Leaders must explore bureaucratic notions of health-care delivery in a turbulent environment

Editor’s note: This article is part of a monthly series on leadership in health care from CHLNet, which represents more than 40 health organizations.

This month’s Top Three focuses on the public administration of health care as contained within the Canada Health Act and the role of leadership in critically examining our delivery models in light of current social demands. Canada relies primarily on large health-service delivery organizations – provincially regionalized into one organization as in Alberta, Saskatchewan and Nova Scotia; or as six publicly administered regional health authorities in B.C., five in Manitoba, two in New Brunswick, four in Newfoundland, one in P.E.I.; in Quebec and Ontario, it is less centralized but moving toward larger delivery models (i.e., Ontario Health Teams).

The public administration criterion of the Canada Health Act relates to the administration of provincial/territorial health-care insurance plans for medically necessary health-care services. The intent is to prevent private health insurance plans from competing with publicly administered plans. The public administration requirement stipulates that provincial/territorial health-care insurance plans must be administered by a public agency on a not-for-profit basis. Yet, it is equally important to understand clearly what the public administration principle of the Canada Health Act does not mean. This principle refers to the administration of health-care insurance coverage; it is agnostic as it relates to the delivery of publicly insured health services. Yet, most of the models or organizational designs have embraced bureaucratic notions: an administrative policy-making group characterized by specialization of functions, adherence to fixed rules and a hierarchy of authority.

This Top 3 profiles articles that explore the wisdom of health-service delivery via bureaucracies. Some recent literature suggests that recent events in society – what has been termed a VUCA environment (volatile, uncertain, complex and ambiguous context for health-service delivery) –demand a critical look at our models of health-system administration and service delivery and their suitability in such an uncertain leadership environment. Health-care leaders must work within an organizational context, but also on that organizational context if it does not enhance the ability to deliver insured health services more efficiently and more equitably, in the spirit of people-centred care.

The three articles contribute to this discourse in the following ways:

Article 1 discusses bureaucracy with respect to the popular notion of distributed leadership and examines the relationship between the two. The author argues that bureaucracy, as a way of organizing health service delivery, is still robust as a “means of shaping and containing power in a way that is sophisticated.”

Article 2 looks at the impact of COVID 19 in terms of what the authors call “turbulent problems” arising in a VUCA environment. It specifically outlines the consequences of the new focus on robust governance for public administration and leadership.

Article 3 outlines alternative ways to organize health-service delivery, in keeping with the notion of offering employee “emancipation” and “autonomy.” It explores ideal organizational forms that suggest delivery models other than traditional bureaucratic organizational approaches. The author makes the claim that some of these approaches are “especially viable in industries where interdependence between units is low”; which may – or may not – reflect the ideal health-delivery system of the future.

A review of these three articles is interesting because it enables us – as leaders – to explore ways of organizing and delivering services.


Article 1: Distributed leadership and bureaucracy. Educational Management Administration & Leadership.

This article discusses organization design in the context of the education sector of public administration. It considers distributed leadership in the context of post-bureaucratic organizations.

The author suggests that both distributed leadership and bureaucracy are ideal types. He outlines the development of bureaucracy as an organizational form and challenges its often-stereotypical criticisms. He explores the notion that bureaucracy is conceived as a means of shaping and containing power in a way that is sophisticated and has developed considerably since Weber’s original idea.

The article also outlines the development of distributed leadership and critiques the assertion that it offers a means of redistributing power, arguing there is little evidence that this happens in any reliable way. His conclusion is that bureaucracy offers a more realistic and deeper engagement with issues of power, and that its rejection, except as a butt of criticism, deliberately ignores an enduring and important aspect of leading organizations. Finally, he postulates that educational leaders need to engage positively with bureaucracy if they are to transform education.

Article 2: The COVID-19 pandemic as a game-changer for public administration and leadership? The need for robust governance responses to turbulent problems. Public Management Review.

The pandemic has revealed that the public sector is not only facing simple and complex problems, but also turbulent problems characterized by the emergence of inconsistent, unpredictable, and uncertain events. Turbulent problems call for robust governance solutions that are sufficiently adaptable, agile, and pragmatic to uphold a particular goal or function in the face of continuous disruptions.

This article defines the concepts of turbulence and robustness and provides examples of robust governance strategies that are illustrated by the COVID-19 response. Finally, it draws the consequences of the focus on robust governance for public administration and leadership, which directly relate to our leadership practices within bureaucratic organizational models to adapt and adjust organizational design to respond to the challenges of a VUCA environment.

Article 3: What makes self-managing organizations novel? Comparing how Weberian bureaucracy, Mintzberg’s adhocracy, and self-organizing solve six fundamental problems of organizing. Journal of Organization Design.

The bureaucratic organizational structure has been challenged by a number of organizations that claim to offer employee emancipation and autonomy through self-management, self-organizing, or “holacracy.”

The author examines self-organizing organizations as a type of organizational form, comparing it to two more established organizational forms, Weberian bureaucracy and Mintzberg’s adhocracy.

More particularly, he uses a framework of six fundamental problems of organizing – task division, task allocation, rewarding desired behaviour, eliminating freeriding, providing direction and ensuring coordination – to demonstrate how these three forms of organizing have found different solutions.

In the author’s view, the radically decentralized model of authority at the heart of self-managing is shown to lead to solutions to these problems that are based on peer-based accountability and rewarding, transparency of key information, and bottom-up emergent processes where employees have the authority and responsibility to identify necessary tasks and ensure that they get done. It is concluded that the self-managing organization indeed is a novel form of organizing that can better explain certain real-life organizational outliers than the existing paradigms of organizing. It is argued to be especially viable in industries where interdependence between units is low, outputs are highly tailored, and employee expertise and motivation are high.


The three articles suggest health leaders explore our public administration organizational models of service delivery, and potentially challenge our predisposition to accept current – bureaucratic – models as a given. The three articles also provide the opportunity to apply the “system thinking and critical thinking” capability to organizational designs we may need as we move forward. Organizational designs that may well imbue many of the characteristics of bureaucracy but also embrace some of the notions of self-organization so we can react more effectively in a turbulent environment and provide the people-centred care so desperately needed.

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Graham Dickson


Graham Dickson (PhD) is a professor emeritus of leadership studies at Royal Roads University; a principal in LEADS Global; and the Research Advisor to the Canadian Health Leadership Network, a role that stimulates sharing of articles relative to the practices of modern health leadership in Canada and abroad.

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