunner with dementia care
- Daily practices: like checklist on iPad, citizens do exercises independently
- Organizational: early detection, efficiency
- Social & political context: demographic challenges, labor shortages
Macro level
Multi-level governance
In this course we analyze policy on 3 levels:
1. In people’s daily practices (micro)
2. Within organizations (meso)
3. In the broader socio-political context (macro)
And how these levels interact
,Government: how policies are made and implemented in society
- The state is not just about Rutte, like it used to be
- People at the top of the hierarchy, deciding things
Two examples
1: “Dual hospital governance” 2: “Multi-problem households”
Governance: ambiguity, lack of rules that allows different stakeholders to meet each other (geven en
nemen)
Multi-problem households: different stakeholders involved like wijkagent, leerplichtambtenaar,
socialworker etc. (network-setting)
Negotiation: all conflict in daily lives that take place, that requires negotiation. You have to go back
and forth and communicate with each other to get things done (push and pull).
During the course:
- Strategy as design: about rationality, thinking really well and analyzing problems, then
implementing solutions.
- Strategy as practice: about understanding context and how stakeholder behave in such a
context, about situated practices.
Part II – Guest lecture by Bert de Graaff: governing care during an emerging epidemic
Governing care during a crisis?
“I found the start very tough, also because of the quick changes. I no longer recognized my own
department, and we suddenly no longer saw our regular patients. You could no longer rely on your
,clinical experience. […] Normally I can close myself off from work, but now I did take it home with
me.” (Interview nurse, May 14, 2020)
Learning how to dance
• Dancing with a virus: focus on situated, reflexive responses of organizations and the
resilience of institutional arrangements (‘strategy-as-practice’)
• Question: adaptive governance of care during a 'chronic' crisis (pandemic)?
• Empirical focus: the regional networks of acute care delivery (ROAZ), in interaction with
national and local level.
Ethnography of the crisis-organization
• Hanging-out: observing (video-) meetings (480 hours)
• Travelling: local, regional, national (focus on 3 acute care regions/ROAZs)
• Talking: 175 targeted interviews and many informal conversations
• Reading: hundreds of meeting documents
• Reflecting: sessions with participants, policymakers
Adaptive governance?
Resilience at the ROAZ?
A mixed picture:
• The ROAZ has become the 'spider in the web' of acute care during the pandemic: new links
with long-term care, data infrastructure.
• Focus on hospitals and IC as a central value: little input from other sectors, patients, nurses
(work floor).
• Adjustment interferes with the existing system: fair share, relation to regular and postponed
care (logic of guided planning vs. logic of market and logic of professionalism), also
relocation of care.
Lessons for governing care (1)
• Resilient system is no ‘quick fix’, but requires long, layered approach and system learning.
o But, also important to make room for learning during the crisis
• Crisis changes over time, situation, actor importance of framing
• How ‘the’ crisis is framed shapes the relevant collective to deal with that problem:
o Working on relations important for trust and solidarity (trust is relational and
requires work)
o But clear need to organize countervailing powers
Lessons for governing care (2)
• Macro: Tensions between institutional logics (competition, coorperation, professional self-
regulation)
• Organizational: Data-infrastructure requires (informal) work and politics
• Organizational: Representation of the complete chain of (acute) care is crucial
• Daily work: Role of frontline workers should be acknowledged
Lessons for governing care (region)
• Macro: Who, what, where is ‘the region’? (Safety region, GGD-GHOR, ROAZ, water
authorities, etc.) → fragmented institutional landscape produces neer constant coordination
• Macro: Who ‘owns’ care during a crisis? (governance question, there cannot be a clear
answer, decentralized multicentered system, coordinating between all those different
systems)
• Acute vs long term care
, • Role of regulatory agencies, insurers
• Centralised vs decentralised coordination
Governance during crisis
Mandatory literature
- Rhodes, R.A.W. (2007). Understanding governance: Ten years on. Organization Studies, 28
(8):1243-64.
Rhodes argues something has changed on each level: micro/meso/macro.
→ The key argument is: hollowing out of the state led to a shift of government to governance
• For instance:
• “many unclear separations of public and private powers” (p. 1257)
• “governance refers to governing with and through networks” (p. 1246)
• “This approach focuses on beliefs and ideas, on the games people play, and on the
role of both in explaining how the practices of network governance change.” (p.
1252)
From government to governance: “Hollowing out the state” (Rhodes 2007)
This multi-level understanding of
governance is supported and
expanded by Peters & Pierre
(2001)
The main message regarding the
definition of governance revolves
around its evolving nature and
diverse interpretations. Rhodes
revisits the concept after a
decade, acknowledging the
multifaceted understanding of
governance prevalent in
contemporary discourse.
Week 1
Lecture 1 – From government to governance
Learning goals:
1a) describe the concept of governance.
1b) describe the concept of networks in governance theory.
