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Theorizing coordination: towards a novel theoretical framework
Paper prepared for EGPA Permanent Study Group VI
Governance of Public Sector Organizations
Edinburgh, 11-13 September 2013
Sorin Dan
Doctoral researcher
KU Leuven Public Management Institute
Parkstraat 45, Bus 3609
3000 Leuven, Belgium
E-mail: sorin.dan@soc.kuleuven.be
Tel: 003216323633
Abstract
This paper looks at coordination from a theoretical perspective. It looks at the most prominent
theories in the field of political science and public administration and asks what these theories
have to say about coordination. The goal is first to distill some main themes of coordination
from these theories. Then, second, on the basis of the theoretical overview, it introduces a
theoretical framework based on sociological institutionalism and principal-agent theory and
applies it to the study of national coordination of public hospitals in European healthcare
systems. It argues that this framework can significantly help us to understand governance
processes more generally and coordination problems in particular.
The research leading to these results has received funding from the European Union’s Seventh
Framework Programme under grant agreement No. 266887 (Project COCOPS), Socio-
economic Sciences & Humanities.
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Theorizing coordination: an introduction
Thinking about coordination can be traced back to as far as there are written documents about
government. As social and economic life became increasingly complex and differentiated,
interest in coordination has continuously grown. Studies looking at coordination emphasize a
number of problems in the scholarship and treatment of the topic. These problems range from
definitional and conceptual ambiguity and insufficient theorization to problems with
operationalizing the concept in empirical research (Alexander, 1995; Bouckaert, Peters and
Verhoest, 2010). One or more of these limitations are frequently mentioned both in the past
and the current literature on coordination. There have been few detailed pieces of work
dealing explicitly with coordination. However, since the practice, if not the concept of
coordination, has a long history, ideas about coordination are not new. Different schools of
thought embracing different theoretical traditions have been dealing with the topic in one way
or another. What can be noticed is that interest in the idea and practice of coordination has
grown and is blooming in the current era of integration and “joining-up”.
The first part of this paper looks at theories of coordination. We do this by taking this fragile
concept by its hand and walking with it in some of the central squares of the field of political
science and public administration. The first question which we seek to tackle is: What do
these major theories have to say about coordination? What are some of the main themes that
can be distilled from these theories that pertain to coordination? This section is inevitably and
intentionally pitched at a high level of abstraction. We do this because we believe that this is
missing from the current literature on coordination and in this sense aspire to contribute to this
literature. In a second part, based on this overview, we present a theoretical framework for the
study of coordination and then apply it to the healthcare sector, particularly to issues of
national (central) coordination of publicly-owned hospitals in European health care systems.
The theoretical approach to studying coordination cannot be separated from that of other areas
of research in political science and public administration (Bouckaert, Peters and Verhoest,
2010, p. 34). Theories in political science and public administration are relevant for
understanding what drives and hampers coordination in the public sector. Almost twenty
years ago, in one of the most detailed treatments of the topic, one scholar argued that what
was missing in the study of inter-organizational coordination (IOC) was not some grand
theory, but a focus on the “mechanics of coordination” (Alexander, 1995, p. 47). He argued
that “the research and study of IOC have neglected what we might call the ‘mechanics’ of
coordination. Instead, attention has tended to focus either on the relatively abstract and
general, or on the very concrete and particular.” In his view, the abstract and general
represented theories explaining why coordination occurs while the concrete and particular
stood for various tools of enacting coordination. What was missing, he argued, were the
structures of coordination – the intermediate level – or what is often referred to currently as
the mechanisms of coordination – following the now classical three-point typology of
hierarchy, market and networks.
Nevertheless, various scholars have stressed that “the general and abstract”, if present in
current scholarship, have somehow been left behind and decoupled from the more daily
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mechanics of coordination, which reigns supreme in much of the work on the subject (e.g.
Jennings and Krane, 1994). This view was shared by Alexander (1995) himself who claimed
that the starting point in tackling the study of coordination is the theory (or theories) behind
various conceptualizations of the term. These various theories can explain the different
understandings and explanations of the concept (p. 7). Omitting them may leave the reader
wondering what the basis is for the overall narrative, what particular theoretical lens
structures the narrative, and what assumptions are embedded in the narrative. The words of
Frederickson and Smith (2003, p. 3) speak specifically to this point:
“There is no more clever theorist than the scholar who claims to have no theory. Simply to
arrange the facts, describe the research findings, and claim no theory may appear to be safe.
But theory of some kind will have guided the selection of which facts to present, how to order
those facts, and how to interpret them. All theories have weaknesses, and denying theory
while doing theory has the big advantage of not having to defend those weaknesses. Denying
theory while doing theory helps to avoid the stereotypes of, say, decision theorists or rational
choice theorists […] These are all compelling reasons to avoid theoretical boxes and
categories, but these reasons do not diminish the centrality of theory in all of public
administration.”
The subject of coordination is a “nebulous” one, spanning various academic disciplines,
policy areas, organizational forms and theoretical traditions (Hood, 2005, p. 20). However,
there is no one single coherent theory of coordination (Malone and Crowston, 1994). The
theories that are more commonly used to tackle the topic are organizational and institutional
theory, rational choice theory and governance “theory”. The choice of these perspectives is
based on their centrality in the fields of political science and public administration, and by
extension to the more specific area of coordination. They also constitute a combination of
“old” and “new”, and a mix between structure and behavior. That these four theories are
central to the field of political science and public administration is no surprise. Many of the
theoretical summaries and handbooks in our field include these four theories (e.g. Bevir,
2011; Frederickson and Smith, 2003). While necessarily limited, we are confident that by
surveying these theoretical traditions we are casting the net wide enough to capture some of
the essential aspects of how coordination is approached theoretically in political science and
public administration.
