Autonomy, Transparency and Management
Reform dynamics in health care: a comparative project
Project summary
The responsibility for the Norwegian public hospitals has been
transferred from the counties to central government. Five regional health
enterprises have been established, and there has been a reform in the rights
of patients, and in the way hospital departments are to be managed. The aim
of this project is to study such processes of reform and change within the
Norwegian health care sector, make comparisons with Sweden, Denmark and
other countries, and estimate the consequences for quality, cost efficiency
and legitimacy. Three research modules are introduced:
- AUTONOMY. The ambition to establish autonomous organizational units,
with a focus on the health enterprise.
- TRANSPARENCY. The dynamics involved in the strive for transparency,
exemplified by the introduction of still more detailed instruments for
monitoring of performance and quality, as well as patient’s rights to
be informed.
- MANAGEMENT. To establish a more professional and distinct managerial
role at all levels is a major ambition for most of the recent reform
programs.
A comparative research design is employed - regional, cross-national and
global - in order to analyze the relationship between reform activities,
organizational changes and service provision. The aims are to:
- Generate research on the preconditions for change in health care by
the means of comparative research
- General competence development in organization and management of
health care
- assist the health institutions in their efforts to improve service
delivery and create more innovative structures for organization and
management.
- Develop a forum for research on organization and management of health
enterprises, in cooperation with Health Bergen, as well as a Nordic and
International research group and network
Introduction
The aim of this project is to study processes of reform
and change within the Norwegian health care sector, make comparisons with
Sweden and Denmark and other countries with similar reforms and estimate the
consequences for quality, cost efficiency and legitimacy of health services.
How are reform initiatives translated into practice, in health enterprises
and other institutions for specialized health care? Under what circumstances
do reform programs lead to organizational changes with effects for service
quality, legitimacy or cost efficiency?
The first research area relates to the ambition to
establish autonomous organizational units. This idea is central in the
recent ownership reform in Norway, which have introduced the health
enterprise as a major unit at a local and regional level and transferred
ownership from the counties to the state. The second research area is to
study the dynamics involved in the strive for transparency, exemplified by
the introduction of still more detailed instruments for monitoring of
performance and quality, as well as patient’s rights to be informed and
make choices. The third research area is management and leadership. To
establish a more professional and distinct managerial role at all levels is
a major ambition for most of the recent reform programs. This may be
exemplified by the recent law enacted by the Norwegian parliament requiring
from all clinics and hospital departments that they implement a system of
unitary management. Similar reforms are undertaken in other sectors of
public administration and in other Scandinavian countries.
The focus within each research area will be on 1) content
of the various reforms programs and the discourses provoked by them 2) how
such programs and debates differ among the Scandinavian countries, and also
among countries with different health systems 3) in what way practices in
the hospital system are affected by the various reform programs, and 4) what
are the likely consequences for quality, efficiency and legitimacy. A
comparative research design is employed - regional, cross-national, global -
in order to analyze the relationship between reform activities,
organizational changes and service provision. The aim of the project is to
both develop knowledge, durable partnerships and modules for education and
research that may assist the health institutions in their efforts to improve
service delivery and create more innovative structures for organization and
management. Similar challenges face other public institutions, and the
project clearly has relevance for a whole range of sectors and policy areas.
The project is also a contribution to the development of theories and
perspectives in the field of management and organization studies.
The research group and the institution serving as host
The Stein Rokkan Center for Social Studies at the University of Bergen is
responsible for the project. A broad range of researchers, research
institutions and health organization are brought together in a concentrated
effort. We have created a research team with different kind of competences,
research experiences and networks, led by researcher, dr.polit Haldor
Byrkjeflot. Other participants are: professor Ivar Bleiklie and professor
Per Lægreid, the Rokkan Center and Department of Administration at
University of Bergen, Ph.d. Katarina Østergren at PWC and the Rokkan Center
, Associate professor Hallgeir Gammelsæter at State College of Molde , Ph.d.
- candidate and research associate Kristijane Cook Bulukin, at Norwegian
School of Business and Management, Bergen (NHH) and Ph.d.-candidate and
associate professor adjunct Dag O. Torjesen, Agder State College.
