What matters in the local adaptation of Western social innovation to China: deep core beliefs, institutional boundary conditions or managerial practices?

Abstract

The article tests three contextual factors, including institutional boundary conditions, core beliefs and professional managerial practices, to analyse the local adaption of a Western social innovation to China. With a case study of 23 semi-structured interviews of stakeholders in China and the Netherlands and content analysis of these data, the article aims to examine the facilitating and hindering effects of institutional isomorphism on transnational social-innovation diffusion. The results indicate that social innovations face diverse pressures of isomorphism that necessitate their capitulation to homogeneity within the environment. Some isomorphic processes within the organization, however, may counterbalance external pressures in the long run. This article contributes to a better understanding of the transnational diffusion of social innovation between two different institutional and cultural settings.

Keywords:

• Social innovation
• transnational diffusion
• elderly care
• China
• diffusion

1. Introduction

The transnational diffusion of innovations allows different countries to learn about the problems and solutions from others and, at least theoretically, allows them to adopt new successful ideas, policies and practices. Innovations, often defined to be ideas, policies or practices that are new to its adopters (Rogers 1983; Berry and Berry 1999), may sound transferrable, but – as famously noted by Lijphart (1977) – foreign models are not universally applicable to other contexts. National contexts ‘enable’ or ‘disable’ the intended mechanisms of change as Pawson and Tilley (1997, 70) suggest, and adoption into a new environment requires adjusting to local conditions and preferences. This is particularly true for social innovations sparking social action by bringing about new ideas, models or practices that fuel collaboration among relevant stakeholders and address societal needs (Voorberg, Bekkers, and Tummers 2015). This inclusiveness and relation to societal needs makes social innovation particularly prone to adjustments to local conditions and preferences. Therefore, criticism that calls for innovations to be seen as more than just outcomes of their diffusion process (Dobbin, Simmons, and Garrett 2007; Gilardi 2016) seems relevant, especially regarding social innovations. Although localization or ‘indigenization’ of innovations is frequently called upon (Stone 2012, 489), very few studies attempt to assess innovation diffusion empirically. Those that do cover one country or region (e.g. Berry and Berry 1999; Jans et al. 2015; Ma 2013; Sugiyama 2008; Walker 2006), whereas the field of transnational diffusion of innovation remains under-researched. This article fills such a void by analysing the diffusion of an example of social innovation from Western Europe to Asia: We analyse the transnational diffusion and localization of a successful organizational model in elderly home-care services from the Netherlands to China and illustrate a case of Western social innovation aiming to spark social change by cultivating new ideas and proposing alternatives in rapidly ageing China (Osborne and Brown 2011; Sørensen and Torfing 2011; 2012; 2017). The particular example also illustrates how such social innovations adapt into new contexts as they enter a new political, organizational and cultural environment. To explore our research question – ‘Which factors facilitate and/or hinder the transnational diffusion of Western social innovations to China?’ – the article draws on classic work on institutionalism to study how social innovations evolve in new environments and how contextual factors enable or disable the transnational diffusion process. It combines the classical work on organizational sociology with seminal insights from political science on the role of core belief systems as well as on public-management literature to detangle and analyse institutional, organizational and cultural factors affecting the transnational diffusion of social innovation. Derived from key-actor interviews and document analysis, the article shows transnational diffusion between two considerably different institutional and cultural contexts and is valuable in understanding the processes that occur during the localization process. The social innovation analysed faced pressures that necessitated it to yield to homogeneity within the environment it was adapting to. It was however also found that the isomorphic processes within the organizations could counterbalance some of the external pressures. In this way, the article provides a substantial empirical account of transnational diffusion of Western social innovation to China and adds to the scholarly understanding of diffusion between affluent European countries to the evolving Asian continent.