Organizational, institutional theory and coordination
If there is one particular field of study that has been steadily concerned since its beginning
with matters of coordination that field is organizational theory. The obvious challenge in
distilling themes of coordination from this perspective is its long history of the practice of
coordination and multitude of orientations within the theory of organizations. At a
fundamental level it can be argued that coordination has always been an element of
organizations, though not the single or necessarily the most important one. The need for
creating structures and processes to coordinate intra and inter-organizational activities has
always existed, but methods of coordinating have changed. Organizational practice and
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theoretical developments have shaped the more “mundane” tasks of ensuring that the various
parts of an organization are connected in some way. As far as history goes, a chronology of
organization theory begins in 1491 B.C. during Exodus times when the father-in-law of
Moses, Jethro, advises Moses to delegate authority hierarchically over the various tribes of
Israel (Shafritz and Ott, 2001). A look at the same chronology reveals the rapid pace of
development of organizational theory since the beginning of the 20th
century with increasingly
more work in the second half of the century. As for its breadth, organizational theory
currently comprises at least nine perspectives: classical organization theory, neoclassical
organization theory, human resources theory (or the organizational behavior perspective),
“modern” structural organization theory, systems theory and organizational economics, power
and politics organization theory, organizational culture and sense making, organizational
culture reform movements and postmodernism and information age (Shafritz and Ott, 2001).
This convinced some scholars that there is no one single theory of organizations due to the
lack of theoretical coherence across the various schools of thought (Scott, 2001, v-vi).
Alexander (1995, p. 48) distinguishes two branches that look at inter-organizational
coordination: organization theory, on the one hand, and political science, policy science,
planning and public administration and implementation, on the other hand. He notes that the
former is more systematic and is a subset of the broader literature in inter-organizational
relations and behavior. This body of literature is mainly concerned with describing and
explaining inter-organizational behavior and processes of how coordination occurs. The latter
is less systematically developed and views coordination as a (usually) desirable goal, not just
as a subject of inquiry. An implication of this distinction for our purposes is that coordination
has received relatively more theoretical elaboration in the organizational theory perspective
(e.g. Mulford, 1984) than in the more practitioner and goal-oriented perspective common to
policy and administration research (e.g. Jennings and Krane, 1994).
Considering this distinction we now turn to survey how different schools of thought in
organization history have approached the subject of coordination. We pay particular attention
to showing how institutional and cultural perspectives have gained increasingly more
attention within organization theory, but these perspectives do not address coordination
specifically. We argue that in this respect there is room for contributing to the current
academic discussions on coordination using a sociological institutionalism perspective. An
analytical framework building on this discussion is then presented in the second part of the
paper.
Coordination occupies a central place in classical organization theory in the tradition of
scientific management, Max Weber or Luther Gulick. In an early essay, Gulick (1937, p. 3)
noted that “the theory of organization has to do with the structure of co-ordination imposed
upon the work-division units of an enterprise”. He memorably made a case for the need for
coordination: “When many men work together to build a house, this part of the work, the
coordinating, must not be lost sight of” (p. 5). Classical organizational theory was concerned
with the study of formal organizations particularly with how “coordinated interaction is
authoritatively achieved within formal organizations”. In this literature organizations are seen
as places of “imperative control” or “imperative coordination” (Weber, 1947 cited in Tsoukas,
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2003, p. 608). The aim of formal organizations was to foster rule-based compliance for
regulating behavior. In his foreword to Shafritz and Ott’s (2001) Classics of Organization
Theory, William Scott sets apart two grand themes of classical organizational theory: the first
one is coordination and the second one is cooperation. He describes the theme of coordination
as “enduring” and coordination as a structural component par excellence. The central question
was how to best find a balance between hierarchy and specialization, differentiation and the
division of labor in order to maximize coordination.
Classical management theory and science in the tradition of Frederick Taylor emphasized
productivity gains in production processes through an optimal design of work which needed
to be rigorously controlled and coordinated (Taylor, 1911). Henry Fayol’s (1916)
Administration Industrielle et Générale identified coordination as a separate function of
management. Coordination was understood as the design and operation of organizational
processes to bring separate elements together (see also Hood, 2005). The central goal
undergirding this literature was rationalization and optimization of industrial production. The
means to achieve this goal was through vertical control so that self-interested workers would
pursue not their own interest but the general interest of the organization. Needless to say, it
was assumed that goal conflict was part of the equation. Coordination was necessary due to a
high degree of division of labor and specialization which were – and still are – seen as
grounds for coordination problems today (e.g. Christensen and Lægreid, 2008, p. 97). In a
context of economic enterprises aiming at efficiency and profit maximization, coordination
was seen as a process, not as a goal in itself.
Mintzberg (1979) usefully summarized a large body of research in organization and
institutional theory, building on the work of Herbert Simon, James March and other
organizational theorists that came after the classical school and questioned its assumptions.
The key ideas as they pertain to coordination can be synthesized as follows (Malone and
Crowston, 1994, pp. 113-4). Activities or objectives that involve multiple actors need to be
assigned to various actors in a specific way. This involves decisions on how to manage
interdependencies between actors. A number of coordination mechanisms can be employed to
manage interdependencies, such as standardization of work processes, outputs and skills,
direct supervision and mutual adjustment (March and Simon, 1958; Mintzberg, 1979, pp. 3-
5). Standardization involves the use of consistent rules governing each activity. Under direct
supervision one actor assumes a leading role in managing interdependencies while mutual
adjustment relies on on-going adjustments between actors or groups. This body of literature
was concerned with organizational processes and structural configurations in formal
organizations, and with finding effective mechanisms to structure organizations. The
underlying assumption of the structural school as it relates to coordination was that problems
of coordination would result from organizational structures and from structures put in place to
effect coordination. The structure was the problem and it was the structure that above all else
had to be set right. In the “modern” structural school, control and coordination were essential
for promoting organizational rationality and achieving established objectives through rational
processes and behaviour in a system with clear rules and formal authority (Bolman and Deal,
1997).
