HARRI RAISIO Embracing the Wickedness of Health Care Essays on Reforms, Wicked Problems and Public Deliberation ACTA WASAENSIA NO 228 SOCIAL AND HEALTH MANAGEMENT 5 UNIVERSITAS WASAENSIS 2010 Reviewers Professor Ismo Lumijärvi Department of Management Studies FI–33014 University of Tampere Finland Professor Markku Temmes Department of Political Science P.O. Box 54 FI–00014 University of Helsinki Finland III Julkaisija Julkaisupäivämäärä Vaasan yliopisto Marraskuu 2010 Tekijä(t) Julkaisun tyyppi Harri Raisio Artikkelikokoelma Julkaisusarjan nimi, osan numero Acta Wasaensia, 228 Yhteystiedot ISBN Vaasan yliopisto 978–952–476–316–5 (nid.) Filosofinen tiedekunta 978–952–476–317–2 (pdf) Sosiaali- ja terveyshallintotiede ISSN PL 700 0355–2667, 1796–9352 65101 VAASA Sivumäärä Kieli 277 Englanti Julkaisun nimike Terveydenhuollon pirulliset ongelmat: Esseitä reformeista, kompleksisuudesta ja kansalaisdeliberaatiosta Tiivistelmä Tutkimuksen tavoitteena on kehittää terveydenhuollon reformien toteuttamiseen ideaalimalli kompleksisuusajattelun ja erityisesti pirullisten ongelmien problema- tiikan (wicked problems) näkökulmasta. Tutkimuksen keskeinen väite on, että perinteinen mekanistinen käsitystapa terveydenhuollon uudistamisesta ei ole yk- sinään riittävä, eikä sovellu käytettäväksi sellaisenaan yhä kompleksisemmaksi muuttuvassa yhteiskunnassa. Tutkimus koostuu kuudesta artikkelista ja yhteenveto-osiosta. Artikkeleissa ra- kennetaan alustava näkemys terveydenhuollon reformien ideaalimallista ja sy- vennetään ymmärrystä wicked-problematiikasta sekä erityisesti siitä, miksi ter- veydenhuollon reformit epäonnistuvat tavoitteissaan. Teoreettinen tarkastelu suuntautuu lisäksi moninaisälykkyyden (co-intelligence) ja deliberatiivisen de- mokratian merkityksiin terveydenhuollon pirullisten ongelmien käsittelyssä. Artikkeleiden empiirinen aineisto koostuu terveydenhuollon reformien suunnitte- lijoiden haastatteluista, kansalaisille että kolmannen sektorin järjestöjen edustajil- le suunnatuista kyselyistä sekä terveydenhuollon reformeja käsittelevästä doku- menttiaineistoista. Väitöskirjan yhteenveto-osio syventää edelleen ymmärrystä tutkimuksen teemaan. Tutkimus havainnollistaa terveydenhuoltoon liittyvää kompleksisuutta ja lisää tietoisuutta terveydenhuollon pirullisten ongelmien olemassaolosta. Tutkimukses- sa luodaan terveydenhuollon reformeille ideaalimalli, joka toimii suunnannäyttä- jänä tulevaisuuden terveydenhuollon reformeille. Mallia voidaan käyttää sekä tieteellisessä analyysissa, että myös konkreettisesti terveydenhuollon uudistamis- työssä. Asiasanat Kompleksisuus, terveydenhuolto, hallinto, reformi, deliberatiivinen demokratia V Publisher Date of publication Vaasan yliopisto November 2010 Author(s) Type of publication Harri Raisio Selection of articles Name and number of series Acta Wasaensia, 228 Contact information ISBN University of Vaasa 978–952–476–316–5 (paperback) Faculty of Philosophy 978–952–476–317–2 (pdf) Social and Health Management ISSN P.O. Box 700 0355–2667, 1796–9352 FI–65100 VAASA Number Language FINLAND of pages 277 English Title of publication Embracing the Wickedness of Health Care: Essays on Reforms, Wicked Problems and Public Deliberation Abstract The insufficiency of the mechanistic worldview in reforming a health care sys- tem is the fulcrum of this study. Acknowledging the complexity of the modern world, it can be stated that the mechanistic view alone is not sufficient. New ways of seeing and understanding are needed. This research provides an alterna- tive view on the issue of reforming health care, by developing an ideal model for a health care reform from the perspective of complexity thinking and the concept of the wicked problem. The study consists of a summary-part with six articles. In the articles a prelimi- nary view of the ideal model for a health care reform is created. Also the under- standing of the concept of the wicked problem, and the question of why health care reforms tend to fail in their objectives, is deepened. Additionally, the dis- cussion is focused on the significance of co-intelligence and deliberative democ- racy in tackling wicked health care problems. The empirical data of the articles consists of interviews (of health care reform planners), two electronic surveys (to citizens and NGO representatives), and document material covering health care reforms. The objective of the summary-part of the study is not just to sum up the individual articles, but to further deepen the understanding of the researched topic. As central contributions, the study illustrates the complexity of health care, in- creases the awareness of the existence of wicked health care problems and cre- ates an ideal model for a health care reform; this is not to be used only in scien- tific analysis, but also