2. Purpose: understanding social-innovation diffusion and localisation

Citizens’ growing demands and mounting public concern regarding the financial sustainability of public institutions have created a vacuum for innovative public policies and management. In these vacuums, innovations are expected to increase the productivity and effectiveness of public policy, the quality of services and the problem-solving capacity of the public sector. Yet, understanding the local adjustment of social innovations remains limited to theoretical accounts (Benson and Jordan 2011; Dolowitz and Marsh 2000; James and Lodge 2003; Marsh and Evans 2012; Stone 2012), and it lacks empirical grounding (e.g. Hartley, Sørensen, and Torfing 2013; Osborne and Brown 2005; 2011). Most studies examine the transnational diffusion of innovations as happening from one administrative system to another, most frequently between neighbouring countries and regions sharing similar administrative, political or cultural traditions (Dolowitz and Marsh 2000; Obinger, Schmitt, and Starke 2013). These studies suggest that differences in ideology, social norms and values, and inherent political, economic and cultural settings – stemming from different historical legacies, economic conditions and administrative realities – determine the success of the import of innovations from one context to another. The diffusion of innovations from one context to another is most likely to occur between countries with similar institutional and cultural contexts, for instance between Anglo-American countries (Dolowitz and Marsh 2000; Hall 1993), and within similar regions, e.g. the Nordic countries (Kvist and Greve 2011) or Latin America (Weyland 2005), or between neighbouring countries or countries in otherwise close geographic proximity. Very few studies have analysed transnational policy diffusion between different administrative contexts. The notable exception to this is research focusing on the import of New Public Management ideas (Common 1998; Manning 2001; Cheung 2005). Most of this research finds Western models poorly transferred (or translated) to Asia, Latin America and Africa. Béland et al. (2018) and Betz and Neff (2017), on the other hand, have recently found a smooth adoption of Western-based social programs in Ghana, the Philippines and South Asia. Yet, these studies focus on cases where international actors have a powerful influence on the diffusion process. What is lacking is a better understanding of the contextual influences – institutional and cultural – through which transnational diffusion processes occur, and of how social innovations are facilitated or hindered in cases of diffusion between considerably different contexts. We attempt to fill the gap by exploring the transnational diffusion process of social innovation, and by exploring a case of how social innovations are merged into a local context and diffused into an existing set of social relationships (see also Meier, Rutherford, and Avellaneda 2017; Pawson, Tilley, and Tilley 1997). Through this exploration, we can study the parallel, sometimes contradictory, institutional forces in the local adoption process of a social innovation.

2.1. Institutional boundary conditions

This article draws on the classics of institutionalism to advance our knowledge of structural factors and the role of institutions and organizations shaping social innovations. DiMaggio and Powell’s (1983) influential work suggests that institutional entities, like organizations, become uniform through isomorphic processes: same sets of environmental conditions and pressures lead to homogeneity in structure, culture and output (1983, 147). Following on this thought, organizations in the same line of business, or new innovations brought to a new context, will converge with existing contexts over time (1983, 148). In their popular term, isomorphism, this conformity occurs through three mechanisms of institutional isomorphic change: specific, obligatory rules and regulations (coercive isomorphism), copying and mimicking (mimetic isomorphism), or the adoption of specific values and norms pushed by relevant peers and professional organizations (normative isomorphism). The same fundamental claim of institutional forces in homogenization was made by Tolbert and Zucker (1983) who analysed the diffusion and institutionalization of change in formal organizational structures. Their conclusion was that the success of innovations is determined by the extent to which they are institutionalized.

The specific political-administrative context of China is one of strong coercive isomorphism, using Powell and DiMaggio’s terms. Public policy and administration in China are characterized (Worthley 1984; Chan and Chow 2007; Wu, Ma, and Yang 2013) as possessing the stringent cleavage between responsiveness and political control of the Communist Party of China (CPC). The opening of Chinese economy from 1978 onwards has created some room for innovative ideas outside of central-government bureaucracy (van Gerven and Yang 2017; Glaser and Medeiros 2007; Mertha 2009). For instance, the government has let in non-profit and for-profit partners to social-service production (Jing and Gong 2012; Zhao, Wu, and Tao 2016; Jing et al. 2021). Osborne and Brown (2005) suggest that environmental challenges foster social innovation. Public-sector challenges often stem from public performance deficits, lacking efficiency and/or ineffectiveness of policies. (Repeated) public-sector failures drive policy learning and a necessity to innovate. In the case of China, one of the most rapidly ageing countries in the world, the state has a strong role in steering the society and supporting innovations that can help alleviate the pressures of an aged society (van Gerven 2019). Yet, for transferring Western social innovations, the political-administrative environment in China can be challenging. Rothstein (2015, 533) suggests that China lacks the rule-of-law-based, apolitical, predictable and objective public administration that is the basis of Weberian bureaucracy in the Western world. In this Chinese ‘administrative particularism’, local governments are responsible for delivering public welfare and have some autonomy in public management (Chan and Chow 2007), but they follow command-and-control policies from the central government. In addition, having connections or ‘relationships’ in China is key to the success of any organization in China, and successful innovations must be embedded in networks of friendly relationships of guanxi (关系). Interacting with people within existing networks can provide organizations with much trust and social capital, but guanxi also plays a part in China’s challenges with corruption, nepotism and comradeship (Chan and Chow 2007). The innovation environment is challenged by Laoban (老板/闆) traditions, stringent hierarchical relations within the society that subject local bureaucrats and professionals to following directives from above. As for diffusion into China, the literature suggests a strong dominance of state in policymaking (coercive isomorphic processes) that is likely to hamper the diffusion of Western social innovation. Following the logic of Powell and DiMaggio (1991), the more dependent an organization is on another organization (e.g. central government) – and the more resources and supplies are centralized – the more it resembles the organization upon which it is dependent.

