Institutional field-level change in post-Soviet contexts: logic elaboration in primary care restructuring

Abstract

This thesis examines the evolution of the healthcare field in two countries, Estonia and Lithuania, using an institutional theory perspective and focusing specifically on institutional logics. The study finds that institutional change does not only occur through a shift in dominant logics, as the current literature suggests, but it can also occur through the elaboration of existing logics. Logic elaboration is a process of reconstruction of role-identities, organisational forms, governance structures, and practices and their gradual incorporation into the existing logic. This research shows that logic elaboration may unfold as a process of grafting or appending, depending on specific societal and field-level factors. Societal level factors relate to the flexibility to accept plurality and the ability to synthesise conflicts in a particular societal context. Field level factors relate to the legitimacy of theorisers within a given field and society, the concentration of theorisers in a field and their ability to channel resources and maintain high commitment, and the socialisation of practitioners to the new role-identity. This research makes several contributions to institutional theory. First, it introduces and develops the concept of logic elaboration. Second, it expands our understanding of logics as toolkits, whose elements can be variably combined in a field. Third, it identifies key contextual factors that shape or impact upon the trajectory of change toward logic elaboration. Key words: logic elaboration, institutional logics, institutional theory, institutional change, institutional field, health systems, health reforms, primary care, family medicine, transition countries, Estonia, Lithuania.