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Changing
governance in social and
health care sectors
Ingo Bode
GermanyMaster course in SOCIOLOGY AND SOCIAL
SERVICE, University of Bologna
Structure
Talking about governance in social and health care
The political side of governance
Governance and networks
Subsidiarity on the move: the role of the Third sector
Government-Third-sector relations today : The case
of Germany
International moves: The example of elderly care
What all this does to nonprofits?
Conclusion
Talking about (the) governance (of
welfare)‘ in social and health care
Governance: Making sense of a trendy catch-all concept
the non-sense of evolutionary concepts of governance:
empirically, the co-organization of social welfare does not follow a
simplistic movement from government over markets to
governance/networks
however:
historically and in current times, social and health care provision is
being organized by a multitude of societal actors at different levels
and by several means
- bureaucracies
- professionals
- local or national civic forces and interest groups
- volunteers (in different roles)
From the perspective of the social sciences, a key challenge is to
understand changes in this ‚welfare mix „ and to infer conclusions from it
Programme Service Developemt
social support to the
disabled
services to support the daily living of the
handicapped
+
long-term care to the
frail elderly
nursing and personal care +
child rearing day care ++
social empowerment
(youth help, ...)
counselling, company -
economic integration
health care
poverty relief activities
job integration services
medical services
-
+
-
What are we talking about: Major social and health care services in Europe
Welfare provision und governance theory
the role and nature of various actors
Institution Family State Market Third sector
Productive core domestic work public
bureaucracy
commercial
practice
(intermediary
zone)
dominant
unit of action
families & friends administration private entreprise associations
dominant
mechanism of
social
coordination
personal
obligation /
mutual exchange
hierarchy competition voluntarism
rules for access ascription legal rights solvency (group-related)
needs
key value reciprocity /
altruism
equality freedom
(of choice)
(group-related)
solidarity
„currency“ personal
recognition
law money communication
Leaning on: Evers, A. / Olk, Th, Wohlfahrtspluralismus, Opladen 1996
Why does a „productive“ Third sector exist?
Three popular models
Theory
(authors)
Summary Key Concept Focus
Public Goods
Theory
(Weisbrod)
Public sector provides goods
on demand by the median
voter, leaving special
demands unmet; nonprofit
organizations respond to the
latter
Public good;
heterogeneity in group
claims
nonprofits as „gap fillers‟ for
government failure
Trustworthiness
Theory
(Hansmann)
Where monitoring expensive
and windfall profits likely,
mission makes nonprofit
organizations more
”trustworthy” than for-profit
firms
Nondistribution constraint;
trust; opportunistic behavior;
transaction costs;
information asymmetry
Structural difference between
private for-profit and nonprofit
undertakings; nonprofit
organizations as a response to
market failure
Heterogeneity
Thesis and
Entrepreneurship
Theories
(James)
Nonprofit organizations are a
reflection of societal
heterogeneity that is dealt
with by entrepreneurs who
maximize nonmonetary
benefits
Pluralism in society;
entrepreneurs; nonmonetary
benefits
Culture matters: Religious and
ideological entrepreneurs as most
crucial driving forces
Voluntarism:The critical factor of Third sector agency
Boards: collective (democratic) and non-interested decision
making
Day-to-day practice
- where organisations handle a lot of money and professional
services
- complementary volunteer work of rank and file members
- financial add-on (donations…)
- networking (local politicians etc.)
- in social movement & small initiatives
- as a cornerstone of organisational agency
- with creativity and innovation as a critical resource
Change underway?