Chinese particularism, however, can also foster the diffusion of novel ideas and policies. Instead of the enactment of a law, like in the West, social innovations in China commonly begin with a phase of regional experiments. The central government orders certain cities to try out new policies, and after evaluating the economic benefits and political risks of these local experiments, it may promote or terminate the project (Zhu 2014). Successful projects, at least in the eyes of the central government, can be reasonably quickly diffused throughout China and across different sectors (Wu, Ma, and Yang 2013; Zhang and Zhu 2019). Therefore, the strong dominance of state in policymaking (coercive isomorphic processes) can also foster the diffusion of Western social innovation.

2.2. Belief systems and (deep) core beliefs

The second mechanism of institutional isomorphism emphasizes the role of existing norms and paradigms. Organizations often exist in environments with many uncertainties, and that is certainly the case for Western operators in China. DiMaggio and Powell suggest that uncertainty encourages imitation (mimetic isomorphism), and especially in an environment with ambiguous goals, organizations tend to model themselves after other organizations (under mimetic isomorphism p. 151). In China, the freedom of action and new ideas is limited as the CPC continues to balance between inclusive governance and political control. Therefore, to legitimize themselves and cope with uncertainty, transnational innovations may need to mimic national innovations.

Strong norms are also the basis of the Advocacy Coalition Framework (ACF) which explains how beliefs turn into action in complex policymaking systems. Sabatier’s (1988) concept of belief systems ‘consisting of a set of basic values, causal assumptions or problem perceptions which the members of the society share’ (Sabatier and Jenkins-Smith 1993, 25) enables actors to form advocacy coalitions that compete with others. The belief systems range from the most general ‘deep core’ beliefs to the most specific ‘deep core’ beliefs that comprise an individual’s fundamental beliefs about basic social norms and values (Sabatier and Jenkins-Smith 1993). Although the ACF sketches belief systems as relatively stable and resistant to change, it also contains a vision for change. Policy actors sharing similar deep core beliefs can transform their core beliefs into actual policy or practice (Sabatier 1988). A similar understanding of the power of ideas and discourses in policy change is prominent already in the seminal works of Heclo (1974) and Hall (1993), and it is further developed by the discursive institutionalist school (Jenson 2010; Schmidt 2008, 2010).

Deep core beliefs in China are grounded in Communist doctrines and Confucian traditions. Filial piety (Chinese: 孝, xiào), for example, traditionally obliges children to obey and respect their elders and parents and to care for them. Although the Chinese are prone to looking for ideas abroad (Stepan and Müller 2012; Yuan 2013), the diffusion of new ‘Western’ core beliefs remains contested in this light (see also Foster 2016; van Gerven and Yang 2017). This would propose that (through mimetic isomorphism processes) strong cultural norms, core belief systems, push towards the preservation of traditional ideas and beliefs and hamper the transnational diffusion of Western social innovations.

2.3. Professionalism and management

The third mechanism of institutional processes is normative isomorphism grounded on professionalism (DiMaggio and Powell 1983, 152). Based on education and professional networks, socialization within sectors and business can lead to a shared understanding and legitimation of goals and practices. Here, DiMaggio and Powell (1983, 153) also point towards the importance of the professionalization of management. This is strongly recognized in public-management theories where individual persons in management position are often seen as key to implementing social innovations (Hartley 2005; Sørensen and Torfing 2012; Kuipers et al. 2014; van Meerkerk and Edelenbos 2018). Entrepreneurial leaders function as brokers between different people and fuel the intrinsic motivational factors of employees (Demircioglu and Audretsch 2017).

