title: A structuration framework for bridging the macro-micro divide in health-care governance.
abstract: Extant studies demonstrate that macro (hierarchical) and micro (relational) governance initiatives in health-care settings continue to be developed in isolation rather than interactively. Government-driven hierarchical governance endeavours that guide health-care reforms and medical practice are disconnected from micro-level physician-patient interactions being unable to account for patient preferences in the macro-level policymaking.
  
  
  
  We undertake a review of the recent literature to couch our argument for a unified governance framework for bridging the macro-micro divide in medical contexts. Adopting an interdisciplinary approach to health-care delivery, we maintain that the (strong) structuration theory provides a fruitful opportunity for narrowing the gap between hierarchical and relational governance.
  
  
  
  Emphasizing the coexistence of institutional structures and human agency, the (strong) structuration theory elucidates how macro and micro governance devices shape each other's structure via mutually reinforcing cycles of influence. Micro-level encounters between patients and physicians give rise to social structures that constitute the constraining and enabling forces through which macro-level health-care infrastructures are altered and reproduced over time. Permitting to illustrate how patients' agency can effectively emerge from complex networks of clinical trajectories, the advanced structuration framework for macro-micro governance integration avoids the extremes of paternalism and autonomy through a balanced consideration of professional judgement and patient preferences.
  
  
  
  The macro-micro integration of governance efforts is a critical issue in both high-income states, where medical institutions attempt to deploy substantial realignment efforts, and developing nations, which are lagging behind due to leadership weaknesses and lower levels of governmental investment. A key priority for regulators is the identification of relevant systems to support this holistic governance by providing clinicians with needed resources for focusing on patient advocacy and installing enabling mechanisms for incorporating patients' inputs in health-care reforms and policymaking.
authors.affiliation: School of Business Administration, American University of Sharjah, P.O. Box 26666, Sharjah, United Arab Emirates.
authors.forename: Virginia
authors.initials: V
authors.lastname: Bodolica
authors.affiliation: School of Business Administration, American University of Sharjah, P.O. Box 26666, Sharjah, United Arab Emirates.
authors.forename: Martin
authors.initials: M
authors.lastname: Spraggon
authors.affiliation: National Health Insurance Company, MD 2005 Chisinau, Republic of Moldova.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Tofan
mesh_terms: D054976:Clinical Governance; D003254:Consumer Advocacy; D003695:Delivery of Health Care / Q000458:organization & administration*; D006291:Health Policy; D006801:Humans; D026684:Personal Autonomy
keywords: Hierarchical governance; macro-micro integration; patient involvement; relational governance; structuration and strong structuration theories