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Subsequent schools of organizational theory began to question the central tenets of the
classical school. What followed had been a process of “institutionalization” within
organizational theory to the extent that it has become increasingly difficult to distinguish
organizational theory from institutional theory. Clearly there is much overlap: some elements
in institutional theory and new institutionalism – for instance the place of informal routines
and the role of culture – are also part of the organizational culture school within
organizational theory. What is clear, however, is that various criticisms were put forward that
challenged the classical school (e.g. Tsoukas, 2003, pp. 608-9). They include, first, the lack of
social embeddedness of organizations. Organizational structures, it is argued, are to some
extent a product of societal metaphors, symbols and myths. Second, the mainstream approach
to organizational theory focused on static structures and failed to explain how organizations
and organizational structures change within their embedded environment. Third, individuals
are “beings” possessing feelings and emotions that create bonds and epistemic communities
of practice where socialization occurs. This socialization takes place within the professions
characterized by their own culture and influence. This moves the focus from individual
explanations of social processes to group explanations. A particularly salient line of research
has been the role of the medical profession – as an archetype of the power that professionals
can wield. This view challenges what Tsoukas (2003, p. 613) calls the “ontological
individualism” of organizational theory which “obscured the collective nature of
organizations”. He argues that “a more rounded view of organizational life is possible when
we discard ontological individualism and begin to appreciate that inter-subjective meanings,
manifested in discursive practices, are constitutive of individuals; and, at a higher level of
analysis that societal self-understandings are constitutive of organizations.” (p. 613).
The role of informal norms and cultures has gradually received increasing attention leading to
the organizational culture and sense making school of thought and furthermore to
institutionalism in the mid-1980s in its historical and particularly its sociological strand (Hall
and Taylor, 1996; Peters, 1999; Powell and DiMaggio, 1991). Cultural perspectives have
influenced the study of coordination. Alexander (1995) devotes one chapter to analyzing how
coordination can be supported or obstructed by informal factors. These include kinship and
community, ideology and values, education, profession and “clans”. Informal links can act as
a glue fostering coordination but they may equally pose barriers to effective coordination in
case of conflicting or unrelated goals and interests, incompatible values or professional
boundaries. Institutions of various forms – both formal and informal – can coordinate
individual action and organize effort and create what March and Simon (1993, p. 2) call
“systems of coordinated action among individuals and groups whose preferences,
information, interests or knowledge differ”. According to Kilmann et al. (1985) cited in
Shafritz and Ott (2001, p. 361) “culture is to the organization what personality is to an
individual – a hidden, yet unifying theme that provides meaning, direction and mobilization”.
Sociological institutionalism provides the most detailed treatment of culture of all versions of
the new institutionalism. Cultural elements are not new, however. For instance, Max Weber
was concerned with how cultural values shape formal organizations while Emile Durkheim
was interested in how societal characteristics, including symbols and values, affect
institutions. Institutions provide ‘systems of meaning’ exerting dynamic influence on the
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members of institutions in one way or another. As Peters (1999, p. 107) notes “his view that
institutions must shape behavior is the dominant perspective within the sociological study of
institutions, with emphasis on the manner in which individuals within organizations become
habituated to accepting the norms and values of their organization”. A broader conception of
institutions in sociological institutionalism distinguishes it from institutional approaches in
political science. In the sociological view, institutions include “symbol systems, cognitive
scripts, and moral templates” that provide “frames of meaning” shaping behavior (Hall and
Taylor, 1996, p. 947). As Hall and Taylor point out this leads to a blurry relation between
institutional explanations and cultural explanations and a reconceptualization of what
constitutes culture to include routines, symbols and scripts in addition to attitudes and values
(see also Swidler, 1986). These are expected to influence the preferences and identity of
actors. A logic of appropriateness guides actors to behave in a way that fits the culture of their
organization or system.
Rational choice theory and coordination
The title of this section that looks at coordination from a rational choice perspective is slightly
imprecise. The basic, original assumptions of rational choice theory clearly form a distinct
lens to viewing social life and are worth discussing as such in relation to coordination. What
we do here, however, is to take a broader look at rational choice theory and include ideas from
theories that can only loosely be associated with the original, “pure” ideas of rational choice.
This means that we include views that preserve some of the original ideas about self-
interested, means-ends rationality, but qualify or soften the original claims of rational choice.
These views have been proposed in response to absolute rational choice claims. Rational
choice theory as an umbrella term that groups various theories around the assumption of
rational individual behavior is commonly related to neo-classical economics, agency theory
(or principal-agent theory), public choice theory, property rights theory and transaction cost
theory.
More than any other theoretical perspective on coordination, rational choice theory has
focused on how coordination can be achieved – the mechanisms of coordination – and has
embraced the market as the main, and sometimes the only, coordination mechanism.
Mainstream microeconomic theory assumes that coordination of market-based economic
action is realized through the “invisible hand” of the market. The interaction of sources of
supply and demand is expected to yield an optimal allocation of resources. Organizational
economics, however, starting with Coase’s seminal article (1937) The Nature of the Firm has
challenged the assumption that price theory provides the only possible method of
coordination. It claimed that hierarchy also needed to be considered. Under certain conditions
hierarchy may be a better way to ensure coordination than a market (Williamson, 1975, see
also Malone and Crowston, 1994, p. 113). Neither market nor hierarchy is a slogan that has
become increasingly common in the past decade (Bouckaert, Peters and Verhoest, 2010;
Fountain, 2001). Networks, fuelled by the development of the internet and modern
information and communication technologies, are seen as a third coordination mechanism
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(Gretschmann, 1986; Peters, 1998). Unlike Williamson (1975), who saw hierarchies and
markets as the only pure organizational forms, scholars argued that networks can give rise to
efficiencies and benefits not possible within the other two forms. Networks, they argue,
possess their own logic and a distinct comparative advantage (Powell, 1990; Powell et al.
