Institutional change, isomorphism and politics: the
adaptation of municipalities to care reforms
Master thesis
MSc BA – Organizational & Management Control
University of Groningen, Faculty of Economics and Business
Thesis supervisor: Dr. E.G. van de Mortel
Co-assessor: Dr. B. Crom
Nadieh Mulder student number: 2203928 n.i.mulder@student.rug.nl
Abstract
The purpose of this research was to discover how Dutch municipalities adapt to the institutional
changes in the care sector when both isomorphic and political ideological pressures are present
and influence this adaptation. The results show that isomorphic pressures influence
municipalities to adapt similarly as other municipalities to institutional change. They are
influenced in such a way that their general policies concerning care are similar. However results
also show that differences in political ideology cause municipalities to adapt differently with
concern to the execution of this more general policy and the emphasis they put on certain
responsibilities. The results are based on nine interviews held within seven municipalities
across the Netherlands. A contribution is made to both the public interest and to institutional
change theory, research on isomorphism in the public sector and a combination of isomorphism
and political ideology within institutional change.
Key words: Adaptation to institutional change, isomorphism, political ideology, similarities,
differences.
JEL classifications: H75, I18, R50
Word count: 21.337
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INDEX
1. INTRODUCTION ... 2
2. SECTOR DESCRIPTION ... 6
2.1 Responsibilities of municipalities in the care sector ... 6
2.2 Changing institutions for municipalities ... 7
2.3 Structure, tasks and legislation of municipalities ... 10
2.4 End of chapter conclusion ... 12
3. LITERATURE REVIEW ... 13 3.1 Institutional theory ... 13 3.2 Institutional change ... 15 3.3 Politics ... 17 3.4 Conceptual model ... 20 4. METHODOLOGY ... 23 4.1 Interview method ... 23 4.2 Data collection ... 25 4.3 Data analysis... 30 5. RESULTS ... 31 5.1 Institutional change ... 31
5.2 Influence of political ideology... 39
5.3 Isomorphic influence of the environment ... 41
5.4 Largest influence on policy ... 47
6. DISCUSSION AND CONCLUSION ... 49
6.1 Discussion and conclusion ... 49
6.2 Limitations and recommendations ... 54
7. REFERENCES ... 55
7.1 Academic references ... 55
7.2 Internet references ... 57
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1. INTRODUCTION
“Large differences in care rates of municipalities” states RTL News on the 6th of April 2015. Care rates represent the amount municipalities charge for a certain care facility and according to research of RTL News there are large differences in the height of these care rates between municipalities. RTL News found that for the same type and amount of care, needy people in one municipality pay almost twice as much as in another municipality (Kropman, 2015). This could be caused by the fact that since the first of January 2015 a lot of responsibilities for care have been decentralized to municipalities. This means that certain types of care are no longer arranged by the central government, but municipalities now have that responsibility. Apart from messages in the news, the Council for Public Health and Care also states that one of the risks of this decentralization is that unwanted differences between municipalities can arise (Raad voor de Volksgezondheid & Zorg, 2014). Since the decentralization of these new responsibilities, municipalities had to change their ways of working from delivering a standard care package per disability to indicating someone based on their personal circumstances and demands. In Dutch this shift in working methods is called ‘kanteling’, here the term demand-based care is used. If municipalities do not apply this demand-based care forceful enough, gaps could arise in informal support between municipalities. Another risk is that municipalities offer a limited amount of facilities because of cost savings (RVZ, 2014). Dutch citizens worry, that because of these risks, differences between municipalities and thus inequality will arise. If however inequality or differences causes citizens to worry, why did the Dutch central government choose to approach this care reform by decentralizing the authority? Decentralization namely, will cause differences between municipalities.
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limited timeframe, it only focuses on the changing regulations concerning the Wmo 2015 within municipalities. When receiving these new responsibilities for the Wmo 2015 and the Jeugdwet, municipalities should perhaps also receive the authority that comes with these responsibilities.
The central government states that municipalities can provide better care and at lower costs because they are closer to citizens. Therefore, municipalities receive more responsibilities for the care of elderly and disabled people in supporting self-reliance and stimulating participation. They have to make sure these people receive care that is customized to their needs as well as enhancing the quality of care, while taking into account that there is a limited budget. Within the responsibilities that are granted to municipalities there are two opposing forces that both influence policy making. On one side municipalities have to conform to certain limitations and restrictions from the central government, while on the other side they receive quite some freedom in designing their own policy. This debate between influence from the central government and political freedom of municipalities has been a topic of great discussion in the past years. The Council of Public Administration (Raad voor het openbaar bestuur, Rob) and the Council of Financial Relations (Raad voor de financiële verhoudingen, Rfv) wrote an advisory report in 2005 about the autonomy of municipalities within the Netherlands. They wrote that the constitutional autonomy of municipalities within the Netherlands holds that municipalities are in principle, free to handle and look after every subject or public interest and that their administrative and regulatory freedom cannot be limited without cause. Administrative autonomy at the same time means that municipalities should have financial autonomy as well. The central government has however interfered in almost every area, which has led to the fact that many subjects that were previously handled by municipalities directly are now handled by the central government and then decentralized to municipalities again. This has led to the impression that municipalities only carry out government policy, which is a threat to municipal autonomy and the quality of government regulations. Since responsibilities for the new Wmo 2015 are also decentralized, this could limit the authority of municipalities concerning the Wmo 2015 as well.
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is called isomorphism in academic literature. Freedom in designing own public policy would however make room for political ideologies to influence policy making. This could lead municipalities to adapt to institutional change in very dissimilar ways, because Waldorff (2013) and Waldorff & Greenwood (2011) found that different political parties hold dissimilar ideologies and this causes their interpretations of best problem solutions and policies that have to be implemented to differ. The presence of two different pressures influencing policy making of municipalities thus causes municipalities to either adapt to institutional change in different or similar ways. The question still remains which force is of a stronger influence, isomorphism or political ideology. Therefore the question central to this research can be stated as follows:
“How do municipalities adapt to institutional change from care reforms, when both isomorphic and political ideological pressures influence this adaption process?”