Our main institutional partner is Health Care Bergen, represented by Vice
President Tore Nepstad and director of unit for organizational development
Cand Polit. Trond Søreide. Other active partners are Finn Borum, Professor
in organization theory at the Department of Organization and Industrial
Sociology, the Copenhagen Business School, and professor Kerstin
Sahlin-Andersson at Department of Business Administration at University of
Uppsala.
The research group will have close contacts with the program for Health
Economics in Bergen (HEB), a program located at the Rokkan Center and based
on a co-operation between the University of Bergen and the Norwegian School
of Economics and Business Administration (NHH). Important links also include
the research on health history and health services at the Rokkan Center, and
the strong research tradition on public administration and professions at
the Department of Administration and Organization theory. We also cooperate
with the Institute for Research in Economics and Business Administration (SNF)
in Bergen.
Research needs and perspectives
It is a commonly held view that the hospital sector is
facing great challenges with respect to management, organization and
governance, but not much research is undertaken on this issue. There is a
great deal of activity within research on health economics, and in the more
development-oriented fields of consulting and education. Previous studies of
Norwegian health care provide aggregated data (e.g. Kjekshus et al 2001) and
analysis of structural preconditions for efficient service provision (e.g.
Askildsen and Haug 2001). These studies are important, but there is also a
need for studies that focus more explicitly on organization and management.
Several reforms have been introduced, the ambition is to
change the way managerial and professional actors operate and behave. The
reform makers put large hope in the logic of economics and try to implement
economic incentives to increase productivity. Politicians rely on advice
from shrewd experts in formal modeling. The assumptions about what goes on
inside the organization may be wrong, and frequently not at all spelled out.
Sometimes models that are believed to have been successful in other contexts
are copied without concern for how action frames differ. Studies are needed
that focus on what goes on inside the “black box” of management and
organization. What are the preconditions that need to be fulfilled in order
to activate the capacities of the critical actors and their motivation to
participate in reform work? Under what circumstances do actors learn from
their own and each other’s experiences?
Although important if one wants to understand many of the
crucial issues in modern health care provision, these internal matters have
not been systematically studied in a Norwegian context. Previous studies
show that there are problems with implementing new reforms. Firstly, reforms
may be rejected, either by veto-groups or by the professional system as a
whole (Søreide 1999). The second problem with implementing reforms has been
that reform ideas are adopted, but then in a passive, superficial way, as
part of a windows-dressing strategy (Brunsson 1989). Many attempted reforms
may just have been a waste of time and resources, and others may even have
decreased the actor’s capacities to act in a concerted and innovative way,
as seen in the example of “organizational blockage”, a situation with
collapse in communication (Crozier 1964). A third possible response to
implementing reforms is that a translation occurs. Translation happens when
reform ideas are transformed as they meet the organizational members and
their local patterns of thought and action (Czarniawska and Sevon 1996,
Røvik 1998). A precondition for translation may be actors that have
developed knowledge and have a work-situation and position that allow them
to take an active and creative approach to reform ideas. As shown there are
different ways of dealing with new reforms in organizations and in this
project we want to know how professionals and managers in Norwegian health
care respond to the the new reforms.
Introducing reforms, one also has to take into
consideration that most changes happen for other reasons or in despite of
political reform efforts or deliberate organizational strategies. New
knowledge and technologies, professional strategies, the expansion of
patient organizations, all these dynamic elements affect the way health
services are delivered. Boundaries between organizational units and between
the health system and other relevant systems get blurred, e.g. as a
consequence of intervention by the pharmaceutical industry and insurance
companies (Scott et al. 2000). A whole range of intervening factors and
actors may undermine the existing power balance. Therefore, we will
emphasize studies with different perspectives, with a focus on institutions
(Røvik 1998), actor-networks (Latour 1986, Blomgren et al 1999),
organizational politics (March 1994), the politics of audits, transparency
and categorization (Power 1997, Bowker and Star 1999). Such perspectives may
stimulate conversations among researchers as well as among researchers and
practitioners, and contribute to a capacity to act, based on a deeper
understanding for why and how change occurs in health care organizations.
There is also a lack of comparative studies. A means to
assess the impact of various variables and actors in such a complex system
is to make comparisons across settings; regional, cross-national and global.
Transnational networks are influential in the development of knowledge-based
groups and technologies in health-care, as well as management. Individualism,
human rights, patient-as-customer, the right to choose doctor and hospital,
these are “world models” with great implications for hospital management
(Meyer et al. 1997, Boli et al. 2000, Meyer 2002). Therefore, we will have a
focus on comparative studies.
