Sopimusohjaus ohjausmenettelynä sairaanhoitopiirin ja terveyskeskusten yksiköissä ja niiden lääkärien työssä

This study concerns the implementation of steering by contracting in health care units and in the work of the doctors employed by them. The study analyses how contracting as a process is being implemented in hospital district units, health centres and in the work of their doctors, as well as how these units carry out their operations and patient care within the restrictions set by the contracts. Based on interviews with doctors, the study analyses the realisation of operations within the units from the doctors perspective and through their work. The key result of the study is that the steering impact of contracting was not felt at the level of practical work. The contracting was implemented by assigning the related tasks to management only. The management implemented the contract by managing their resources rather than by intervening in doctors activities or the content of their tasks. The steering did not extend to improving practical care processes. This allowed the unchanged continuation of core operations in an autonomous manner and in part, protected from the impacts of contracting. In health centres, the contract concluded was viewed as merely steering the operations of the hospital district and its implementation did not receive the support of the centres. The fact that primary health care and specialised health care constitute separate contracting parties had adverse effects on the contract s implementation and the integration of care. A theoretical review unveiled several reasons for the failure of steering by contracting to alter operations within units. These included the perception steering by contracting as a weak change incentive. The doctors shunned the introduction of an economic logic and ideology into health care and viewed steering by contracting as a hindrance to delivering care to patients and a disturbance to their work and patient relationships. Contracting caused tensions between representatives of the financial administration and health care professionals. It also caused internal tensions, while it had varying impacts on different specialities, including the introduction of varying potential to influence contracts. Most factors preventing the realisation of the steering objective could have been ameliorated through positive leadership. There is a need to bridge the gap between financial steering and patient work. Key measures include encouraging the commitment of middle management, supporting leadership expertise and identifying the right methods of contributing to a mutual understanding between the cultures of financing, administration and health care. Criticism of the purchasers expertise and the view that undersized orders are due to the purchaser s financial difficulties underlines the importance of the purchaser s size. Overly detailed, product-based contracts seemed to place the focus on the quantities and costs of services rather than health impacts and efficiency of operations. Bundling contracts into larger service packages would encourage the enhancement of operations. Steering by contracting represents unexploited potential: it could function as a forum for integrated regional planning of services, and the prioritisation and integration of care, and offer an opportunity and an incentive for developing core operations.

Aluesuunnittelu ja kestävä kehitys Luoteis-Venäjällä : Ympäristösuunnittelun mahdollisuus paikallisissa hallintatavoissa

In this Ph.D. thesis I have studied how the objectives of sustainable development have been integrated into Northwest Russian urban and regional planning, and how the Russian planning discourse has changed after the collapse of the Soviet Union. By analysing the planning discussion, processes, and strategic documents I have also investigated the use of power and governmentality in urban and regional planning. As a methodological foundation I have used an approach that I call geographical constructivism . It was possible to answer in a relevant manner the question of how sustainable development has become a part of planning in Northwest Russia through a discourse analysis of the planning discussion. During the last decades, the aim of sustainable development has become globally one of the most central societal challenges. Urban and regional planning has a central role to play in promoting this process, since many meta-level objectives actually take shape within its sphere. An ever more actual challenge brought by sustainable development is to plan regions and places while balancing the conflicts of the pressures of safeguarding a good environment and of taking into consideration social and economic needs. I have given these unavoidable conflicts of sustainable development a central place in my work. In my view, complementing instrumental and communicative rationality with conflict rationality gives environmental planning a well-equipped toolbox. Sustainable development can be enhanced in urban and regional planning by seeking open, and especially hidden, potential conflicts. Thus, the expressed thinking (mentality) and actions taken by power regimes in and around conflicts open an interesting viewpoint into Northwest Russian governmentality. I examine the significance of sustainable development in planning through Northwest Russian geography, and also through recent planning legislation and four case studies. In addition, I project my analysis of empirical material onto the latest discussion of planning theory. My four case studies, which are based on independent and separate empirical material (42 thematic interviews and planning documents), consider the republics of Karelia and Komi, Leningrad oblast and the city of Saint Petersburg. In the dissertation I argue how sustainable development is, in the local governmentalities of Northwest Russia, understood as a concept where solving environmental problems is central, and that they can be solved through planning carried out by the planning professionals. Despite this idealism, environmental improvements have been overlooked by appealing to difficult economic factors. This is what I consider environmental racism, which I think is the most central barrier to sustainable development in Northwest Russia. The situation concerning the social dimension of sustainable development is even more difficult, since, for example, the development of local democracy is not highly valued. In the planning discourse this democracy racism is explained by a short history of democracy in Russia. However, precisely through planning conflicts, for example in St. Petersburg, planning has become socially more sustainable: protests by local inhabitants have bypassed the poorly functioning representational democracy, when the governmentality has changed from a mute use of power to one that adopts a stand on a conflicting issue. Keywords: Russia, urban and regional planning, sustainable development, environmental planning, power and conflicts in planning, governmentality, rationalities.