Sub-questions which will help answer the main research question are:
1. “Which reforms will take place during this care reform and which parts of the care reform cause changes for municipalities?”
2. “What does isomorphism look like in the public sector?”
3. “What different types of political ideologies are present within Dutch municipalities?” 4. “Will differences in political ideologies lead to different ways of adaptation?”
5. “Will isomorphism cause all municipalities to adapt to this institutional change in the same way, creating uniformity amongst municipalities, either through normative, coercive or mimetic isomorphism?”
6. “Which influence is stronger in this situation, isomorphism or political ideology?”
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has an exploratory nature. Second, very limited research has investigated isomorphism within the public sector, thus this research also contributes to literature concerning isomorphism by investigating another sector in which isomorphism could play a significant role. By combining two topics that have recently brought up quite some discussion, the care reform of 2015 and the autonomy of municipalities, this research aims to contribute to both academic literature and the public interest. This research could provide some interesting insights concerning policy making for central and local governments, but also concerning the discussion about the autonomy of municipalities and which tasks should be executed by lower level governments and how this should be done.
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2. SECTOR DESCRIPTION
This chapter will elaborate on which formal institutions within care will change, which changes will affect municipalities and also what the purpose of this reform is. With that it answers sub-question one:
“Which reforms will take place during this care reform and which parts of the care reform cause changes for municipalities?” Apart from that, the governmental system of the Netherlands will be
explained shortly and the way in which policy is formed by municipalities is also explained.
2.1 Responsibilities of municipalities in the care sector
The care reform is a very large reform and encompasses four main changes. First municipalities will become responsible for supporting elderly and disabled people at home. This means that they have to support those people to live independently, supply support with daytime activities, arrange protected living facilities, provide assistance to informal caregivers for example family, support these people in their participation in society, and provide client support. These duties fall under the Wmo 2015. The second responsibility that is given to municipalities is that they will bear all responsibility for youth care services. This means that children up until 18 years old receive the help they need from municipalities, unless it is twenty-four-hours care. These duties are arranged in the Jeugdwet. Third, the Zvw organizes the responsibilities of care insurance companies. In general they are responsible for the nurture and care at home. This holds that they are responsible for district nursing, personal care and intensive childcare. Finally the State will stay responsible for long-term nearby intense care. This encompasses care within healthcare facilities or at home, permanent and twenty-four-hour care within close proximity, care for the oldest, most fragile people and people with large disabilities. All these new rules fall under the Wlz (Rijksoverheid, b). To give a clear overview of the changes within the current care reform, table one summarizes all the changes and shows which law arranges these changes.
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2.2 Changing institutions for municipalities
2.2.1 Purposes of the care reform of the Wmo
The changes in the Wmo are part of the decentralization of the responsibilities of long-term support to municipalities. With this change, municipalities become responsible for the self-reliance and participation of people with a disability. The goal of this support is to assure that people can live in their own surroundings for as long as possible. There are several reasons that the central government mentions for this care reform of long-term care and the goals that are strived for by reforming the system (Memorie van toelichting Wet maatschappelijke ondersteuning, 2014).
First, and foremost the central government wants to adjust the quality of social support to the changing circumstances. People want to be able to live at home for as long as possible, keep control over their own life and do not want to become lonely. The central government wants to make more use of the possibilities to provide customized care to people in their own environment by using the own social network of people and with the help of municipal facilities. Municipalities are therefore assigned to improve the accessibility to facilities and services for people with disabilities to involve them more in society. The central government aims to widen the responsibilities of municipalities concerning support and care, and in this way assure that people receive care that suits their personal circumstances. Vital to this reform is that municipalities are assigned to work with health insurance agencies, care providers and other parties to assure that a coherent care and support system is available to citizens within their own neighborhood or village ((Memorie van toelichting Wet maatschappelijke ondersteuning, 2014).
Second, the central government tries to enhance the involvement of people within society. To be able to enable people to live in their own home longer and to decrease loneliness, the social network of people
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and volunteers should get more involved in helping out. That is why the central government wants to strengthen the position of informal caregivers and volunteers, wants to lighten the burden of their job and wants to improve formal and informal care and support. Municipalities become responsible for achieving these goals (Memorie van toelichting Wet maatschappelijke ondersteuning, 2014).
Finally this decentralization of authority must be seen in relation to the financial task that the central government set for itself and municipalities. It is expected that municipalities are able to deliver this support with a smaller budget than the central government could, because they can more easily invoke on people’s own abilities and their social network and can deliver more general and personalized facilities. The central government expects that municipalities will use their freedom to design their own policies extensively in order to adjust policies to regional circumstances, needs and habits. Local democratic decision-making will determine the content, availability and the scope of care. This will have the consequence that facilities will differ between municipalities. The central government does expect that local councils will involve people in the design of municipal policies and be open to initiatives from society (Memorie van toelichting Wet maatschappelijke ondersteuning, 2014). These are the three main reasons for changing the current legislation concerning long-term care and home care support.
2.2.2 Wmo 2015, what has really changed for municipalities?
Several changes in the Wmo and in the transmission of the Wmo to the Wmo of 2015 have led to changes in the responsibilities of municipalities. A lot of the tasks mentioned above were however already part of municipalities’ responsibilities. In this section it will be explained which tasks and responsibilities really change because of the care reform of the first of January 2015 (Movisie, 2015). In short, municipalities have received one extra task in comparison to the previous Wmo and the other tasks that were already within their responsibility were adapted slightly.
First, because of the new legislation municipalities have a wider responsibility with respect to the participation of disabled people in the society. Apart from that, they have to offer appropriate support so people are able to perform the necessary daily activities and run a structured household, which makes them self-reliant. People who used to receive support for these activities through the AWBZ can now ask municipalities for this support through the Wmo 2015.
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offer a coherent system of support, customized to each situation. One of the things that will not change but which is still very important is the fact that municipalities are still held accountable for end results. The starting point is that self-reliance and participation are peoples’ own responsibility, however municipalities are obligated to form policy to support the people who cannot fully provide for their own self-reliance and participation or who need protected living facilities (Movisie, 2015).