Recent reform initiatives and important research questions
Since 1 January 2002 the responsibility for the Norwegian public
hospitals has been transferred from the counties to central government. Five
regional health enterprises have been established, which in turn have
organized the hospitals under 47 health enterprises with 250 institutions
under their jurisdiction. These enterprises are of various size and
geographical span; some are encompassing just one hospital, while others
organize hospitals as divisions under larger health enterprises(1).
At the same time there has also been a reform in the rights of patients, and
in the way hospital departments are to be managed, towards unified
management. These three reforms can be seen as representative of three kinds
of programs, 1) an ambition to establish organizational autonomy 2) a strive
for transparency 3) a strive for professional leadership. Altogether these
programs represent an ambitious effort to move away from the traditional
public-administrative system for funding and organization towards a more
decentralized, transparent and managed system.
From a place-bound, planned system of resource allocation to
decentralized autonomy?
The public-administrative system was based on fixed
government grants and a strong belief in the possibility to establish “
objective criteria” for health needs and equality in service provision,
and operationalize them into regional and national health plans. An
important precondition for this relatively stable, hospital-based and
place-bound system was a centralized employment policy, encompassing
professional groups, and a medical profession that took a key role in health
planning as well as in the allocation of positions and resources (Erichsen
1995).
The new enterprises are believed to be autonomous, which means that they
have to find the best way to allocate resources in a cost-efficient way. It
is no longer an option to return to the government for more resources, the
enterprises have to make the priorities themselves and make structural
changes if necessary. Therefore they have to take another perspective than
the hospitals. Such local and regional hospitals may not be easy to control,
however. They have became rooted in their respective communities, due to
their importance as employers, their role in local politics, as a source for
journalists, and as symbols of belonging and security for the population at
large. It has been easy to mobilize communities in defense of them, and it
is an open question whether the new enterprise model will be able to keep
local hospitals from repeating their successes in mobilizing against plans
to rationalize and reorganize health services.
From a system with unlimited expansion towards a transparent system with
cost control.
The constitution of health enterprises has accentuated the need for
transparency and new identities, a governance regime that has been
classified as new public management (NPM), corporate governance or even “managed
care”. New public management refers to the introduction of quasi market
mechanisms (purchaser-provider models, contracting), along with an increased
emphasis on the role of management (unitary management) and the customer (freedom
to choose), as well as the expansion of expert-based agencies for quality
control and evaluation (Lægreid and Christensen 2001, Pettersen 2001). We
therefore want to know whether a new set of business-oriented and
expert-based players will intervene into the health terrain, and whether the
new rules will make it possible for such actors to initiate a change towards
transparent and autonomous units. Alternatively, one may suggest that the
same actor-networks and professions that have been the powerful players in
the traditional system will be able to reject reforms or adapt to them just
in a symbolic way, in order to maintain the status quo.
From professionals to managers.
It has been observed that
professionals-as-managers gain in power, whereas collegial professional
formations loose power (Fitzgerald and Ferlie 2000: 722) in those countries
where NPM-reforms have been advanced the furthest. In health services it has
commonly been the professional that has had the upper hand over the manager,
but they are now changing places, with the consequence that the professions
become less unified, a managerial strata is developed within each profession
(Leicht and Fennell 2001). Norwegian health professions are still more
unified than those in many other countries (Erichsen 1996). This means that
they carry with them a complex and contradictory set of values and
priorities that may lead them in many directions (Bleiklie 1997).
Many see the new role of managers and reformers, not as a contrast to
medical professional values, but rather as a reconstruction of the existing
actor-networks, and values (Kjekshus 2002, Llewellyn 2001). Managers,
politicians and professional actors make different interpretations of the
reforms and the forces they seek to influence. We are here interested in how
the medical professions respond to the demand to take a more managerial role.
Research design
In order to control for many and complex intervening variables we will
use a comparative design. The reforms seek to establish a clearer division
of labor between institutions and organizational units. It may thus be
useful to compare with other settings where other kinds of division of labor
has been institutionalized, e.g. Sweden where there has been an effort to
have treatment at right level, that is a stronger emphasis on primary care
than in Norway, and putting more emphasis on treatment in hospitals. The
project will be organized in three research modules (below) and we will
employ three kinds of comparative research designs (frames):
Frame 1. Regional implementation of health reforms.