1996; see also Fountain, 2001, p. 66). This discussion implies that coordination can be
fostered through a combination of the three mechanisms depending on country and sector-
specific conditions (Bouckaert, Peters and Verhoest, 2010).
The narrow rationality assumption of rational choice theory has been vividly challenged since
the bounded rationality school. Two broader lines of criticism have been advanced. The first
one concerns the reality of rationality and a second one focuses on the collectively
problematic effects of individual behaviour when the rationality assumption does hold (e.g.
Hay, 2004). On the one hand, the claims of mainstream rational choice theory are highly
deductive and predictive, and are based on a naturalist approach to social phenomena. Some
scholars have rightly challenged this narrow view and argued that economic action is
embedded in broader social structures that affect individual behaviour (Granovetter, 1985;
Perrow, 1986). This theme resonates with our previous discussion of “ontological
individualism” in organizational theory. On the other hand, what is important are the effects
of rational individual thinking and action on collective goals. In this respect public choice
theory occupies a central place, looking for instance at the collectively irrational effects of
budget-maximizing bureaucracies (Hay, 2004, p. 42). Public choice has been intimately
associated with NPM as originally envisaged. A key pillar of NPM – and a main target of
attack from NPM enthusiasts – was the monolithic, integrated bureaucracy which was deemed
inefficient, ever growing and slow to respond to local needs and a changing environment.
Downs (1967, p. 160) emphatically argued: “The increasing size of the bureau leads to a
gradual ossification of operations…the bureau becomes a gigantic machine that slowly and
inflexibly grinds along in the direction in which it was initially aimed. It still produces
outputs, perhaps in truly impressive quantity and quality. But the speed and flexibility of its
operation steadily diminish.” To respond to these perceived flaws, proponents of NPM
recommended the creation of semi-autonomous agencies operating at arm’s length from
government and enjoying some degree of management autonomy (James, 2003; Pollitt et al.
2004; Preker and Harding, 2003; Verhoest et al. 2012), and/or corporatization or privatization.
Another notable theme within rational choice theory related to coordination is the
identification of the free-riding problem (Hay, 2004, p. 42). Despite collectively positive
outcomes, self-interested rational actors have an incentive to non-participation. Self-interested
behavior hampers coordination giving rise to collectively, and possibly individually, sub-
optimal consequences. Relatedly, individual action and problems of coordination have been
approached from a game-theoretic perspective (Calvert, 1995; Schelling, 1960). In particular
Calvert (1995) discusses from a principal-agent perspective how institutions can address
coordination problems by specifying rules and standards, rewards and punishments and
through organizing effort. He argues that a coordination problem is characterized by more
than one individual sharing a common goal, the achievement of which is obstructed by the
decision of which goals to pursue, imperfect (incomplete) communication and disagreement
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over what decisions to make and which goals are best. This approach builds on neo-
institutional economics and the rational choice strand within neo-institutional theory. In this
view the narrow rationality assumption has been qualified under the influence of structure
over agency. The key focus from this perspective has changed from assuming universal self-
interested rational behavior to understanding the circumstances under which actors behave
rationally (Hay, 2004, pp. 43-4). If coordination is affected by individual, non-cooperative
behavior, then this question becomes highly relevant to explaining coordination processes
more generally and coordination problems in particular.
Principal-agent theory (or agency theory), more than any other strands within rational choice,
has been particularly concerned with issues of ensuring coordination. The key concern is what
governance (coordination) mechanisms to put in place to solve the agency problem –
imperfect information and conflicting goals between the principal and the agent. A main focus
of the theory is to design and adjust instruments that can foster coordination and reduce
information asymmetry and conflict between the principal and the agent. These include
outcome-based contracts to reduce agent opportunism, information systems and performance
indicators to hold the agents to account (Eisenhardt, 1989). This is the key aspect that
distinguishes coordination from a principal-agent theory perspective (commonly based on
hierarchy and some form of control) from voluntary market-based coordination common to
price theory. Agency theory combines price theory mechanisms (e.g. market incentives) with
hierarchical mechanisms (Shafritz and Ott, 2001, p. 246).
As one prominent representative of neo-institutional economics, principal-agent theory does
not necessarily assume absolute rationality. In her influential overview of agency theory,
Eisenhardt (1989, p. 59) points out that one of the “human assumptions” of the theory is
bounded rationality along with self-interest and risk aversion. The author claims that “agency
theory offers unique insight into information systems, outcome uncertainty, incentives and
risk”. She goes on to say that “agency theory is an empirically valid perspective especially
when coupled with complementary perspectives”. The author concludes that “the principal
recommendation is to incorporate an agency perspective in studies of the many problems
having a cooperative structure” (p. 57). We favor this recommendation and as we shall see
later when we discuss the theoretical framework we incorporate the key concepts of principal-
agent theory – in addition to concepts from sociological institutionalism – to explain
coordination problems in European hospital systems.
Governance “theory” and coordination
Governance as theory is still in its infancy, and much of the current scholarship in political
science and public administration hesitates to call governance a theory. While there is much
discussion on the merits and clarity of the concept of governance in the literature, what is
clear from the outset is that this body of literature has much to teach us about coordination.