The third change caused by the reform concerns changes in concepts. In the former Wmo there were nine performance fields according to which municipalities formed their policy. In the new Wmo 2015 these performance fields do not exist anymore, the new law describes the term ‘social support’, which municipalities have to hold to (Movisie, 2015). The term ‘social support’ includes:
- Stimulate social coherence, support from informal caregivers, accessibility of facilities, services and spaces for people with a disability, the safety within the municipality as well as preventing and fighting domestic violence.
- Support self-reliance and participation of people with a disability within their own environment for as much as possible.
- Offering protected living facilities and shelter.
This concept of ‘social support’ is something all municipalities have to use as a guideline in forming their policies (Movisie, 2015).
The fourth change allows municipalities to outsource their tasks, if they take into account certain criteria. The new law also states that municipalities have to involve their clients in the procurement policy. They have to strive for a diversity in contracted companies and creative possibilities for offering customized care when standard care-packages are not sufficient. Within this customized care, freedom of choice and that clients have a say in what they receive are important. There is also a new section about the quality of care and support. Sixth, municipalities become responsible for preventing and fighting domestic violence, even if the actual help comes from the regional or national level. Municipalities are also responsible for child-abuse, therefore the ‘Support Domestic Violence’ and the ‘Reporting point Child-abuse’ have to merge within municipalities (Movisie, 2015).
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For this research it is important to see the institutional change within municipalities. Municipalities thus receive the extra responsibility of arranging day-time activities and are responsible for supporting self-reliance and participation of disabled people in society. It will be interesting to see whether this institutional change is implemented similarly throughout municipalities because of certain boundaries set by the central government, or that the fact that municipalities receive quite some freedom in designing their own policy will cause differences between policies of municipalities.
2.3 Structure, tasks and legislation of municipalities
2.3.1 Decentralization or autonomy
In the Netherlands the governmental organization can be separated into three different layers. These are the state, provinces and municipalities. A lot of laws and regulations within the Netherlands are executed by the Dutch central government, however the central government can also decide to delegate certain tasks to lower level government such as provinces or municipalities. This process of delegating tasks to lower level government is called decentralization. From the first of January 2015 municipalities are responsible for youth care, work and income and long-term care. As was shown above, part of these tasks were already within the responsibility of the municipalities and some will be decentralized from provinces or the central government to municipalities. The reasoning behind this is that municipalities are closer to citizens and therefore they can deliver care more effective, with less bureaucracy and at a lower cost (Rijksoverheid, Nederland, b). Certain responsibilities that municipalities received on the first of January 2015 are however very expensive and difficult for especially small municipalities to arrange on their own, for example youth care. Therefore municipalities are allowed to work together with other municipalities in order to execute the increasing amount of responsibilities.
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forming policy, either delegated by the central government or from municipal autonomy is, central within this research because it influences how municipalities adapt to institutional change.
2.3.2 Structure and democratic system of municipalities
Municipalities are one of the governmental layers within the Dutch system. Municipalities are closest to the citizens and they are chosen through a democratic system. They have local tasks and duties, such as housing, traffic, culture, education and public order. Apart from that municipalities perform tasks that used to belong to the state but were then decentralized to municipalities, such as employment and environmental planning. For some duties municipalities receive money from the state, but they can also raise taxes themselves, however this is bound to a lot of rules and regulations (Parlement and Politiek, a). On the first of January 2015 the Netherlands consists out of 393 municipalities (CBS, a). At the head of the municipality stands the local council. This local council is democratically chosen by the citizens and its job is to formulate the policy of the municipality and to check whether or not the executive committee is doing their job right. This executive committee is formed by the mayor and the aldermen (Parlement and Politiek, a). The size of municipalities differs a lot, as well in acreage as in the number of citizens. Municipalities have had their borders since the year 1813, however there are almost yearly municipal restructurings that take place. The number of municipalities in the Netherlands has been decreasing ever since 1813 when there were around 1100 different municipalities. In the year 2000 that number had decreased to 538 municipalities (CBS, b) because of municipal restructuring and now, in 2015 there are only 393 municipalities left.
2.3.3 Politics within municipalities
Within the Netherlands it is very unlikely that one political party has a majority within the Second Chamber, but also within the local council of municipalities. This is different from other countries such as the U.K. or the U.S.A where politics are dominated by two large political parties. The reason for this is that the Dutch democratic system is a system of proportional representation. This means that not one candidate of every district is delegated, but all votes for a political party across the country are added together and then seats within the Second Chamber are divided according to the proportion of votes a political party received. This way smaller political parties also have a chance of becoming a member of the Second Chamber. Because not one political party will have the majority, and thus won’t be able to make decisions on its own, a majority must be formed by political parties working together and forming a coalition (Parlement & Politiek, b). This is not only the case with the election of the Second Chamber, but also with local councils of municipalities.
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political parties a coalition contains (Le Maux, Rocaboy & Goodspeed, 2011). In this case the coalition then does not exists of two or three large parties, but of more smaller parties who have to work together and who’s political ideologies might be further apart. Political fragmentation thus causes more political parties with perhaps different political ideologies to work together. This political fragmentation makes it more difficult for local councils to have either a strong left or strong right political visions, since they have to compromise with other parties, ending up somewhere in the middle. Sometimes, however councils can be formed with a few large parties, being either left or right and thus having a specific political ideology prevailing within a coalition. Political ideologies prevailing within a coalition could strongly influence the policy that is formed by that local council. As is mentioned in the study of Amenta & Poulsen (1996), the nature of political party systems plays a significant role in forming their policy. This could be very interesting within this research because then policy concerning this care reform could differ between municipalities. If this influence of political ideology is present and how it might influence policy making will be investigated in this research. The presence of other institutional forces should however not be forgotten.
2.4 End of chapter conclusion
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3. LITERATURE REVIEW
This chapter will explain the most important concepts within literature that are relevant to this study and will form the theoretical basis for this research. Two main subjects will be discussed because there is a tension between these two forces within municipalities. First institutional theory and institutional change will be deepened, with special attention for isomorphism within institutional change. When looking at isomorphism sub-question two “What does isomorphism look like in the public sector?” will be answered. After that theories related to politics explain the political spectrum and the role of politics within institutional theory. These concepts form the basis of the conceptual model that represents this specific context of institutional change within municipalities. The chapter concludes with the conceptual model.