The focus will be on
national variations in the implementation of the various reforms by
comparing processes in various hospitals, local enterprises and regional
health enterprises, and also the introduction of unitary management in other
sectors than health. The major research effort will be done in cooperation
with Healthcare Bergen, a health enterprise established under the
jurisdiction of Health West in January 2002, as 11 former independent
institutions were merged into one organizational unit. Healthcare Bergen is
among the largest health enterprises in Norway with 7500 employees. We will
also cooperate with researchers at Agder State College and the State College
of Molde. They will use empirical data from another two regional enterprises:
Health Mid-Norway and Health South.
Frame 2: Health reforms in Scandinavia
This frame will be used to focus
on the role of management and organization in the health services in
Scandinavia. There is a common trend towards unitary management and away
from dualistic and troika models of management in medical units and
hospitals, and similar reforms towards the use of new public management
instruments, in order to establish autonomous, transparent and accountable
organizational units.
Although the principles of governance of specialized health services in
the Nordic countries are rather similar, there are also relevant differences.
Funding is provided by taxpayers in all countries, but a difference is that in
Sweden and Denmark the counties have more leverage in collecting tax money for
health purposes. Furthermore, there is also a difference in public ownership,
whereas such services are still owned by the counties and not the state in
Sweden and Denmark. How far are patient reforms and benchmarking activities
relating to quality, customer satisfaction and cost effectiveness advanced
in the various countries? We will cooperate closely with researchers at
Uppsala University, Sweden and at the Business School of Copenhagen, as well
as the FLOS project, in Denmark.
Frame 3: European variations and the role of international circulation of
management concepts.
This frame will focus on the internationalization trend
within health services, and on the more systematic variations in the effect
of management and organization in various contexts. We plan to develop an
application for the EU and other international and national agencies, with
partners from France and Britain, as well as organizations with a
multinational or international orientation. We will focus more on
international variations in division of labor, management and organization.
What are the consequences of the trend towards internationalization in
regulation of professions, as well as the development of new agencies and
instruments for quality control in health services, as exemplified by the
growth of international medical associations and transnational agencies (Evetts
1999) We plan to organize the project in such a way that scholars with
different kind of research focus meet each other continually and have to
consider each others perspectives in their daily work.
More specific research areas
1. The ambition to create organizational autonomy.
The first project module will study the impact of the movement
away from hospitals and toward health enterprises, a dynamic encouraged by
the recent health reform, and establish hypotheses about possible
implications for the governance of the field of specialized health care
services and cost efficiency/quality of health services. There are
variations among the regions as to how they organize the health enterprises,
and also what kind of expertise is predominant among board members and
directors. Some enterprises are based on local and regional hospitals,
whereas others seek to merge hospitals or integrate them into the new
enterprises as divisions or as part of larger organizational units. How do
such choices affect the legitimacy of the health services in general and
hospitals in local communities in specific? Two aspects of the transition
from public hospitals to health enterprises will be given specific attention:
The constitution of boards and enterprise direction.
It is now the
central state and the boards of the health corporations, and not the
counties and local politicians that have the last word when setting
priorities. The patients’ associations have gained a more important role
through the new user councils that have been established in some regions,
apparently as a substitute for politically appointed advisory boards. There
is currently a struggle to define the appropriate role of boards and the
relationships between regional and local health enterprises. How do board
members and directors balance their role as representatives of the state,
their role as experts/professionals and how do they adjudicate between
patient interests and local political priorities? Where do they search for
role models, in private or public firms?
Purchaser-provider models.
Several of the regional health care companies
have decided to implement purchase-provider models, in order to take benefit
of market mechanisms. One of the benefits associated with such models is
that they are time-limited and based on an agreement between two or more
partners. Secondly, it is believed that competition gives lower costs and
more satisfied customers. Thirdly, it may enable concentration in the sense
that purchasers and providers have different roles. The purchaser role is to
decide on what-questions, while the provider’s focus on why-questions. The
purchaser should thus concentrate on managing structural tasks, while
provider responsibility relates to technical, mundane and daily matters.
