Issues in the Governance of Integrated Health Systems (Executive Summary only)


This policy synthesis has three basic goals: (1) to grasp the significance of governance issues as they are experienced—or could be experienced—in integrated health care systems; (2) to clarify the meaning of those issues so that public officials or policy-makers will be able to better address them; (3) to guide the selection of preferred models from a range of possible options, based on criteria suggested by the literature and the practitioners.

This study is not about governance in general, but about governance in a specific context: that of the creation and the operation of a special type of health care networks, generally known as integrated health systems (IHSs). The study of IHSs deals with issues related to the design and activities of those systems—such as the scope of services and the size of the population covered—whereas governance is concerned with the relationships between sets of actors as they create and operate IHSs.

In the last ten years, the concept of governance has been used extensively in scientific literature and in public discourse resulting in a proliferation of definitions. For the purposes of this paper, we have restricted our definition of governance to depict the manner in which decisions are taken and implemented in social or administrative networks. While the governance literature is preoccupied with problems arising at the local or organizational level (i.e., “micro” level) we identify and address multiple levels of governance (i.e., “meso” and “macro”) drawing attention to the policy issues and problems associated with each level.

From our standpoint, there are two key issues that policy-makers must resolve as they draft plans for the governance of IHSs: (1) the degree of autonomy each IHS will have in matters of services, budgeting, personnel, enrollment, etc.; (2) the balance in each IHS between the values and interests of direct or internal stakeholders, like the health care providers, and the values and interests of external stakeholders, i.e., the community at large. “Good” governance of IHSs implies some choices over these key issues, conducive to a balanced organization.