3.1 Institutional theory
Since the institutional environment of municipalities is changing due to the care reform explained in the previous chapter, it is important to see what has been said about institutional theory and institutional change in the literature up until now. As mentioned by Scott (1987) “the beginning of wisdom in
approaching institutional theory is to recognize at the outset that there is not one but several variants”(p.1). The main streams of Institutional theory will be highlighted in this section, namely Old
Institutional Economics, New Institutional Sociology, New Institutional Economics and the perspective of formal and informal institutions of North (1990). Most streams of institutional theory define an institution in their own way, thus a lot of definitions exist concerning this concept. Taking a broad perspective, an institution refers to a formal set of rules (North, 1990) or more informal interaction sequences (North, 1990; Jepperson, 1991). But it can also refer to taken-for-granted assumptions (Meyer & Rowan, 1991) that are imposed on individuals and organizations (Abdul-Rahman, Abdul Latif, Muda & Abdullah, 2014).
3.1.1 Old Institutional Economics (OIE)
Central to OIE are institutions, and these institutions are formed via formal and informal habits, which can also be seen as rules and routines. Although there are many definitions and descriptions of an ‘institution’, a frequently used one within Old Institutional Economics (OIE) is the definition of Hamilton (1932) “a way of thought or action of some prevalence and permanence, which is embedded
in the habits of a group or the customs of a people”(p.84). Thus through creating and recreating of
established habits of thought and action institutions bring form and structure upon human activity (Burns and Scapens, 2000). These habits can take formal and informal forms “The formally recognized way in
which things should be done can be defined as rules” (Burns and Scapens, 2000, p.4). These rules can
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group or organization can be defined as routines, which are the “way in which things are actually done” (Burns and Scapens, 2000, p.4). These rules and routines differ between organizations. By looking at these different routines and rules within municipalities it might become clear how these organizations adapt to care reforms and if different rules and routines cause municipalities to adapt in different ways.
3.1.2 New Institutional Economics (NIE)
According to Abdul-Rahman et al. (2014) OIE is concerned with the assumption that individuals and organizations conform to norms, rules and regulations imposed by the institutional environment to secure their own positions. NIE improves this OIE view by broadening the scope. In the article of Abdul-Rahman et al. (2014) NIE is defined as: “an interdisciplinary enterprise combining economics, law,
organization theory, political science and anthropology to understand institutions of social, political and commercial life”(p.3). NIE thus captures the assumption that individuals and organizations conform
to norms, rules and regulations but it captures a broader environment than OIE.
3.1.3 New institutional Sociology (NIS)
According to Curruthers (1995) it is believed by new institutionalists that humans live in a world that is full of taken-for-granted assumptions and rules which are created through social construction. Most of people’s activities are done unconscious and unintentional because they are part of people’s routines. Within NIS the main focus lies on the assumption that organizational and human behavior can be explained by pressures of external institutions. These external institutions can be either formal, like governments, or informal, such as norms and values. Individual organizations conform their norms, processes and beliefs to these pressures from the external environment in order to be legitimate and receive support (Kondra & Hurst, 2009). Because organizations within the same field adapt to the same pressures, the structure, culture and output of these organizations will be very much alike and thus homogeneous. NIS thus gives an explanation to why organizations within fields are very homogeneous. This can be explained by the three main institutional forces, coercive isomorphism, normative isomorphism and mimetic isomorphism, which will be explained later.
3.1.4 Formal and informal institutions – North
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parties, firms and universities are both influenced by the institutional framework and influence how the framework evolves over time (North, 1990).
3.2 Institutional change
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3.2.1 Institutional change and Isomorphism
Isomorphism is an important concept within this topic because isomorphic pressures tend to cause organizations to adapt to institutional change in the same way. In this case, isomorphism would put pressure on municipalities to adapt to institutional change in similar ways as other municipalities. However differences in political ideologies might cause organizations to adapt to institutional change in different ways. Because both pressures are present within the care reforms of municipalities it is interesting to see the effect both pressures have on the way in which municipalities adapt. First however it will be explained what isomorphism exactly is and which types of isomorphism exist.
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According to Ashworth et al. (2009) Dimaggio & Powell (1983) made one major prediction, that organizations within the same field will, after a while, give in to the isomorphic pressures they are confronted with. Else, the level of support they receive from the external environment will be in danger. Isomorphism has however been researched mainly in the private sector at organizations and limited research has been done about isomorphism within the public sector. Caution must thus be taken when assuming that isomorphism is the same in the public and private sector, but looking at the situation of municipalities in the Netherlands, isomorphism appears to be present here as well. The report of Rob and Rfv (2005) mentioned that the central government has intervened more in the autonomy of municipalities in the past years. Thus since government intervention has increased over het past years, it would make sense that municipalities received more isomorphic pressures within their environment and that they would adapt accordingly. The presence of isomorphism within municipalities thus would make sense when looking at this situation. As is also mentioned by Ashworth et al. (2009) “An area of
increasing interest for researchers has been settings where there is evidence of competing institutional logics”(p.4). Within the setting described in section two, it could be that there are also two competing
institutional logics that have an influence on the policy that is formed by municipalities. On the one side there are the three kinds of isomorphic pressures from the environment to design policy in line with other municipalities, while on the other side there could be the influence of the political ideology of the local council to influence how municipalities design policy. Therefore the next section will investigate if politics can indeed have an influence on policy making and institutional change.
3.3 Politics
3.3.1 Political spectrum
Political ideology, as defined by Grafton & Permaloff (2005) is “an action-oriented model of people
and society”(p.1). In a lot of studies, the terms liberalism and conservatism or the terms right and left
are used. The terms left and right are however very abstract and simplistic concepts. Nowadays within the Netherlands, left can mostly be seen as social democratic, while right stands for a more liberalistic point of view. These two ideologies differ in their perception of how and when government intervention is needed in the economy (Grafton & Permaloff, 2005). Political parties on the left are in favor of a welfare state and parties on the right favor a private and liberal society. It is however not as black and white as is being suggested. Most political parties on the right do not want a completely capitalistic state with too little state intervention and most political parties on the left do not want unlimited government intervention. Political parties within the Netherlands can be placed somewhere along this continuum.