The purchaser-provider models that are implemented will be studied from a
contract theory perspective, an institutional perspective and a political
perspective. The contract theory perspective helps us to understand whether
agents behave according to the principals' needs. The institutional
perspective helps us to understand what implementation of purchaser-provider
models means for actors who belongs to different norm systems in the health
care sector. Finally, the political perspective helps us to understand how
purchaser-provider models affect the political system, the interests of the
actors involved and how democratic values are changed as a consequence of an
increased focus on the rights of citizens and patients. Sources will be
documents, newspaper reports, interviews and participant observation of
board meetings. Parallel to these two studies we will have smaller studies
connected to the above by master students.
2. The strive for transparency: how the movements for patients’ rights
and political control over health services play together and contradict each
other
Stakeholders without insight and knowledge?
The hospital sector has been
difficult to understand for many groups that may have an interest in it as
taxpayers, patients, politicians or journalists. The freedom to choose
hospital-act and, the new procedures for accounting and financing, as well
as new procedures for evaluation and control seek to make new aspects of
organizational life visible and problematic. March (1994) refers to the
measurements that feed such reform movements as “magic numbers”, numbers
that the organizations and its stakeholders are competing and negotiating to
define. Such kinds of processes need to be better understood in order to
arrive at credible hypotheses about the relationship between quality
reforms, budgeting reforms, patient reforms and performance in the health
sector. It is not our main aim to collect more data on quality, cost
effectiveness etc., or to evaluate whether they measure what they claim to
do, but rather to study those who collect, negotiate and use such numbers in
their daily activities and estimate the effects of the dynamics involved.
New kinds of actor-networks emerge and get empowered. They seek to make
their own interpretations, negotiate and influence the “numbers-game”.
Politicians and public administrators are also interested in manipulating or
influencing the objects that have been constructed (waiting lists, treatment
costs, the average hospital etc).
Stakeholders in demand for transparency.
This process will be studied
from three perspectives: a) a patient or consumer perspective where
transparency is related to access to and quality of the services, b) a
citizen or political participant perspective where transparency is
considered a question of availability of the information needed by
politicians in order to assure accountability and exercise political control,
and c) an accounting perspective where transparency is related to
possibility to control. In management accounting the idea is to make the
enterprise transparent by introducing measurement systems. The accounting
system shows “a picture” of the enterprise that is supposedly clear,
objective and easy to categorize. This will work as decision support. Legal
regulations will make the new enterprises more focused on economic
information than the former hospitals.
Patients and those who claim to represent them have gained in strength
due to a new law that gives the patient “the right to choose hospital”.
It is assumed that hospitals may be encouraged to take the role of a
competitor, and provide more information about themselves to the public in
order to attract patients. This means that they will be more appreciative of
the movement towards transparency and allow for media and patients to look
into waiting lists and availability and quality of treatment. Patients must
be informed and have more alternatives in order to act as customers. The
professions, however, may have an interest in bringing the focus away from
performance in each hospital and towards other levels of governance, in
health enterprises (Norway) or function-bearing units (Denmark, Borum
2000,2002). Previous studies of professions and power assume that it is
important for professions to control and often conceal information
concerning the decisions they make within their field of expertise (Johnson
1972). Blomgren (1999), on the other hand, found that quality assurance
programs were welcomed among Swedish nurses, because they made the nurses’
work more visible, and also more abstract. It is thus necessary to study how
such reforms are received and transformed in various professional settings.
Political perspective: from political representation to user
representation.
The citizen’s right to have a say in the priorities of
healthcare is not a focused issue any more, instead there is an increasing
interest in the issue of patient’s rights and a discourse centered on the
patient as customer. The news media seek to increase their circulation by
reporting on matters relating to priority conflicts, maltreatment and
organizational problems. They increasingly take the role as advocate of
patients, consumers and citizens. The expansion of the Internet and the
access opened to alternative sources and kinds of expertise may also empower
the patients and their advocates, as it now gets increasingly difficult for
the experts and managers to control the information flow. The view that the
patient as well-informed customer may take over the role of local
politicians may be questioned, however. It is not only that actual and
potential patients may be too poorly informed, due to the problems
associated with access and filtering of information, but also whether the
new role assigned to the patients' organizations is beneficial from a
democratic point of view. Will only the large patient organizations and
their advocates be heard, or is it also possible for the less well organized
and less well represented to gain influence and argue for their opinion?
