Trajectories of value generation and capturing by public-private hybrids: mechanisms of multi-level governance in healthcare

Our paper unpacks the multi-level process through which hybrids generate value in the long term. By combining interviews, archival and survey data, we examine the longitudinal trajectories of value generation of public-private hybrids (PPHs) established in the regionalized Italian healthcare system (1992-2018). We identify three ideal-type trajectories: a) long-term value generation by stable PPHs; b) long-term value generation by transient PPHs; and c) interrupted value generation by terminated PPHs. We uncover how these trajectories are shaped by the interplay between regional governance arrangements – i.e., institutionally embedded norms regarding who is entitled to generate value for the field, the scope for organizational value capturing and the institutional monitoring system – and organizational governance mechanisms – i.e., the strategic orientation of individual PPHs and their internal monitoring functions. Our paper contributes to theory by conceptualizing the mechanism of “double filter”, which we define as the set of field- and organizational-level governance compensatory mechanisms that, together, allow long-term value generation by hybrids. We also problematize the relationship between hybrids’ value-generation capacities and the persistence of hybrid organizational forms, and ultimately trace it to different field governance arrangements. In so doing, we conceptualize “transient hybrids” as a distinctive organizational form for long-term value generation.