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ownership of production resources, and the role of the government versus a free market economy. Left oriented political parties or social democratic parties are in favor of interference and control in the economy from the government and they focus on diminishing economic inequality by dividing incomes (Franses, Eisinga & Scheepers, 1996). Right oriented or liberalistic political parties promote an open and free market economy with limited interference of the government, privatizing the industry and maintaining economic inequality (Eisinga et al., 1996). Political parties with a more moderate point of view can be placed at the center of this continuum, as well as a lot of the Christian political parties. Centered political parties often have a combination of left and right values also differing within political parties at the center. That makes it hard to assigning certain points of view to these parties. Christian political parties often favor strong social security and a more Keynesian economy, where interference of the government is necessary. Apart from that, moral issues play an important role, such as abortion. Within this spectrum political parties are placed along this continuum based on their policies and visions concerning care and not necessarily their overall political color. For example the PVV is quite a right-oriented political party because of their strong thoughts about immigrants, on the subject of care however they appear to be more left-oriented, therefore this party is placed more to the left than it would normally be.
The following political spectrum gives an overview of the largest Dutch political parties placed along this continuum of left- and right-oriented political parties. To summarize, the core norms values of left, Christian and right parties are represented as well (Mens en samenleving, 2015). Norms and values of centered parties are not explained because they are always a mix between some left and some right norms and values.
3.3.2 Politics and Institutional theory
As was mentioned above by North (1990), a change in formal institutions does not necessarily mean that informal institutions also change immediately. Thus differences can exist between municipalities where different informal institutions and political ideologies play a role. Therefore, it is interesting to look at the possible relationship between political ideology and institutional theory. Municipalities are chosen democratically and this could have consequences for their policies concerning care. As we saw
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in the research of Waldorff (2013) for example a conservative government would possibly use an approach that stresses that individuals bear the responsibility for their own health, while a more social democratic view would put more emphasis on the fact that the government is responsible for the health of its citizens. This implies that municipalities where the policy for care is formed by a more left-oriented political party could implement institutional changes in the care sector in a very different way than a more right-oriented party would do. Thus political ideology would then cause differences between the policies of municipalities concerning care. The relationship between politics and institutional theory could thus shed an interesting light on the care reforms currently taking place. Hereafter some literature already present about the relationship between politics and institutional theory is presented.
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hand city councils that are more ‘right’ and ‘individualistic’ would focus more on individual benefits and perhaps spend money otherwise by arranging customized care for everyone.
The above literature suggests that political ideology could play a significant role in determining public policy. Based on that, and combined with the information provided in section 3.4.1 some expectations can be formed on what influence political ideology could have on forming policy concerning the care reforms in the Netherlands. Municipalities with a more left-oriented local council would be expected to design their policy in accordance to these standards and thus design a policy where everyone deserves equally good care and support. Right-oriented local councils on the other side would be more individualistically focused and inequality is not necessarily seen as a bad thing. Therefore it can be expected that they design more customized care, differing from situation to situation. For Christian-oriented local councils it could be expected that they rely more on support of family and the own social network of people since supporting and helping people is often a central concept within religion.
3.4 Conceptual model
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Since the combination of isomorphism and political ideology has not been researched before still a lot of questions need to be answered. First, this research looks at institutional change and isomorphic pressures. Coercive isomorphism such as rules and regulations from the central government, influence from care providers and influence from health insurance agencies could all coerce municipalities to adapt to institutional change in similar ways because municipalities all experience the same pressures from these environmental factors. Three forms of mimetic isomorphism could play a role in these circumstances. First, municipalities could imitate care policies from neighborhood or regional municipalities. Second, municipalities could copy care policies from municipalities with similar political ideologies in their coalition and third, municipalities could imitate policies which are seen as successful from other, more innovative municipalities. Since municipalities copy or imitate policies concerning care when mimetic isomorphism is present, because of uncertainty in their environment, municipalities could look more alike because they use each other’s ideas. Normative isomorphism is caused by socialization through similar professions of professional groups such as political parties. This could also cause municipalities to look more alike, either because the people who design or implement policy are similar to each other because they have similar professions or because they hold the same norms and values based on their political ideology. Whether or not isomorphism in these three different forms will lead to uniformity amongst municipalities will be researched in the remainder of this thesis.
Second, this research also looks at institutional change and political ideological pressures within municipalities. As was mentioned in earlier sections of this chapter, based on previous literature, it seems that if municipalities differ in terms of political ideology they could also differ in their policies concerning care. More left-oriented municipalities could have a focus on equality and good quality for everyone, while more right-oriented municipalities could have a tendency towards care that is arranged more individualistically. However since research on this topic is scarce, this thesis will investigate if indeed political ideology can be seen in the care policy of a municipality and if differences in political ideology cause differences in the adaptation of institutional change between municipalities.
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4. METHODOLOGY
The aim of this research is to answer the main question: “How do municipalities adapt to institutional change from care reforms, when both isomorphic and political ideological pressures influence this adaption process?”. In order to answer this research question, qualitative research is the appropriate approach and more specific contextual qualitative research. Contextual qualitative research is namely concerned with identifying what is going on in the world around us and how things manifest themselves (Maruster & Gijsenberg, 2013). Questions aiming to uncover what is going on and how phenomena are occurring have also been labeled descriptive or exploratory methods by authors (Marshall & Rossman, 1999; Robson, 2002). These methods are very suitable for research fields that need to be explored further. Since this research is aiming to uncover how municipalities adapt to institutional change and the field of study concerning this topic still needs to be explored further, the qualitative research method is most suitable for this research. In-depth interviews are one of the most common methods to collect data used in qualitative research (Maruster & Gijsenberg, 2013) and are therefore the method by which data will be collected in this research.
4.1 Interview method
4.1.1 In-depth interviews
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the results are replicable. Interviews will be around 60 minutes long so that all questions relevant to this research can be asked in detail and respondents have enough time to give their opinion and their input.