From an accounting point of view there may be a limit to how much
information the patients should be able to get on their own, and what kind
of alternatives should be available to them. Some kinds of information is of
bad quality, it is maintained, and other kinds of information will open the
avenue for patients to make choices that are not beneficial from a public
health point of view. There is thus only a partly overlap among those who
want to increase transparency in order to control costs and create
legitimacy, and those who argue that the patients should be enabled to act
as customers. In some cases politicians with an ambition to control cost,
and professions, with an ambition to conceal their knowledge, may create
coalitions in order to slow down the dynamics of the movement towards
transparency. In other cases there may be a dynamic where all stakeholders
feel compelled to jump on the transparency bandwagon, with the consequence
that the whole system is overloaded with audits and transparency games (Llevelyn
2002).
This project will link up with a similar Swedish project, undertaken by
Kerstin Sahlin-Andersson and her research team that will 1) map how
widespread the use of audits of various kinds is in the Swedish hospital
sector. 2) How audits are initiated and undertaken. 3) How audits are used
in political governance and in management 4) Consequences for organizational
and professional practices (enclosure 6). Although it will be our aim to
collect comparable data where possible, we will concentrate on how audits
are used and what consequences they have for organizational and professional
practices. One question is how new systems for quality control and
management lead to changes in organizational routines and what are the
learning effects of struggles over whether such systems should be rejected,
“adopted” or translated.
3: From tandem and troika management to unitary management
The Norwegian parliament has enacted a law requiring from all hospital
departments that they implement unitary management structures from 2002.
There has been a trend away from dual, collegial and representative
management structures within other sectors as well. This represents a break
with development patterns since the 1970s, since when there was a trend
towards democratization and more collegial management structures (Sommervold
1997). More specifically, in the health sector there was a strong tendency
towards the establishment of dual (Norway and Sweden) and troika management
(Denmark). By the end of the nineties this trend had come to an end in all
these countries (Østergren and Sahlin-Andersson 1998, NOU 1997:2, Bentsen
2001)
The intention of those who seek to establish autonomous health
enterprises is to gain a stronger grip on management in relation to the
structure of the health service, e.g. by means of the distribution of
functions. The individual enterprises will be given greater responsibility
and freedom, and great hopes are put in the hospital department managers.
They are supposed to be able to create a better health care organization
with higher cost-efficiency. When such a leadership role is established,
then this is supposed to be an engine in itself that will create change
inside the organizations. Not only is a productivity increase expected, but
the management reform will also give rise to higher quality and a more
innovative organization.
What are the preconditions that need to be in place for the department
managers to act like the role assigned to them in policy documents? We want
to contribute to a discussion about what is possible, what is reasonable,
and what the department manager can do under present circumstances. This has
to be based on an investigation into their experiences, and comparisons with
similar managerial roles in other contexts, e.g. hospitals in other
Scandinavian countries and other sectors. It is on this basis possible to
paint a more realistic picture of what the clinic and departmental managers
can do and how they may handle the many different and contradicting claims
relating to their role as managers and decision-makers. How do they handle,
balance, and coordinate between professional, administrative/economic and
political principals (Østergren and Sahlin-Andersson 1998, Blomgren 1999)?
One level of comparison is the Scandinavian, since the implementation of
such reforms are likely to be influenced by nation-specific contexts;
professional configurations, ownership roles, level of political influence
etc. There may also be a lot of local experimentation involved among those
institutions that are now on the way to implement management reforms. One
project will make a comparison between management reforms in the Norwegian
social insurance offices and the specialized health services. A comparison
with similar management roles and concepts in the US hospital sector may be
useful. US management ideas, and professional recipes developed as responses
to them, are continuously imported to European contexts (Byrkjeflot 1997,
1999). We will thus encourage studies with a focus on the international
circulation of ideas relating to management (Sahlin-Andersson and Engwall
forthc.) and more specifically how these are translated into various
professions, expert groups in hospitals.
In our studies we will interview department managers and have them
describe their own experiences. Secondly, we will observe managers in their
daily work contexts, also in meetings, in order to get a better grasp of
interprofessional dynamics, and problems with drawing boundaries between
professional and managerial roles.
Literature
[1]
Even though this reform is often called a hospital reform, it also includes
most county municipal specialist health services and we will thus refer to
it as the enterprise reform, highlighting the importance of the introduction
of the enterprise model into public health services.
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