1c) describe a shift from government to governance and the hollowing out of the state
1d) analyze the interaction between institutional context and healthcare governance, through micro,
meso, and macro level lenses.
Movie about the future of elderly in Denmark
- Denmark is international frontrunner with dementia care
- Daily practices: like checklist on iPad, citizens do exercises independently
- Organizational: early detection, efficiency
- Social & political context: demographic challenges, labor shortages
Macro level
Multi-level governance
In this course we analyze policy on 3 levels:
1. In people’s daily practices (micro)
2. Within organizations (meso)
3. In the broader socio-political context (macro)
And how these levels interact
,Government: how policies are made and implemented in society
- The state is not just about Rutte, like it used to be
- People at the top of the hierarchy, deciding things
Two examples
1: “Dual hospital governance” 2: “Multi-problem households”
Governance: ambiguity, lack of rules that allows different stakeholders to meet each other (geven en
nemen)
Multi-problem households: different stakeholders involved like wijkagent, leerplichtambtenaar,
socialworker etc. (network-setting)
Negotiation: all conflict in daily lives that take place, that requires negotiation. You have to go back
and forth and communicate with each other to get things done (push and pull).
During the course:
- Strategy as design: about rationality, thinking really well and analyzing problems, then
implementing solutions.
- Strategy as practice: about understanding context and how stakeholder behave in such a
context, about situated practices.
Part II – Guest lecture by Bert de Graaff: governing care during an emerging epidemic
Governing care during a crisis?
“I found the start very tough, also because of the quick changes. I no longer recognized my own
department, and we suddenly no longer saw our regular patients. You could no longer rely on your
,clinical experience. […] Normally I can close myself off from work, but now I did take it home with
me.” (Interview nurse, May 14, 2020)
Learning how to dance
• Dancing with a virus: focus on situated, reflexive responses of organizations and the
resilience of institutional arrangements (‘strategy-as-practice’)
• Question: adaptive governance of care during a 'chronic' crisis (pandemic)?
• Empirical focus: the regional networks of acute care delivery (ROAZ), in interaction with
national and local level.
Ethnography of the crisis-organization
• Hanging-out: observing (video-) meetings (480 hours)
• Travelling: local, regional, national (focus on 3 acute care regions/ROAZs)
• Talking: 175 targeted interviews and many informal conversations
• Reading: hundreds of meeting documents
• Reflecting: sessions with participants, policymakers
Adaptive governance?
Resilience at the ROAZ?
A mixed picture:
• The ROAZ has become the 'spider in the web' of acute care during the pandemic: new links
with long-term care, data infrastructure.
• Focus on hospitals and IC as a central value: little input from other sectors, patients, nurses
(work floor).
• Adjustment interferes with the existing system: fair share, relation to regular and postponed
care (logic of guided planning vs. logic of market and logic of professionalism), also
relocation of care.
Lessons for governing care (1)
• Resilient system is no ‘quick fix’, but requires long, layered approach and system learning.
o But, also important to make room for learning during the crisis
• Crisis changes over time, situation, actor importance of framing
• How ‘the’ crisis is framed shapes the relevant collective to deal with that problem:
o Working on relations important for trust and solidarity (trust is relational and
requires work)
o But clear need to organize countervailing powers
Lessons for governing care (2)
• Macro: Tensions between institutional logics (competition, coorperation, professional self-
regulation)
• Organizational: Data-infrastructure requires (informal) work and politics
• Organizational: Representation of the complete chain of (acute) care is crucial
• Daily work: Role of frontline workers should be acknowledged
Lessons for governing care (region)
• Macro: Who, what, where is ‘the region’? (Safety region, GGD-GHOR, ROAZ, water
authorities, etc.) → fragmented institutional landscape produces neer constant coordination
• Macro: Who ‘owns’ care during a crisis? (governance question, there cannot be a clear
answer, decentralized multicentered system, coordinating between all those different
systems)
• Acute vs long term care
, • Role of regulatory agencies, insurers
• Centralised vs decentralised coordination
Governance during crisis
Mandatory literature
- Rhodes, R.A.W. (2007). Understanding governance: Ten years on. Organization Studies, 28
(8):1243-64.
Rhodes argues something has changed on each level: micro/meso/macro.
→ The key argument is: hollowing out of the state led to a shift of government to governance
• For instance:
• “many unclear separations of public and private powers” (p. 1257)
• “governance refers to governing with and through networks” (p. 1246)
• “This approach focuses on beliefs and ideas, on the games people play, and on the
role of both in explaining how the practices of network governance change.” (p.
1252)
From government to governance: “Hollowing out the state” (Rhodes 2007)
This multi-level understanding of
governance is supported and
expanded by Peters & Pierre
(2001)
The main message regarding the
definition of governance revolves
around its evolving nature and
diverse interpretations. Rhodes
revisits the concept after a
decade, acknowledging the
multifaceted understanding of
governance prevalent in
contemporary discourse.