4.1.2 Ideal number and size of municipalities
In total there are 393 municipalities in the Netherlands, however since there is a limited timeframe to conduct this research, the aim of this research is to interview nine municipalities. Of these nine municipalities ideally, three would be left-oriented, three right-oriented and three centered/Christian-oriented municipalities. By selecting three municipalities of every political direction the influence of political ideology can be investigated thoroughly. Within this selection of three municipalities per ideology favorably one municipality is small, one is medium sized and one municipality is large. Since small municipalities can have a very different approach than larger municipalities, the best way to give a good representation of the entire population of municipalities is to have some of every size. The basis on which municipalities are labelled small, medium or large is their number of inhabitants. Small municipalities have less than 50.000 inhabitants, medium municipalities have between 50.000 and 100.000 inhabitants and large municipalities have more than 100.000 inhabitants. By interviewing multiple municipalities the evidence is more definite (Herriott and Firestone, 1983) and comparisons can be made across municipalities.
4.1.3 Selecting respondents
Within municipalities the right person should be interviewed. To assure several perspectives on the care reform are captured and to prevent biased results, the aim is to interview two persons per municipality. The first person that should be interviewed is the responsible alderman. The alderman is selected because he can represent the political perspective of the municipality and thus questions concerning political ideologies can be answered properly. The second person should be someone who knows a lot about the transition and transformation of the Wmo, this can be a Wmo policy officer, a Wmo project leader, a Wmo coordinator or a Wmo consultant, depending on who are willing to participate and who are available. These people arrange the decentralization of the Wmo and help municipalities implement their policy. Therefore they have a lot of expertise concerning the reform currently taking place, which makes them a valuable asset to this research. In this research they will be called Wmo experts. In total the aim is thus to interview eighteen respondents, two per municipality and at nine different municipalities. Interviewing such a larger number of people at different organizations reduces the respondent bias, it also increases the chances that the results of the research can be generalized, which increases external validity.
4.1.4 Interview questions
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municipality concerning care was asked, followed by a question on how they experienced this transition. After that more specific questions about the budget and raisings taxes were asked. Second, questions on the implementation of these new responsibilities and how they handled this institutional change came along. The interviewee was questioned about the specific changes that the municipality had implemented, their specific starting points and about cooperation with other municipalities. The third category contained questions about the influence of political ideology in the municipality, here more in depth questions about the coalition and the influence of the political ideology on municipal policy were asked. The fourth and final section asked questions about influences from the external environment of municipalities. This contained questions about pressure from the government, citizens, health insurance companies and other external forces. The complete interview can be found in appendix A.
4.2 Data collection
4.2.1 Selecting the municipalities
The aim was to select nine municipalities who would participate in this study. These municipalities are selected, as mentioned above, based on their political ideology. To determine which municipalities should be selected for this research, first one of the research questions mentioned in section 3.4 must be answered. In order to select three municipalities of each political ideologies, left, Christian/centered or right, the question “What different political ideologies currently prevail in municipalities within the
Netherlands?” needs to be answered. To answer this question, the spread of political parties and
ideologies across municipalities in the Netherlands must be shown. Figure three shows the spread of the largest political parties in a municipality across the Netherlands. This gives a clear overview of which political party is the largest party in every municipality, but in figure three the municipalities are not divided into the four categories mentioned above, left, Christian, centered and right.
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Figure four now gives a clear overview of the spread of political ideologies across municipalities. Based on figure four, twelve municipalities were selected to participate in this study since the expectation was that not all municipalities would be willing to participate. The municipalities in table two were approached to take part in this research.
4.2.2 Actual number and size of municipalities.
Indeed not all municipalities were able or willing to participate in this study. If a municipality was not able to participate and there was still time left to approach another municipality, replacement was sought for that municipality. If there was no time to approach another municipality because of the limited timeframe of this study it was accepted that the research would have a municipality less than expected. The municipalities that were selected based on figure four and were willing and able to participate in this research are shown in table three. Because of the limited timeframe of this research and busy
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schedules of alderman and Wmo experts, in the end seven municipalities were able to participate. Table three also shows the people who participated in this research. Within most municipalities the alderman was interviewed, except for the municipality of Heerhugowaard, where only a Wmo expert was interviewed. In five out of seven municipalities a Wmo expert could also be interviewed and at two municipalities, Leeuwarden and Rijssen-Holten, the interview was held with both people at once. In the end, a total of nine interviews were thus conducted at seven different municipalities and a total of eleven people were interviewed during these nine interviews. Interviews took between 50 to 70 minutes, with one exception of 30 minutes and were as expected all held in similar surroundings.
1Municipalities that are bold-faced actually participated in the research
2 Interview with Leeuwarden and Rijssen-Holten was held with the alderman and Wmo expert at once.
4.3 Data analysis
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5. RESULTS
In this chapter the main results from the interviews will be presented. As was mentioned in section 4.2 the interview questions were divided into four categories. The results will be represented within three sections because the first two categories will be combined so there is one main section about the institutional change in general and then two more specific sections about the political influence and isomorphic influence. Apart from the three main categories other relevant data that was given by interviewees about a combination of isomorphic and political pressures is presented in the fourth section of this chapter. At the end of each section the results will be linked to the part of the conceptual model they represent. Presenting the results is done by illustrating quotes made by the interviewees about these relationships, which is as discussed above, a proper way to represent qualitative data.
5.1 Institutional change
This section gives an overview of how the municipalities that participated in this research adapted to the institutional change of the care sector, which forms the center of the conceptual model presented in section 3.4. First it will be explained how municipalities approached the old Wmo tasks that were already under their responsibility. Second the preparation of the new Wmo tasks is discussed and the third paragraph shows how municipalities approached these new Wmo tasks. In sum this shows how municipalities adapted to this institutional change. At the end of this section the results will be linked to the conceptual model of this research. Finally table four summarizes the interview results about this institutional change, when this is deemed relevant the political ideology of a municipality is indicated by the abbreviation (R) for right political coalitions, (L) for left political coalitions and (C) for centered political coalitions.