Developments are inconcistent internationally, but, overall:
There is a rise of active participation in non-work activities, yet
predominantly in the fields of leisure, culture, and sports
Long-lasting and regulary commitments are decreasing why
spontaneous action is becoming more important
(in mature voluntary / nonprofit organisations)
Tendencies of decoupling between professional and volunteer
members
- at the top, in management
- on the grounds, between professional work and
complementary services
Governance and networks
In some concepts, governance = networks
However, governance understood as a way of organizing a
pluralised system of social and health care contains hierarchy
and markets as mechanisms of social coordination
Hence: networks are one mode of coordination (among
others) in the complex world of governance
As noted earlier: There is no such thing as a move from
government to governance in the sense of networks replacing
hierarchy or market in most European welfare states
And : networks are not necessarily a “silver bullet” for good
governance
Administration
The example of child protection in Germany(how networks should work…)
health office
(family) midwives
psychotherapists
pediatrists
hospitals
…
Öffentliche und freie Träger Anbieter von Hilfen zur Erziehung(z.B. Sozialpädagogische
Familienhilfen (SPFH)) Sozialräumliche Angebote BeratungsstellenInobhutnahmestellen und KinderheimeKindertagesstätten …
police
family court
legal guardians
forensic consultants
coroners
…
Youth welfare office (ASD)health care justice
youth welfare
Public/third sector
educational aid „socio-spatial“ services educational counselling children‘s homes nurseries …
...and what it’s really like
youth welfare office
family court
federal youth welfare office
police
pediatrist
hospital
midwife
health office
third sector
lawyer
"central agency"
coordinators nursery
private agencies
"family pilot"
politics
the mediastakeholders
sponsors
parents
relatives
"child protection agency"
psychotherapist
"child protection service"
forensic consultantlegal guardian
coroner
"qualified person"
foster parents
social assistance office
authorities/administration
"child emergency service"
"ASD"
academic experts
"family midwife"
"social-pediatric center"
district office
bailiff
job center
educational counsel
social elites
custodian
school/teachersCenter
Peripherals
Child protection system
citizens/neighbors
charities
criminal court
children
doctor
The political side of governane
Programs in social and health care are not
exclusively carved out by central Government
Rather, they grow in a complex landscape of
- different layers of the political system
- intermediary agencies (regulators; commissions…)
- diverse purchasing bodies
- different service providers
- and in some instances: active users
social groups from these different layers and parties as well
as form the wider society (want to) participate in opinion-
building, provide expertise and sometimes have critical
resources at their disposal to make their voice heard
The ‚energy supply‘ of Third sector co-governance
or: Why do people invest in collective action?
The classical answer of Mancur Olson:
selective incentives
- exclusive advantage
- active control / avoidance of sanctions
and if this is not enough
- feeling to be part of a criricial mass
- seeing oneselgf as a politicl entrepreneur
- being irrational
Sociologists have a different answer I
Identity
- People live in sense-making worlds (groups, milieu, classes,
belief communities…)
- social action is influenced by social norms, e.g. those related
to feelings of fairness, but also those fostering social
opportunism
- common experiences and collective action produce group
identities to which people tend to conform
II
values
- human beings are driven not only by personal interests, but
also by values (which shape interests): religion, justice, belief in
authority etc.
- personal belief systems influence human action, e.g.
convictions regarding merit, dignity, superiority….
- common communicative action can build collective values
Driving forces behind a certain way of governance
(in the social and health care field)
National culture
Vested Interests and their organization
Identity of collective actors
Values of core groups
Developments in the field as such
- rising complexity in public administration
- changing social needs
- new social problems
How society is governing social and health
care
Movement
Think Tanks,
Initiatives
State/government
Interests
Identities
Co-governance
„round tables“
quasi-market
goverance NPO/provider
consultancy
protest
Associations/
interest groups
Values
Society
The German ‚welfare governance‘ model
Public sector
National public
administration
Regional public
administration
Local authorities
State-related self-
administered agencies
• Social Security
(e.g. sickness funds)
• Job centre
(national headquarter
& regional agencies)
Independent
voluntary
organisations
„Wohlfahrts-
Verbände„
Sellf-help
groups
Welfare state Civil society
Others (mutuals)
For-profit
providers
: corporatist
culture
Subsidiarity and governance
Relevant aspects….
Subsidiarity on the move
The organisation of subsidiarity with „Third parties‟:
Options and trends
Government-Third-sector relations today : The case
of Germany
Why marketization?
