Part 1: Research and theoretical contributions

Governance, governmentality and the medical profession

Influence in the mediated space of reforms

Healthcare is central to the functioning of contemporary states, so much so that political scientists have coined the term ‘mature healthcare states’ (Tuohy, 2012; Ferlie and McGivern, 2013). Our research focuses on the role of medical doctors in reforms within mature healthcare states. Narratives of network governance in the last 30 years highlight governments’ inability to achieve policy changes and objectives on their own (Rhodes, 1996; Torfing, 2005). They need the expertise and agency of non-state actors to bring about policy innovations and change. As suggested by Rhodes (1996), governing without governments opens up a rich dynamic where state, non-state, traditional and non-traditional policy actors, each with their own projects and preferences, reinvent society. Our research looks at the prospect of joint policy-making in healthcare, focusing on the specific case of the relationship between governments and medical doctors in healthcare reforms.

Tensions and conflict persist in the network narrative of governance, but can, in principle, be transcended by setting up adequate, effective and collaborative modes of governance (Ansell and Gash, 2008). The political and policy modus operandi embodied in the network governance narrative is associated with the challenge of achieving consensual politics in a landscape of potentially conflicting preferences, values and interests. Our research empirically probes these tensions and the difficulties of achieving consensual politics while responding to governmental demands for major change. The basic intuition of network governance is that a participatory and open policy process becomes a predominant principle of policy-making in contemporary states as the legitimacy and scope of coercion is reduced. However, this generates the institutional problem of creating convergence among dispersed sets of actors, each of which has its own agency (Meyer, 2010). Our analysis suggests that governments do not easily and consistently invest in renewing policy instruments to overcome challenges associated with distributed agency and the convergence of interests. While the legitimacy of overly relying on coercive approaches in managing healthcare systems remains doubtful, some states like Canada have, over the past few decades, produced a greater number of rules and regulations to support the increasing scope and complexity of government activities (Garant, 2017). This creates additional tensions, but these are not irreconcilable with a participatory policy process.