Coordination is often discussed in the governance literature, and we need to distil what
exactly coordination means and how it is achieved from a governance standpoint. As one
author puts it, the major advantage of the concept of governance is that “it provides for a
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rather abstract frame in order to cover a broad array of institutional arrangements by which
the coordination, regulation and control of social systems and subsystems is enabled and
facilitated” (Schneider, 2004, p. 25). It is difficult to pin down exactly what governance
means and what it consists of. Unlike the “pure” versions of rational choice theory, which
claims to be highly deductive and predictive, governance is anything but that. It brings
together insights from various theoretical traditions and gives them a new feel and “hosts”
them in a new framework. Governance can contain, for instance, cultural elements borrowed
from sociological theory and in this sense it overlaps with neo-institutional theory. The
governance approach has become so pervasive in current social science theory to the extent
that it has “infected” old theories with a governance touch. It is not the purpose of this section
to summarize the large body of governance literature. Many other authors have attempted this
(Bevir, 2009; 2011; Chhotray and Stoker, 2009; Frederickson and Smith, 2003; Pierre and
Peters, 2000; Rhodes, 1996; Stoker, 1998). The goal is to discuss how coordination is
approached within this large and growing body of scholarship.
A relevant salient focus linking governance with coordination is, as in rational choice theory,
the interest in modes (or mechanisms) of governance. Command and control, steering and
rowing or self-steering by societal actors are some obvious modes of governing frequently
discussed in the governance literature. These same modes of governance refer to mechanisms
of coordination. In a discussion of the topic the three “classic” mechanisms – hierarchy,
market and networks – are both thought as coordination mechanisms (Bouckaert, Peters and
Verhoest, 2010; Hollingsworth, Schmitter and Streeck, 1994) and as governance mechanisms
(Bevir, 2011; Pierre and Peters, 2000). The level of generality, as shown below, can explain
this apparent interchangeable use of the terms, although it is far from clear which one is more
general – governance or social coordination. In other words, is coordination one of the
functions of the broader governance or, conversely, is governance a function of the broader
processes of social coordination? In an approach that views governance as a modern variant
of the theory of the state, coordination is a function of state governance (Schneider, 2004).
The state with its institutions has the goal to coordinate, control and integrate various parts in
complex societies. In more general terms, however, governance can be construed as a theory
of the various forms of social coordination (Bevir, 2009, p. 164; Schneider, 2004, p. 25).
The hierarchical mode of governance is contrasted to a socio-cybernetic view where no single
sovereign authority governs alone, but governs with other actors or governs other actors
collaboratively in networks. The role of the governing body is to foster these networks, to set
the stage and coordinate the overall process. Coordination takes precedence over control, and
is more intimately linked to the concept of governance. However, as Pierre and Peters (2000)
emphasize, the state perspective to governance does not become obsolete in the face of a
network-dominated social and political life. Their approach to governance is centered on the
state – not on networks or societal actors. In defense of their approach they argue that “the
role of the state is not decreasing as we head into the third millennium but rather that its role
is transforming, from a role based in constitutional powers towards a role based in
coordination and fusion of public and private resources” (p. 25). The state still maintains its
role in governance, though it is different from what mainstream state theory would posit. Two
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of the main functions of governance are steering and coordinating. Steering derives from
cybernetics – the science of control. Pierre and Peters (2000, p. 23) stress two related
problems related to steering as a governance function. The first one concerns the capacity of
governments to steer society in a multiple-actor environment. The second one refers to what
objectives governments can still steer towards in such a setting and who sets these objectives.
Discussing governance as practice as well as the constraints to govern, Chhotray and Stoker
(2009) show that governance is a political activity characterized by coordination and decision
making in a context of multiple interests and views. Governance and coordination are thus
closely intertwined.
Coordination is presented as one of the tasks of governance among others, including
(de)composition and coordination, collibration and steering and integration and regulation
(Eliassen and Kooiman, 1993, p. 66). Coordination can be both a driving force of governance
and one of the goals of governance (Bevir, 2009, p. 56). The need for coordination in a setting
with multiple interconnected actors leads to changes in governance structures and processes
as well as to the need for cultural change. Are public managers, educated and socialized in a
command and control setting, prepared to take a step back and sit on the table with other
actors on which they previously had hierarchical control over? Effective policy in such a
context involves effective coordination. The quality of coordination becomes a key factor
determining policy effectiveness. Coordination can equally be a goal of governance. If
coordination becomes an important determinant of effective policy then policy makers may
choose (and have chosen) to first tackle coordination problems before expecting effective
policy to occur. Coordination may not be the end goal, but it is an intermediate goal on which
policy outcomes may heavily depend.
Analytical-empirical approaches to the study of coordination in the public sector
Operationalizing coordination in empirical research is difficult to do and rare (Bouckaert,
Peters and Verhoest, 2010, p. 63). Research on coordination, regardless of sector, tends to be
more descriptive rather than explanatory or predictive (Beuselinck, 2008). One approach to
research coordination is the study of coordination strategies, mechanisms and instruments and
their change across countries, sectors or dynamically across time. This can range from a
higher level of abstraction – coordination policy or strategy – to practical instruments of
coordination. This approach can be termed coordination as a process. In this case the
operationalization of coordination consists of specifying and mapping coordination processes
by means of coordination mechanisms and instruments. For instance, Bouckaert, Peters and
Verhoest (2010) systematically investigate the relationship between specialization and
fragmentation in the public sector and mechanisms and instruments of coordination in seven
OECD countries across time. In another study, Beuselinck (2008) looks at initiatives aimed at
improving coordination and possible explanations for these initiatives across various
countries.
Another salient attempt to treat coordination in research can be termed a functional, goal-
oriented approach. Central to this approach is the identification or explanation of processes of
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coordination, broadly speaking, and a distinct interest in the benefits and costs (or problems)
of coordination. For example, Walston, Kimberly and Burns (1996) discuss the anticipated
benefits of vertical integration in healthcare in a North-American context, with a focus on the
healthcare entity level. To attempt to operationalize coordination problems – a key component
of this approach – it is necessary to clarify how they are different conceptually from other
related concepts. Many studies of coordination do not use the term coordination problems,
and prefer terms such as coordination needs, barriers or constraints to effective coordination.