5.1.1 Approach for old Wmo tasks
The approach of municipalities concerning their old Wmo tasks is shown in the second row of table four. It shows similarities between the approaches of municipalities, how many municipalities adopted these responsibilities similarly and what differences there were in the approaches towards the old Wmo tasks. Since the Wmo first changed in 2007 all municipalities that were interviewed adapted to this institutional change by implementing a different way of working. Before, when someone requested care, the basis on which the indication of someone’s need for care took place was on the disability or limitation itself. For example Rijssen-Holten explained that “If someone missed a leg, they had a right to a
wheelchair and a standard amount of care, for example two hours”. Table four shows that this way of
working and thinking was shifted from solely looking at the disability to looking at the individual situation, abilities and network of that specific person. Rijssen-Holten said “Now we look at that
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have very different needs”. By looking at the individual situation, municipalities could take into account
what someone is still able to do himself, what the people in his network are able to do for him and adapt the care that is provided by the municipality to the specific needs of that person. Care is thus customized to the specific situation and needs of an individual person. Delivering care thus shifted from supply-based care provided by the central government, to demand-supply-based care provided by municipalities. The description that is used for this shift in ways of working throughout this research is the shift to ‘demand-based care’, the Dutch term is called ‘kanteling’. The core idea behind this demand-‘demand-based care is that care should be arranged as close to home as possible. Before the new Wmo 2015 was implemented, all municipalities thus already had adapted their way of working to working according to demand-based care for their old Wmo responsibilities. Leeuwarden explained “I think it was a huge advantage that we
had already adapted to this way of working in 2007…So a lot of people are acting like we are going to do something completely new, but we have been working this way since 2007 so for us these changes are not shocking”. As shown in table four, differences between municipalities however exist in the
moment at which this demand-based care was implemented. Some had already started working this way as early as 2007, while others switched to the new way of working in 2013. As the municipality of Dronten stated “the approach that is expected for the Wmo 2015 is fully in line with the approach we
already chose for the Wmo2007”.
5.1.2 Preparation of institutional change
This part explains how municipalities handled the preparation of the new Wmo tasks. The third and fourth row of figure four show how municipalities prepared for this institutional change and how they experienced this transition. First the similarities amongst preparation and experiences are show, followed by the number of municipalities that were similar and finally some differences in preparation and experiences with this change are shown. In relation to the preparation of the new Wmo tasks, the municipality of Hoogeveen explained that “Indeed we received a lot of new tasks and responsibilities,
but if you look at the Wmo we had the advantage that it was already decentralized and a new way of working was already in place. Of course it is not extremely easy to implement those new responsibilities, but it is relatively easier than with for example youth care”. The challenge here was to try to arrange
these new tasks and responsibilities in a similar way as was already done with the old Wmo tasks. But the preparation of implementing these new responsibilities was not extremely hard because of the fact that they already had some experience with this way of working in the old Wmo tasks. One of the most difficult parts of arranging the new Wmo tasks according to the demand-based care, was mapping the group of people that would fall under these new responsibilities. Since the responsibilities were completely new to municipalities they had no clear overview of how many people were in need of these types of care and who they were. Heerhugowaard explained that “Because of the poor administration
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sorted, we had no idea who would actually be our customers and how many people that would be”. This
problem is still not solved and municipalities are doing their best to solve this issue.
Table four shows that all municipalities had to cope with another challenge that played a significant role in the preparation of this institutional change, which was the fear and insecurities of citizens created by the media. Citizens had no clear idea about the changes they were awaiting and what this would mean for them. Therefore municipalities had to invest a lot of time and money in communicating to citizens and care suppliers what was going to change and what consequences this would have for them. Hoogezand-Sappemeer illustrates this by telling “I have been to several meetings with for example
elderly organizations where there was so much stress and fear amongst people … But as soon as we told them that yes, there will be a conversation in which we are going to look if we can provide care at a lower cost, but the fact that when care is necessary it will be provided won’t change. At that moment you would feel the audience become more calm”. All municipalities took a lot of measures to inform
people on forehand and to assure them that if indeed care was necessary that they would still receive the care they need. There are some differences amongst municipalities in how smooth this preparation and institutional change went. Tynaarlo for example stated that “since we started out strong by
communicating a lot with citizens and involving the right people from the field this change went quite smoothly”. While in Hoogezand-Sappemeer, despite their extensive communication and information
they did experience quite some fear and uncertainty from citizens.
Apart from the transition for citizens there were of course numerous changes in laws, regulations and policies which had to be handled with the entire local council, not only the coalition parties. Since there is a coalition and an opposition within the council some difficulties and political conflicts could be expected when choosing a certain approach. However in all municipalities there was no strong political battle within the local council. The local councils experienced this institutional change as a ‘common enemy’, which they should handle together. Hoogeveen illustrated this by saying “We as the coalition
cannot do this on our own, it is a joint undertaking so we need the help of the opposition and also the help of care suppliers”. Solutions should thus be sought with a lot of cooperation and they all felt that
it should be done in the right way for their citizens. Therefore the transition of laws and regulations was experienced as smooth by all municipalities as well. Of course there are some minor differences in the way people think things could be handled, however broadly speaking there was consensus within the local councils on the right approach to take. Leeuwarden also explained that “Because of our structure
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5.1.3 Approach for new Wmo tasks
Row five until fifteen of figure four show the interview results for the approaches of municipalities towards their new Wmo tasks. First the similarities about approaches for the new Wmo tasks are show, followed by the number of municipalities that were similar and finally some differences in approaches taken by municipalities are shown. When looking at the implementation of the new Wmo tasks a distinction must be made between the approaches for 2015 and 2016. In general most municipalities aim to implement this demand-based care and the approach of the old Wmo tasks for the new Wmo responsibilities as well. However since 2015 is the transition year, people who received care according to the laws in 2014 have transition rights up until July of 2015. Therefore implementing this shift can only take place partially in 2015. That is why Hoogezand-Sappemeer chose a different approach, they explained “For the year 2015 we are not going to change anything and with that we provide a continuity
arrangement for all citizens and care suppliers for the year 2015”. This means that care suppliers deliver
the same care they delivered in 2014, but at a lower cost and nothing will change for citizens in that year. Hoogezand-Sappemeer made this continuity arrangement in cooperation with a total of 22 municipalities in Groningen.