Subsidiarity on the move
Subsidiarity as a concept
- catholic background: let the smallest social unit do the
job unless it is unable to do so
- the next higher level of social intervention steps in if the
lower level is failing (= subsidiarity of the higher level)
- importantly: the job has to be done, no one should be
left behind the state has a role to play
… in the EU context: national states remain sovereign in their
social and health care policies
.. As „new subsidiarity‟: some argue the smaller units should
be „reempowered‟ given the strong rise of bureaucracies and
of professions in modern society
however, there is little evidence for strong professions and
states disempowering people per se
Corporatist mode Quasi-market mode
Regulated social market modeBlock-long term contracting
• Commissioning: making others deliver on consensual terms = corporatismProcurement: a logic of purchase and competition = quasi-market(after tender/comparative assessments and output evaluation)
The organisation of subsidiarity with ‘Third parties’:Options and trends in social and health care provision
Technical devises for the 2 forms of governance
Leaning on: Enjolras, B., Le marché providence, Paris 1995, S.204
Forms of regulation for services of
public interest
Welfarist (in French: „tutélaire“)
consensual commissioning
quasi-market oriented, competitive
procurement
Funding Global budgets
Fees per day
(Tax exemptions, incl. for users)
Fees per consumer / act of consumption
Seed money
Contracts
Investment Authorisation -
- funding for investment Continuous / occasional subsidies -
Cost control Approval of collective agreements -
Capacity control Planification
Admissions
Provider competition
Demand control Need assessments
(for a given population)
-
Consumer protection Licence ‘Job descriptions‘
quality standards / quality assurance
Price policy Reimbursements
Fixed co-payment of users
Market price
• In some European countries, public bodies or para-statutory entities (socialinsurance funds/Sozialversicherungen) have involved non-statutory providersfor the provision of social and health care services quite early (in the 20th century) …
market relations were exceptional overall, even though established implicitlyin some fields where users could resort freely to various providers and wherepublic control of the supply side was limited
in Germany e.g. outpatient health care / some areas of social care
• things are different now, in many countries and sectors
in Germany (see below)- ‚implicit‘ procurement / purchase has been extended …
- … a fully-fledged version of procurement can be found in some sectors
elsewhere (see section on elderly care below)
• the debate in the academic field adresses vices and virtues (see below)
The wind of change
Government-Third-sector relations
today : The case of Germany
Procurement and (quasi-) markets on the rise
No relevance: core services for endangered young people
or for the disabled (block-long term contracting is prevailing)
implicit relevance: health care provision, elderly care, youth help
the mechanism here is not procurement per se, but ‚direct
payment„: providers attract/get users, money follows users, state makes
users purchase services
elsewhere, contracts specifying outputs are setup with various providers,
yet with garanties for the latter to get theirexpenses reimbursed
High relevance:
extra-vocational training
purchased after tender from job centres (Bundesagentur für Arbeit);
some small-scale, fixed-term projects run by nonprofit pioneers such
as low-threshold services in various fields of community care
… overall: mixed governance yet more market
What can be observed in the current German welfare mix:
market-driven micro-governance, without interference of public actors:
sell-and-buy operations, competitive agency, `winners-take-it-all„-
‚contexual‘ macro-governance enforced by political/legal authorities
specific regulatory devices setting frames for this
(prices, output norms, procedural provisions for contracting etc.)