For instance, Fountain (2013) emphasizes four institutional constraints to effective cross-
agency collaboration. These include stovepipes, a legislative process that sends ambiguous
messages, blurred lines of accountability and a budget process that inhibits shared resources.
Beuselinck (2008) surveys the literature on coordination and discusses the need for
coordination and barriers to coordination (see also Hudson et al., 1999; Jennings and Krane,
1994).
Some authors, however, refer specifically to coordination problems and distinguish between
redundancies, lacunae and inconsistencies (e.g. Peters, 1998). Huxham and Macdonald (1992)
and Huxham (1993) use almost the same concepts, and distinguish between repetition,
omission, divergence, and counter-production. In their perspective these are pitfalls of
individual action at the expense of collaborative action. The new element in this classification
is the inclusion of divergence. Divergence occurs when the actions of various individual
actors or institutions follow their own goals at the expense of common goals. Counter-
production (or inconsistencies or contradictions) is concerned with rules, laws, operating
procedures or actions – both formal and informal – taken by certain organizations that
contradict or negate the actions of other organizations. Repetition consists of partial or total
overlap of efforts aimed at reaching a certain goal while omission is concerned with actions
that are important to reaching a certain goal, but are overlooked.
The presence of coordination problems is neither new to the public sector nor easy to
overcome. The extent to which these problems are a matter of concern to politicians and
administrators varies geographically and across time. The politics of coordination undergoes
change (Peters, 1998). It is not entirely clear a priori how problematic these problems are at a
given point in time, and in what ways they can pose difficulties to efficiently and effectively
using tight resources and providing public services. The main argument in the fight to
rekindle interest and restore smooth coordination is that these problems can lead to sub-
optimal effects, especially at a group or system level.
Towards a theoretical framework
National coordination in healthcare, sociological institutionalism and principal-agent
theory
The previous theoretical foray has revealed the following key points on which we build our
own theoretical framework and, subsequently, apply it to study national coordination of
publicly-owned hospitals in European healthcare systems. First, institutional and cultural
13
approaches have increasingly gained in importance, but they have been less influential in the
study of coordination in the public sector. Examples, as we have seen, do exist, but it seems
that approaches anchored in ‘classical’ organization theory are still the most common.
However, as we have seen, institutional and cultural factors can have an impact on
coordination as it does on other social, political and administrative processes which have been
more thoroughly documented. Second, we have shown how group explanations through
epistemic communities – the professions – can enhance our understanding of what facilitates
or hampers coordination. Third, we argued that sociological institutionalism provides a useful
theoretical lens to understand the influence of institutional and cultural factors on governance
processes more generally and coordination problems in particular. Fourth, from a rational-
choice standpoint, we argued that principal-agent theory can act as a complementary
perspective to the study of national coordination by providing key insights into goal conflict,
imperfect information and coordination mechanisms. Now we turn to explaining in greater
detail our theoretical framework and its suitability for research into national coordination of
public hospitals.
The theoretical framework is presented in Figure 1. We are interested in explaining
coordination problems and assessing the possible effects of these coordination problems. We
seek to do this by making use of the central concepts of two theoretical traditions in public
policy and administration, namely sociological institutionalism and principal-agent theory. To
evaluate the merits of each of these two theories in explaining national coordination in
hospital systems, we make use of the case study approach based on congruence analysis.
Blatter and Blume (2008) and Blatter and Haverland (2012) distinguish between three types
of case study research on the basis of three distinct ways of drawing inferences: co-variation,
causal process tracing and congruence analysis. Co-variation is presented as the ‘classical’
way to conduct case-study research, and reflects a logic of inquiry that is closer to positivism
and research based on variables. Causal process tracing resembles a way of knowing that is
interpretive par excellence. It is focused on a deep understanding of the many ramifications
and causal configurations of a few cases. This approach gravitates around these cases.
Congruence analysis, by contrast, the authors argue, forms a distinct type of case study
research that is centered on theory. In the case of congruence analysis the main goal is
‘inference towards broad, abstract theories…the emphasis is on intensive reflection of the link
between every significant observation and one or more abstract concepts (without necessarily
covering every step of the process)’ (Blatter and Blume, 2008, p. 334).
We are interested in investigating the role of both formal and informal institutions,
particularly the role of cultural factors and how they affect coordination problems. To do this
we use insights from sociological institutionalism. The theoretical review of major theories
and coordination has shown how sociological institutionalism provides the most detailed
treatment of culture. This explains our choice. We seek to explore how formal institutions,
understood by means of the type of healthcare system and informal institutions – cultures –
affect governance processes in European healthcare systems, particularly coordination
problems. At this high level of abstraction the notions of institution and culture are central. In
this sense we build on previous research on comparative health policy which has made great
14
use of neo-institutional theory (e.g. Blank and Burau, 2004; Freeman, 1999; Immergut, 1992;
Tuohy, 1999). New institutionalism, in particular, with its inclination to explain change at
macro level over time, is often used as a theoretical framework in comparative health policy
and reform. Researchers using this theoretical lens have drawn insights from a common
theoretical tradition, and have used different concepts and foci to explain change in healthcare
policy. Therefore we need to articulate what concepts, institutions and cultural factors will
form the core of our argument. Culture, in particular, is notoriously difficult to conceptualize
and operationalize in research (Freeman, 1999; Schedler and Proeller, 2007). There is an
intimate link between institutions and culture. Healthcare institutions and systems are
characterized by certain cultural factors that presumably set them apart from one country to
another or from one organization to another. This explains our preference for the construct
“healthcare institutions and cultures”. We investigate these healthcare institutions and cultures
across our country case studies and in so doing we seek to explain coordination. We can
expect that different institutions and cultures will influence coordination in different ways in
different countries.