in concretely reforming health care. The model functions as a trendsetter for future health care reforms. Keywords Complexity, health care, administration, reform, deliberative democracy VII PREFACE As I now reflect upon my path of becoming a researcher, I realize how much the theoretical framework of this research actually explains the process. It has indeed been a path characterized by emergence and self-organizing. Things haven't al- ways gone as planned, and rather many surprises were encountered along the way. But now, here I am. In the end, what matters is how you embrace the unex- pected. Also, it must be said that this wasn't a solitary path. As the research of social is- sues takes place in a social world, and not in a closed research chamber, connec- tivity and interdependence in the process are natural. Thus, there are so many people who have had an influence on this research. Below I mention only a few by name, and my gratitude goes to all these people who have been involved in the process. Firstly, I am deeply grateful to my supervisor Professor Pirkko Vartiainen. When she asked me to join the faculty four years ago, I didn't think twice before saying yes. In many ways she has been an ideal supervisor who has supported and in- spired me throughout this process. Most importantly, as I am a person who gets excited easily, it has been essential to have a supervisor who is open to many dif- ferent ideas and who similarly knows to intervene when a person gets too carried away. I have also been lucky to have two highly distinguished professors of public ad- ministration as pre-examiners. Professor Markku Temmes and Professor Ismo Lumijärvi gave valuable comments on my research, for which I am very thankful. During these four years of research I have received funding from many different sources. Thank you belongs to the Finnish Cultural Foundation, the National Post Graduate School in Social and Health Policy, Management and Economics (SOTKA), Nordiska Administrativa Förbundet (NAF), the Academy of Finland and the Hungarian Academy of Sciences. Many academic journals, including one edited book, are part of this research; as platforms for publications. I am grateful to the editors of these journals and for all the constructive comments received from the peer-reviewers. Especially, I would like to thank Professor Jarmo Vakkuri, Professor Ted Becker and Dr. Michael Briand. Similarly I thank those individuals who agreed to be interviewed for my research and who answered to the two surveys implemented in this research. For ensuring the grammaticality of the research I thank Anna Martikainen. VIII I have been fortunate to work with a diverse group of people who share my en- thusiasm for researching the many complexities of social and health care. I thus wish to thank the current and former colleagues in social and health management, members of the research group HYMY and the enthusiastic developers of the BoWer -network. For our almost daily coffee breaks for the past six years, filled with inspiring conversations, I thank my friends and colleagues Juha Lindell and Niklas Lundström. During my research exchange in Hungary I became friends with fellow researcher Katalin Érsek. Kata and I have shared many experiences as young researchers together and have supported each other on our chosen career paths. I am grateful for our friendship. My deepest gratitude goes to my family. For my entire life, my parents Arja and Kalevi and my brothers Jarno and Tero have supported and encouraged me in whatever I chose to do with my life. My dear Nina came into my life, with a big impact, at the later stage of this research. As a friend once told me "Harri, life is more than just work and gym". With Nina, I have realized this to be true. Without her, finishing this long path wouldn't feel the same as it does now. Vaasa, September 2010 Harri Raisio IX Contents PREFACE ........................................................................................................... VII LIST OF PUBLICATIONS ................................................................................. XI 1 INTRODUCTION ........................................................................................... 1 1.1 Objective of the study ........................................................................... 3 1.2 Structure of the study ............................................................................ 5 2 ARTICLES, METHODS AND DATA ........................................................... 6 3 ADVANCED THEORETICAL FRAMEWORK .......................................... 16 3.1 Health care reform – the foundation ................................................... 16 3.1.1 Why? .................................................................................