infused with ideas, interests, and inputs from providers and advocacy
groups = meso-governance BUT
- a lower level of direct public steering
- with weaker inputs from nonprofit forces
- stronger influence from for-profit welfare industies
overall, welfare governance today is not about more pluralistic political
steering (networks, participation etc.); rather, it is
less direct macro, less coordinated meso, more market-driven micro
… vices and virtues (when the objective is: providing ‘trouble-free‘/inclusive social care)
traditional German model(corporatism)
today‘s configuration(with Anglo-saxon flavour)
NOTE
charac-teristics
social partner model• collaborative planning
with little rivalry• input funding /
reimbursements ofactual expenses
shared economic risk
hybrid (post-corporatist) model • quasi-business relationships
& contextual interpartydeliberation
• implicit procurement/fee-for-service without planningof the supply side economic risk devolved
regional & sectoral differences matter considerably
virtues • outcome logic: ‘tireless‘efforts for meeting ends
• high organisational slack/ ‘security‘ for civic &conceptual work
• transparency, openess tonewcomers, diversification
• high accountability & pressure toperform/conform
few data on outcomes, but also few data on actual cost-efficiency
vices • potential waste ofpublic money
• closed shop networks
• short-termism• instrumental collaboration• high transaction costs
social & economiccontext matters
Problems with marketization
With provider competition and economic risks devolved
on providers
- incentives to lower quality where possible (and unnoticed)
- rising needs for quality control (which can be costly and bureaucratic,
and tends to reduce the operational flexibility of service workers)
- stronger differences among providers regarding the capacity to deliver
(as markets create winners and losers)
with for-proft and non-profit providers put on equal footing, sectoral
virtues are ignored (greater importance of the logic of procurement =
fewer volunteers, limited interest in advocacy and developing the public
good)
with nonprofit agencies conceived of as business partners rather than
social partners… less trust, sincere information, dialogue, hence:
disruption in planning and organizing tailor-made services
… making the (welfare) workforce flexible (and often vulnerable)
- more legal options for precarious work
- greater pressures on unemployed citizens
- deregulated collective agreements (segmentation & less security)
31
Less expensive?
* yes: with economic pressures, there may be less ‘open loop’ (waste of time….) and more energy spent in resource management and innovation
* but (empirically), this pressure translates into an reallocation of income (low wages for most, windfall profits for some)
* in addition: much of what is saved in terms of resources gets lost for transaction costs (the effort of reorganizing thingspermanently and for controlling shirking behaviour ofthose geared towards saving their business)
Why marketization?
32
Better quality?
* possibly: provider inspection and accountability obligations create more transparency over results
* in the same vein however: providers spend much of their energy for marketing, selling and ‘whitewashing’ activities, as well as forcreating new projects just for the sake of ‘newness’
* and there are many incentives and options for gaming the system: for instance, providers are enticed to concentrate on things that are ‘easy to manage’ (‘creaming’) or may not tell the full story (about performance, problems, insights) to other stakeholders
if it is not cost-efficiency nor better quality, why thenthe trend towards marketization?
societal developments do matter….
-crisis of interest groups
- new patterns of
mobilisation/volunteering
- ‚post.democracy„ in
interest intermediation
employment
politics
gender
civil society
economy
family & life
course
-new models for
private life
- demographic
change
- new patterns of
social mobility
- fragmentation of
labour markets
- new/modified types of
knowledge workers
- precarious
employment
- equal opportunities
everywhere (as a
social expectation)
- work-life-balance
pressures
- social division of
emancipation
- financial capitalism
- marketization
- knowledge-based
service economy
- New Public
Management
- downsizing of states
- changing elites
International moves:
The example of elderly care
Western European care regimes by tradition: gender roles & fordist
socio-economical regime & charitable civil society
Change in the three spheres independently of evolving care needs
new care regimes on the horizon
- marketized within a semi-professional, precarious service economy
- re-gendered (based on part time arrangements in most places)
post-charitable nonprofit sector, with decreasing „mission„ and
increasing commercialization
Major background: developments in politics (NPM) and in life course
models (desire for mobility and choice in the upper middle classes)
… yet with some notable international differences in all this
Domiciliary elder care as an entangled welfare mix:The home care system in Germany
additional
services
for-profit provider units
professional
exchange
Municipality
individual households
counselling
services
care provision
nonprofit
provider units
Federal government and „Laender“
hospitals
voluntary initiatives
civil society private doctors
long-term care
insurance funds
(federated agencies)commercial
home help
nursing
associations
complementary
services
counselling
What all this does to Third sector welfare providers
Old Hybridity a certain range of ‘social’ goals: (socializing, supporting a
cause or a group of people, ‘making a better world’…) multiple stakeholders
civic communities, politics, employees … diversity of resources:
civic inputs, public funding, ‘fee for service‘ …and nowthe market as a place for ‚making money‘(sales, marketing, economic investment, …)
new hybriditynonprofits as ‚social enterprises‘- cost-efficient like (successful) for-profit undertakings? - pro-social like ‘good old charity’?