Some past research in comparative health policy has found multiple factors relevant to explain
change in healthcare policy. A case in point is Tuohy (1999) who explains major policy
change in three Western healthcare systems, the US, Britain and Canada, by means of the role
of political institutions, policy legacies, public opinion and cultural understanding, political
culture and parties, strategic judgment of leaders, and interests, of which those of the medical
profession occupied a central place. Blank and Burau (2004) discuss a variety of categories of
factors (social, cultural, political and religious, to name but a few) which can all have a role in
explaining healthcare policy change and outcomes.
We take a more focused approach compared to some of the work cited earlier. We focus on
explanations deriving from the healthcare system. A first institutional factor is the type of
healthcare system: for example a tax-based national system or a social insurance system. A
second institutional factor is the role of the medical profession. We treat the medical
profession as an institution. The same is the case for the type of healthcare system. Culture
reflects shared historical developments, routines, values, identities and beliefs. In our case, we
are interested in culture or cultures of the healthcare system, public hospitals in particular.
Again, as in the case of formal institutions, we study culture at the level of the healthcare
system. Freeman (1999, p. 91) argues that much benefit can be drawn from focusing on the
informal (cultural) in addition to formal institutional arrangements:
“As well as being sets of institutional arrangements, health systems are clusters of
assumptions, values, traditions, norms and practices. Institutions – organizations, rules,
routines, procedures and assumptions – themselves are cultural products; in turn they shape
cultures. Health systems are cultural systems.”
There are arguments for these choices. First, we acknowledge that there is growing interest of
treating health systems as “health care states” (Moran, 1999; 2000). This has become a
common way to say that healthcare is embedded in the political-administrative system.
Furthermore, as we have seen, it is very common to have lists of various factors explaining
15
healthcare developments and outcomes by looking at explanations in the broader socio-
cultural environment. While we acknowledge this, we see arguments in favor of a more
focused explanatory. By focusing on factors intrinsic to the healthcare system we argue for
the specificity of healthcare – a certain healthcare culture, certain healthcare institutions that
are different from other sectors, although they may not be entirely unique to the healthcare
arena. Tuohy (1999, p. 108; 117) found evidence for this approach. The author found different
developments in healthcare compared to other social policies. If social policy more generally
in a specific country is embedded in the same political administrative system, then one could
expect a similar path across various policies. This, however, was not the case, and the author
argued that there were unique factors common to health or to the healthcare system explaining
developments in health policy. Again, we do not ignore the complexity of social reality, and
appreciate the value of more holistic, multi-dimensional approaches to the study of
governance processes and coordination (see for example Beuselinck, 2008). However, as
argued earlier, we see the benefit of a more focused and theoretically-informed framework.
Role of the medical profession and type of healthcare system
These elements are not only relevant to change in health policy, but also to governance and
national coordination processes in particular. First, the type of healthcare system classified
based on the main funding mechanism, has much to do with the central governance of the
system of hospitals. Tax-based national systems are thought to be more integrated – or
coordinated – than social insurance systems or predominantly private insurance systems
(Blank and Burau, 2005, p. 131; Freeman, 1999, pp. 84-85; Rothgang et al. 2005). In our case
Norway is an example of a national tax-based system while Estonia and Romania are both
social insurance systems. It is reasonable to expect that the type of healthcare system is a key
element in healthcare governance, but the type of funding is only one of the major
characteristics of a healthcare system alongside provision and regulation. Therefore the
relation between the type of funding and governance processes is complex. Many
combinations and classifications of healthcare systems are possible starting from these ideal
types (see for example Wendt, Frisina and Rothgang, 2009). The functions of provision and
regulation are an integral part of our analytical framework. These are closely linked to reform
in healthcare systems: decentralization, autonomy and the governance and coordination
challenges that these pose.
The role of professions in a context of managerial reform constitutes a vast and vivid area of
research. The response of the medical profession to change in health policy has been
investigated and found relevant in the literature (Immergut, 1992; Tuohy, 1999). The nature
of professional expertise and information triggers the need for regulating the profession and
collaborating with it to obtain information that otherwise would not be available. Tuohy
(1999) in particular amply discusses the role of information and the importance of the medical
profession in understanding change in health policy. A principal-agent approach here seems
relevant due to the nature of medical information and possible conflicts between various
logics, for instance managerial versus professional or central consolidation and coordination
16
versus organizational autonomy. At the same time, however, the medical profession is an
institution, both in a formal sense and an informal, cultural sense. It is reasonable to expect
that there are differences from one country to another (and possibly within the same country)
in how the medical profession responds to governance processes – for instance through
resistance or collaboration. All of this would indicate that the role of the medical profession
is a key factor in explaining governance processes more generally and coordination problems
in particular. On the other hand, we use the key concepts of principal-agent theory that is
divergent goals between the coordinator and the coordinated and incomplete information
about the activity of the coordinated. The following reasons justify our choice of these
concepts. First, these are the core tenets of the theory. Second, it can be assumed that
divergent goals and incomplete information pose difficulties on the coordinator, and
potentially can be a source of coordination problems. Third, the various coordination
mechanisms and instruments used may be a locus of coordination problems. We include these
concepts in our analytical explanatory framework in the same way that we include key
concepts from new institutionalism.
17
FIGURE 1: ANALYTICAL FRAMEWORK: NATIONAL COORDINATION OF PUBLICLY-OWNED HOSPITALS
EXPLAIN IDENTIFY ASSESS
Decentralization of hospitals
Coordination problems Effects of coordination problems
Autonomy of hospitals Typology of coordination problems
1. Sociological institutionalism
-Healthcare institutions and cultures
Type of healthcare system (formal institutions)
Role of medical profession (informal institutions)
2. Principal agent theory
-Conflicting goals
-Incomplete information and monitoring
-Governance (coordination) mechanisms and instruments
18
Analytical-empirical approach
We first need to clarify how we conceptualize coordination. We prefer a simple definition that
focuses on the content of the concept. By coordination we understand:
The effective working together of the various parts of an entity, be it an institution or a
system.
