Institutions and non‐linear change in governance : Reforming the governance of medical performance in Europe

Purpose – The paper aims to account for the substance of non‐linear governance change by analysing the importance of sector‐specific institutions and the pathways of governing they create. Design/methodology/approach – The analysis uses recent reforms of the governance of medical performance in four European countries as a case, adopting an inductively oriented approach to comparison. The governance of medical performance is a good case as it is both, closely related to redistributive policies, where the influence of institutions tends to be pertinent, and is subject to considerable policy pressures. Findings – The overall thrust of reforms is similar across countries, while there are important differences in relation to how individual forms of governance and the balance between different forms of governance are changing. More specifically, sector‐specific institutions can account for the specific ways in which reforms redefine hierarchy and professional self‐regulation and for the extent to which reforms strengthen hierarchy and affect the balance with other forms of governance. Originality/value – The recent literature on governance mainly focuses on mapping out the substance of non‐linear change, whereas the development of explanations of the substance of governance change is less systematic. In the present paper, therefore, it is suggested coupling the notion of non‐linear change with an analysis of sector specific institutions inspired by the historical institutionalist tradition to better account for the substance of non‐linear governance change. Further, the analysis offers interesting insights into the complexity of redrawing boundaries between the public and the private in health care.