Critical Analysis of historical context surrounding policy reform and institutional relationships at its core needed


Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed, according to a new research project by Trinity College, Dublin.

“The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018–2023,” was published in May in BMC Health Services Research.

The researchers said that effective governance arrangements were central to the successful functioning of health systems. While the significance of governance as a concept was acknowledged within health systems research, its interplay with health system reform initiatives remained underexplored in the literature.

“This study focussed on the development of new regional health structures in Ireland in the period 2018–2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation.

“This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity). the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis.”

They said the analysis revealed important lessons for policymakers across the five TAPIC domains of governance. These included deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified.

“Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlighted how these challenges could be addressed through strengthening governance arrangements and processes. Importantly, the research revealed the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes.”

The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018–2023.

Researchers Katharine Schulmann, Carlos Bruen, Sarah Parker, Rikke Siersbaek, Luisne Mac Conghail and Sara Burke.