Effective in our understanding involves working together that is characterized by two things:
1. Limited coordination problems, namely repetition, omission, divergence and
contradiction and
2. Limited negative effects from these coordination problems.
This definition, we believe, is intuitive and captures the essence of the concept. We follow the
approach to coordination that emphasizes the goals of coordination efforts, and assess the
state of coordination in a given organization or system of organizations by means of
coordination problems and their effects. We define coordination problems as specific
instances where poor coordination can be observed in practice – that is, the existence of
observable failures in the working together of an organization or system. We follow a
taxonomy of coordination problems used in the literature and distinguish between four types
of coordination problems: repetition, omission, divergence and contradiction (Huxham and
Macdonald, 1992; Huxham, 1993; Peters, 1998). By repetition we understand the partial or
total overlap of efforts aimed at reaching a certain goal. Omission is concerned with actions
that are important to reaching a certain goal, but are overlooked for one reason or another – in
organizational terms they fall between two (or N) stools. Divergence occurs when the actions
of various individual actors or institutions follow their own goals at the expense of common
goals. Contradiction as a type of coordination problem is concerned with rules, laws,
operating procedures or actions – formal and informal – taken by certain organizations that
contradict or negate the actions of other organizations.
For clarity a distinction is in order between what is known as the “problem of coordination”,
which is commonly referred to in the literature (Bouckaert, Peters and Verhoest, 2010; Hood,
2005; Peters, 1998), and the specific types of coordination problems defined earlier. The
problem of coordination is situated at a higher level of abstraction and denotes the general,
age-old, challenge of reaching coordination. Repetition, omission, divergence and
contradiction are examples of specific categories through which this general problem of
coordination manifests itself in organizational practice. The concept of coordination problems
is a key element of this thesis. The four-point typology can be used to distinguish between
different problems associated with coordination processes in national healthcare systems. It is
possible that differences exist between countries in how salient and consequential these
problems are. In some countries some of these problems (but not others) may pose greater
difficulties to health policy makers and planners than in other countries.
While this typology is useful, the question remains how these problems can be
operationalized and identified in empirical research. Coordination problems can be identified
19
and assessed by conducting interviews with relevant stakeholders and by means of
comparisons with good practices. This is particularly the case for comparative, cross-national
research which looks at healthcare systems in transition countries and compares them with
developed systems. The element of cross-national learning, despite evident contextual
variation, is not to be overlooked. The good-practices method can be used by analyzing
legislation, policy documents and empirical data to assess what is on the ground in a specific
country and to compare coordination problems with those in other countries. Coordination is
likely to trigger different interpretations from different actors. The same is true for
coordination problems. What is a coordination problem to one stakeholder, say, the Ministry
of Health, may not be a coordination problem to other stakeholders, say hospitals. For this
reason it is important to account for these various constructions in empirical research.
However, coordination or lack of it is not entirely a socially constructed concept and
organizational practice. It may differ from one stakeholder to another, but apart from these
there is also more “objective” ground for identifying coordination problems. This can be
achieved through studying processes and structures, and see how they work and fit together.
Similarly one can look at legislation and policy documents and see whether there are any
observable contradictions. Both approaches, we believe, need to be used for a more realistic
assessment of coordination problems and their effects.
The decision to build the argument around the idea of coordination problems is theoretically
and practically justified. In the public management academic and practitioner literature much
is being written about the perils of decentralization and autonomy reform. The loss of
coordination, it is argued, is one of these major perils. We argue therefore that for this
argument to be true the loss of coordination needs to be evaluated by means of actual
coordination problems and by means of the effects that these coordination problems may
have. It is for this reason that the concept of a coordination problem occupies a central role in
our approach. Additionally, from a more practical standpoint we argue that the usefulness of
research on coordination can be enhanced by focusing attention to ever-present and feared,
but seldom-assessed coordination problems. However, we do not close our eyes to instances
of coordination success, but the idea of coordination success can be tackled through the same
lens. We treat the lack of coordination problems as evidence of coordination success.
This approach resembles problem-oriented policy research. Similarly, it indicates an outright
decision to focus on a negative approach to coordination. Some clarification is necessary at
this stage. The decision to focus on identifying and assessing coordination problems in
national hospital systems does not exclude the idea of coordination success. The approach is
not necessarily biased towards “chasing” and solving coordination problems where
organizational practice has shown that problem-free coordination is extremely difficult, if not
impossible, to achieve in practice. It may also not always be desirable or efficient to reach a
state of perfect, problem-free coordination. Coordination problems are not dichotomous – you
have them or not – but a matter of degree. A full “eradication” of repetition, omission,
divergence or counter-production appears neither realistic nor, possibly, desirable. Some
repetition, for instance in providing a certain public service, may act as a backup to individual
failure (Huxham, 1993, p. 603, see also Landau, 1973). Repetition can be a means to ensure
20
that a critical service gets performed properly and effectively. It is not always and necessarily
the worst of things. Achieving coordination, as important as it may be, may have its own
costs, and it may give rise to problems of other nature, such as possibly stifling individual
action, innovation or organizational-level performance. The language and reality of trade-offs
and unintended consequences apply equally to the realm of coordination as it does to that of
NPM-type reforms – which were chastised for leading to such trade-offs and unintended
effects in the first place. The cycle of trade-offs may know no limits. Solving a type of
problem – lack of coordination – may give rise to a host of other problems. It is important,
therefore, to seek to understand the complexity of these potential trade-offs when evaluating
coordination efforts.
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