Environmental change and options for coping with it
Change in the societal position of nonprofitsmuch less ‘voice’ and ‘loyalty’, much more exit
typical contemporary Third sector providers subject to public sector managerialism and market processes
Social enterprises as a solution?Limits set to ‘double bottom line management’
- product/user market as a moving target, with strong (often for-profit) competitors, ephemeral niche market positions, little scope for strategic development hybrid nonprofits as weak market players
- public bodies as major clients, driven by managerialist orientations(contracting out ‘by numbers’, ‘on the spot’, devolving risk onproviders while controlling the quasi-market….) hybrid nonprofits as managerialised market players
Three major risks
• commercialisation: mainstream social service prividers reinvent themselves as ‘market entrepreneurs‘ selling services to ‘quasi-customers‘, with less energy devoted to their social mission
• marginalization of civic involvement: intraorganisational separation of mere service delivery functions and classical ‘nonprofit sector‘ roles (advocacy, concept building, societal perspective) which however allow for social innovation and ‚voice‘ given to other than economic stakeholders
• pressure on organizational slack (Organisationsreserven)‘: human cuts in salaries, growing job insecurity and greater expectations regarding ‘organisatinal citizenship‘
Managerial options
The good old days are over…
• permanent tensions between goals, means, stakeholders … likely to occur
‘old hybridity’ under strain – much has to be done simultaneously- supervision / mission-based evaluation- sustainable financial management- civic participation in government consultations and
campaigning- coordination of stakrholder communities
(volunteers, members)- participative board governance
• excellence in double bottom line management impossible to achieve(the exception prove the rules, but can also be delusive…..)
Muddling through management as ‘one best way’
real-type (Third sector) social enterprises are
- permanently urged to search for second-best solutions - hectically drawing on prior experience and available routines,tweaking them here and there in an evolutionary way
- evaluating alternatives only occasionally and speculating on‘return-on-investments’ in complex environments
- highly dependant on post-modern adventurists who forego a classical career track, accept biographical insecurity, and believe in a precariousmission
whether this is a sustainable foundation for a welfare mix based on a well-performing Third sector is another question…
Reading• Bode, I., In Futile Search of Excellence. The ‘muddling through agenda’ of service-providing ‘social
enterprises’ in contemporary Europe, in: Denny, Simon & Fred Seddon (ed.), Social Enterprise:
Accountability and Evaluation around the World, London: Routledge 2013, 196-212
• Bode, I., B. Champetier and S. Chartrand, Embedded Marketization as Transnational Path Departure.
Assessing Recent Change in Home Care Systems Comparatively, in: Comparative Sociology (12) 6,
2013, 821-850
• Bode, I., Comment on: Hendriksen et al., At the Eve of Convergence? Transformations of Social
Service Provision in Denmark, Germany and the United States, in: Voluntas (23), 2, 2012, 502-508
• Bode, I., Creeping Marketization and Post-corporatist Governance: The Transformation of State–
Nonprofit Relations in Continental Europe, in: Phillips, Susan D. & Steven Rathgeb Smith (ed.),
Governance and Regulation in the Third Sector, London: Routledge 2011, 115-141
• Bode, I., Thinking Beyond Borderline A German Gaze on a Changing Interface Between Society and
the Voluntary Sector, in: Voluntary Sector Review (1) 2, 2010, 139-161
• Social Care Going Market. Institutional and Cultural Change Regarding Care Services for the Elderly,
in: Comparative Journal of Social Work [online journal] (5) 1, 2010
• Aiken. M. and I. Bode, Killing the Golden Goose? Third Sector Organisations and Back-to-work
Programmes in Germany and the UK, in: Social Policy and Administration (43) 3, 2009, 209-225
• Bode, I., Co-governance within Networks and the Nonprofit-forprofit Divide. A Cross-cultural
Perspective on the Evolution of Domiciliary Elderly Care, in: Public Management Review (8) 4,
2006, 551-566
• Bode, I., Disorganised Welfare Mixes. Voluntary Agencies and New Governance Regimes in
Western Europe, in: Journal of European Social Policy (19) 4, 2006, 346-359
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