For 2016 table four shows that all municipalities aimed to complete the implementation of demand-based care and work according to that approach. This means that from 2016 on, in all municipalities that were interviewed, care needs of citizens will be indicated through individual conversations with each citizen that requested care. In Dutch these conversations are called ‘keukentafelgesprekken’. These individual conversations are meant to clarify the individual needs, abilities, network and situation of people, and based on that, customized care will be provided. Two main approaches can be distinguished in who performs the individual conversations. In four out of seven municipalities this is done by neighborhood teams or networks. Hoogezand-Sappemeer was one of those municipalities, they said
“We chose to do this with social teams within the neighborhoods in our municipality”. Leeuwarden is
slightly different because there these teams not only indicate but also provide some parts of the support. In two other municipalities indications for domestic help were outsourced to external bureaus and the remaining conversations are done by consultants. Hoogeveen explained this by saying “We hired an
external bureau to indicate the situations of people for domestic help because everyone had to receive a new indication, which concerned thousands of people, so we were not able to do that ourselves”.
Heerhugowaard was the exception since there they have a social square where people can ask questions or go to.
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quality is the number one priority, however the budget must be kept in mind as well. Municipalities thus differ in their focus on either budget or quality, however in general it can be said that both weigh quite heavily only there are minor differences in which one they put first. Some general starting points for every municipality are that people who need support should receive support, no one should fall between two stools, we must look at the individual situation and abilities of a person and one family, one plan. Differences exist on areas that receive extra attention. Rijssen-Holten for example stimulates church and sport associations to take more care of one another, while in Leeuwarden, Dronten and Heerhugowaard a special focus lies on prevention. Heerhugowaard also focusses on providing PGB (Dutch abbreviation for personally bound budget) instead of care in kind, “By providing more PGB instead of care in kind
we want to reach the goal of the Wmo that people receive more responsibility and are able to provide for themselves”. While Tynaarlo and Hoogeveen give extra attention to informal caregivers. Tynaarlo
mentioned “We pay special attention to informal caregivers, every year we take them out for a day so
that they have a nice day off. We also collect a lot of information from informal caregivers during that day so we can also improve our policies”.
Another very important concept in most municipalities mentioned in table four is integral working. This means that consultants of the Wmo work together with consultants of the other two fields, youth care and participation. Especially in multi-problem families this integral work is important because then citizens can work with one person to arrange everything instead of a different person for every problem. Rijssen-Holten explained that “Integral working is very important within the new Wmo … if there is a
multi-problem family they receive one director with whom they can communicate and arrange everything, if it is a singular problem they are assigned to the specialist consultant on that area”. There
is however a difference between municipalities in how far they have developed this integral working. Municipalities which have been working according to the demand-based care approach for a long time have developed this integral working more than municipalities where this demand-based care was implemented later on.
Municipalities also stimulate that care is arranged in general facilities wherever that is possible. Arranging care in general facilities is a lot cheaper than providing everyone with care from a professional. Hoogezand-Sappemeer gave the example of Humanitas, “Humanitas is a voluntary
organization that supports people with administrative duties. By providing citizens with help from Humanitas instead of an expensive professional, a lot of costs can be saved since this is much cheaper but still good quality service”. These approaches are in general implemented in all municipalities that
were interviewed and only minor differences exist on execution.
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contains on average two to six municipalities. Leeuwarden is the exception here because they cooperate with and act as the center-municipality for the entire province on a lot of subjects and Rijssen-Holten cooperates with quite a large group of fourteen regional municipalities. Cooperation with social institutions is done in a general way, all municipalities cooperate with a large group of care suppliers.
Finally the results in table four concerning the budget show there is one general approach in all municipalities. The budget they receive from the central government is the budget they want to stick to. If however the budget is too tight they either use money from the two other decentralizations, use extra money from reserves or savings put aside for this transformation, or will complain with the central government. Raising extra taxes is not an option so they must cut the costs where they can, but municipalities will always continue delivering care, even when that means crossing the budget. Leeuwarden illustrated this by saying “It will never be the case that if in November the budget has been
used completely, and someone needs support in December that we do not provide care. On the contrary, we will always provide care, if that means crossing the budget then so be it”.
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5.2 Influence of political ideology
This section explains the influence of political ideologies on the adaptation to institutional change. It summarizes the results that were generated from the questions concerning political ideology during the interviews. And with these results the influence of the left side of the conceptual model will be investigated. Table five gives a summary of the answers provided by the municipalities on these questions. The first column of the table shows the subject of the questions followed by the similarities between municipalities on that subject. After that some differences are shown between municipalities concerning their answers about the influence of their political ideology on policy making and the adaptation to institutional change. The last row shows what political ideology prevails in the coalition of every local council.
5.2.1 Similarities between municipalities
Most interviewees agree on one thing and that is that no matter which municipality is asked, within the local council there is agreement on the course of action and the approach that is chosen by the coalition as can be seen in table five. This transformation is seen by municipalities as the responsibility of the whole local council and not just the coalition. With a local council every decision has to be made with a majority of the votes. With the implementation of this care reform, municipalities do however not only try to get the majority of the votes but involve the opposition in such a way and inform them thoroughly so that most decisions can be made unanimously or almost unanimously. Dronten explained this by stating “Because we involved the opposition in our approach right from the start as well, the approach
towards care is felt as a common approach, which is supported by everyone within the local council and not just as the approach of the coalition”.
Apart from engaging the opposition in the decision process, another explanation of this is that the differences between political parties are not very big on this subject, everyone agrees on the fact that good results are essential and that this needs to be done through customization. Dronten supported this by saying “This vision is not bound to a specific political party, it is the red wire that runs through the
entire transition. Of course a political party like the VVD would put more of an accent on staying within the budget, but in the end those differences are just about nuances and not about major differences in opinions about the course of action”. Hoogeveen also supports this by telling “If you look at the different political ideologies in Hoogeveen, there is not that much of a differences between these political parties on how they think the Wmo transformation should be approached”. The municipalities in this research
