Strategy and practices. A qualitative study of a Brazilian public healthcare system of telemedicine

• DOI: https://doi.org/10.1108/IJPSM-12-2016-0207
• Published date: 09 April 2018
• Date: 09 April 2018
• Pages: 347-371
• Author: Paulo Alberto Battazza Iasbech,Rosalia Aldraci Barbosa Lavarda
• Subject Matter: Public policy & environmental management,Politics,Public adminstration & management

Strategy and practices

A qualitative study of a Brazilian public

healthcare system of telemedicine

Paulo Alberto Battazza Iasbech

Curso de Doutorado em Administração de Empresas –CDAE,

Fundacao Getulio Vargas Escola de Administracao de Empresas de Sao Paulo,

Sao Paulo, Brazil and

Programa de Pós Graduação em Administração –PPGA,

Universidade Federal de Santa Catarina, Florianopolis, Brazil, and

Rosalia Aldraci Barbosa Lavarda

Programa de Pós Graduação em Administração –PPGA,

Universidade Federal de Santa Catarina, Florianópolis, Brazil

Abstract

Purpose –In analyzing the field of strategic management in public organizations, scholars have noted

a lack of studies that investigate how public organizations actually apply strategic management tools

(Hansen, 2011) as well as studies that investigate how strategic knowledge is developed and used in practice

in public organizations (Bryson et al., 2010). Voicing similar concerns, the 2013 World Health Report pointed

out the challenges facing many governments in providing universal health coverage and the importance of

conducting new studies that focus on practical approaches using the existing knowledge rather than only

investing in research related to new technologies. The purpose of this paper is to analyze how Telemedicine

System of Santa Catarina (TSSC)’s strategy has resulted in significant improvements as seen through the lens

of structuration theory (ST).

Design/methodology/approach –The authors support the analysis using the strategy as practice (SAP)

framework of practice, praxis and practitioners and the ST of Giddens (1984), using Orlikowski’s (2000)

technology in practice framework. The authors have applied a qualitative methodology using a single case

study which analyzes a healthcare system that has resulted from a successful cooperation agreement between

two public organizations in Brazil. This research is based on the analysis and identification of the structural

aspects (interpretative schemes, facilities, norms and stock of knowledge) that are enacted by the practitioners

through their practices and praxis.

Findings –The authors have identified five strategic practitioners that perform six strategic practices and

praxis, and have analyzed the structures they enact during their praxis. The authors have also identified

the interpretative schemes, norms and facilities that motivate these social practices and how they influence

the results of the TSSC.

Research limitations/implications –As limitations of this study, the authors highlight the focus given

to the service provider practitioners, leaving aside the political practitioners and patients. The researcher

perception and possible biases must be considered also as a limitation, despite of the efforts to minimize

them with the rigor of the methodology and the use of mixed data collection techniques to enable data

triangulation.

Practical implications –This research contributes to a better understanding of the benefits that the

practice perspective offers and provides insights into the possible management cooperation between

institutions. It also provides substantial evidence of the relationship between SAP and ST as it contributes to

the reinforcement of empirical studies using ST. In addition to academic advances, this study contributes to

the field by highlighting how the relationship between practices, praxis, practitioners and the existing

structures has positively influenced the results of a public healthcare system and by presenting a successful

initiative that has helped to improve the public healthcare system.

Originality/value –The authors believe that this paper will contribute to the field by highlighting how the

relationship between practices, praxis, practitioners and existing structures has positively influenced the

results of a public healthcare system and the roles played by the human agents involved.

Keywords Telemedicine, Qualitative research, Strategy as practice, Healthcare public cooperation,

Structuration theory

Paper type Research paper

International Journal of Public

Sector Management

Vol. 31 No. 3, 2018

pp. 347-371

© Emerald PublishingLimited

0951-3558

DOI 10.1108/IJPSM-12-2016-0207

Received 29 December 2016

Revised 24 April 2017

16 July 2017

Accepted 7 August 2017

The current issue and full text archive of this journal is available on Emerald Insight at:

www.emeraldinsight.com/0951-3558.htm

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Strategy and

practices

1. Introduction

Ever since Whittington’s (1996) seminal article “Strategy as practice,”several studies have

shared the understanding that strategy is a situated and socially acquired activity based on

the interaction between different agents and micro-activities carried out by people within an

organization( Jarzabkowski,2005, 2010; Whittington, 2006;Johnson et al., 2007; Lavarda et al.,

2011; Andersen, 2013). This practice perspective has also begun to influence other fields of

study, such as information systems (Brown and Duguid, 2000; Orlikowski, 2000; Hayes and

Walsham, 2001; Pozzebon and Pinsonneault, 2005; Von Krogh et al.,2 012; Whittington, 2014).

As organizations look for new modes of production and value creation to overcome

problems and difficulties that old systems are facing, organizational researchers are

increasingly observing new initiatives that might offer a step forward in the direction of a

solution to the new challenges of this generation.

In analyzing the field of strategic management in public organizations, scholars have

noted a lack of studies that investigate how public organizations actually apply strategic

management tools (Hansen, 2011) as well as studies that investigate how strategic

knowledge is developed and used in practice in public organizations (Bryson et al., 2010).

According to Bryson et al. (2009), most studies end up focusing on strategic planning and do

not take the fundamental issue of linking processes with institutional contexts very

seriously. Since performative aspects are what we observe: “real actions, by real people, in

specific times and places”(Bryson et al., 2009), or in other words, they involve behaviors and

actions that are determined by both individual human agency and structural/institutional

forces (Bryson et al., 2010). In addition, strategic choices are made by individuals and groups

who are embedded in social structures, which are reproduced and shaped by the actions of

individuals and groups across time and space ( Jarzabkowski, 2008). In some cases, middle

managers play a crucial role in promoting user acceptance and team commitment during the

process of change, which behaviors perceived to achieve success (George et al., 2017).

One of the main messages from the 2013 World Health Report on universal health

coverage was that many countries face challenges when trying to expand their health

services with limited resources. Therefore, it also highlighted the importance of conducting

new studies focused on practical approaches using the existing knowledge rather than only

investing in research related to new technologies.

The Brazilian Government faces a daunting challenge in providing public health services

for its entire population due to the country’s continental dimensions and social inequalities,

demographic complexity and political and financial situations (Paim et al., 2011). A special

issue of The Lancet journal was published in 2011 to highlight these challenges and discuss

them. Entitled “Health in Brazil,”this special issue contained the following six papers, which

were intended to provide an overview of Brazilian health achievements and challenges:

Paim et al. (2011), Victora, Aquino, do Carmo Leal, Monteiro, Barros and Szwarcwald (2011),

Barreto et al., 2011; Schmidt et al., 2011; Reichenheim et al. (2011) and Victora, Barreto,

do Carmo Leal, Monteiro, Schmidt, Paim and Reichenheim (2011).

Although it appears that the Brazilian healthcare system has been improving, recent

reports have shown that the results have not been as encouraging as expected. There is

evidence that long-standing problems in the Brazilian healthcare system have been

exacerbated by economic and political crises, including a lack of infrastructure, medical

supplies, basic medical accessories and equipment (Watts, 2016). New public health

problems such as the Zika virus during the 2016 Olympic Games (Petersen et al., 2016) have

also made the health situation during economic and political crises more difficult, which has

thus resulted in poor health services for the population, which in turn has sought to redress

this situation through the courts (Alves et al., 2016). This underlines the need to reopen a

discussion of the government’s role in guaranteeing every citizen’s right to healthcare, as

well as its operating and funding model (Oliveira Santos and Alves, 2016).

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