The practice and ideology of New Public Management (NPM): The Greek NHS at a time of financial austerity

Abstract

This study explores the practical and ideological implications of the New Public Management (NPM) paradigm as introduced in Greece by the so-called “Troika”, a sobriquet referring to a triumvirate comprising representatives of the IMF, the European Union, and the European Central Bank. In the past, attempts had been made by Greek officials to implement managerial practices within the Greek National Health Service (NHS) and the hospital sector in particular, albeit at a more leisurely pace than that of other countries’. On arrival to Greece the Troika imposed a number of changes to improve the country’s public services; and set a brisk pace to accelerate their implementation. The present doctoral thesis seeks to critically evaluate the issue of whether those reforms, especially those salient to the Greek NHS system, are true manifestations of a shift in the NPM paradigm or whether they represent yet another archetypal Greek public sector restructuring. It will also evaluate responses to and outcomes of the successive reforms in the Greece’s NHS system, ascertain the factors contributing to and/or impeding the adoption of those reforms, and identify new opportunities for growth. In order to gain access to a more profound insight into the Greek context, the collection of secondary data provides, among other things, an historical background of Greece’s public healthcare system; reviews the system’s characteristics in terms of healthcare policies, and probes into the state of working conditions within public hospitals. The heightened managerial spirit prevalent in Greece at the moment and brought about by the Troika’s tenure, has made it necessary for the literature review of the present work to focus on the ways that managerial practices and ideologies are imposed on other countries so that their public sector dysfunctionalities may be rectified. Drawing on the literature reviewed, the study develops an integrated analytical framework anchored in NPM, so as to test it in the Greek case and contribute to understanding the Greek NHS organisational realities as well as to evaluating how the new changes have been evolving and faring within Greece’s healthcare organisations. The framework is comprised of a review of the NPM paradigm so as to contextualise the Greek reforms in terms of ideology and practices; a review of Principal-Agent Theory (PAT) for illuminating the interrelationships and involvement of the key actors with the reforms; and a review of Critical Realism (CR) for assisting to reveal the underlying mechanisms and structures that bind the actors with the organisations and their development. Apart from providing the conceptual basis of the thesis, the framework also serves in informing its methodological design (i.e., generating the interview schedule), analysing the findings, and steering the discussion. The study adopts an in-depth, qualitative research approach that views social life within organisations in terms of processes, events, actions, and activities between key actors as factors unfolding over time. To that purpose, semi-structured interviews were conducted with the key stakeholders of the Greek NHS system: State hospital doctors, hospital managers, and policymakers. The contribution of the study is an in-depth analysis of reform implementation as carried out in Greece’s medical system which now stands, within a turbulent economic and political context. By means of that analytical framework, it is shown that Greece is a sui generis case whose context and historical background are altogether different than those of other countries’. Moreover, the framework demonstrates that, despite the fact that NPM is firmly ensconced, as far as practice and ideology go, it is too soon to be drawing any conclusions: NPM is still in its infancy and reforms to the Greek NHS system have yet to be finalised as they continuously stumble on the inefficiencies and blunders of the past which hinder them from functioning properly. Last, the thesis does possess one more unique feature: it delves into the thinking, manoeuvres, and behaviour of the Greek healthcare professionals as a group, a world rarely if ever explored by empirical studies.