China has a strong hierarchical (Laoban) structure that necessitates employees’ complying with authorities. Therefore, leadership is a particularly prominent factor in (public-sector) management. However, the dominance of managers can also hinder the innovation process in China. Jing (2012), for instance, refers to the decoupling behaviour of the Chinese (public) employee: their tendency to have strong rule compliance on paper, but low adherence in practice. This leads to the expectation that the hierarchical management structure in China is top-down oriented and likely to hinder the diffusion of (Western) social innovation. However, leadership, in combination with socialization on-the-job, may infuse new ideas or practices, which may erode some of these hindrances.

The theoretical understanding of the institutional, organizational and cultural aspects of social-innovation localization is next put up to test with empirical analysis of the local adoption process of a Western social innovation to China.

3. Methods

To study the transnational diffusion of social innovation, a case study of the diffusion and localization of a Dutch elderly home-care model to China was explored. Unlike in China, where elderly care has been traditionally the responsibility of families, or medical hospitals if an elder has health issues, the Dutch home-care model has been strongly developed from the 1980s onwards towards favouring the elderly staying independently at home and receiving adequate medical and social care by professional home-care services. One of the leading home-care providers in the Netherlands has been the non-profit organization Buurtzorg (‘Neighbourhood care’ in English). The home-care organization and its organizational model have been seen as a true innovation both in the Netherlands and beyond (Nandram and Koster 2014; Kreitzer et al. 2015; Leichsenring 2015). The home-care model is centred around the slogan ‘humanity over bureaucracy’. This foresees that the core organizational model aims to reduce unnecessary bureaucracy and layers of management and prioritizes the autonomy of nurses in decision-making together with their clients and with their formal and informal networks (Alders 2015; Johansen and van den Bosch 2017; Kreitzer et al. 2015; Monsen and DeBlok 2013).

In 2021, Buurtzorg Netherlands employees over 10,000 nurses in 850 teams in the Netherlands, but it has also opened international offices in 17 different countries in Europe and Asia, as well as in India, Brazil and Australia. Revisiting the definition of social innovation noted earlier, Buurtzorg constitutes a social innovation in both the Netherlands and China: It has challenged the traditional long-term care model of clinical care in hospitals and/or informal care provided by a spouse (and/or children) with integrated and patient-centred professional medical and social care provided by independent healthcare professionals at clients’ homes. It has also put much emphasis on the professionalism of individual nurses and on their autonomy.

This explorative case study studies the diffusion process of the Buurtzorg model to China in the first three years of its existence (2015–2018). From 2015, Buurtzorg has operated in a growing number of Chinese cities (for instance, Shanghai, Qingdao, Zhangzhou and Weifang), and by 2017, the organization has had more than 1,000 clients in China, making it still a small operator in a megamarket. The empirical case is focused on Buurtzorg Shanghai, the main headquarters of Buurtzorg and the company’s largest unit, and the city where Buurtzorg first settled. At the time of the interviews (2018), Buurtzorg Shanghai operated in two day-care centres in three districts of Shanghai and was limited in size (comprising 14 persons, including one team of five nurses), but it has expanded rapidly thereafter. Ageing very rapidly, Shanghai is a city where national pilots on extending healthcare for the elderly with a new long-term care insurance were experimented in 2015–2017. At least theoretically, the home-care model that Buurtzorg offers can provide the Shanghai government a solution to the ‘wicked problem’ of providing care and cures for the rapidly ageing population at home. This is also the reason Buurtzorg entered China.

The research question for the paper was: Which factors facilitate and/or hinder the transnational diffusion of Western social innovations to a Chinese context? It hereby locates itself in modest scholarly work (Stone 2012; Gilardi 2016; Béland et al. 2018) on transnational diffusion and social-innovation diffusion between two radically different institutional and cultural contexts. This study aims not to determine whether the home-care organization developed into a real social innovation in China, but rather, it sheds much-needed empirical light on understanding which factors hamper and foster the localisation of Western social innovation to China. The primary data is derived from key-expert interviews: 23 semi-structured interviews were conducted with current and former Buurtzorg professionals (operating in China and with close connections to the Chinese office), experts in Chinese public affairs and Dutch and Chinese government officials between May 2017 and June 2018. See Table 1 below for the list of respondents.

Table 1. Respondents interviewed.

Respondent	Code	Date of interview
1. Buurtzorg nurse	BZ1	June 2017
2. Buurtzorg nurse	BZ2	June 2017
3. Buurtzorg manager	BZ3	June 2017
4. Buurtzorg nurse NL	BZ4	June 2017
5. NL local government	OFNL1	June 2017
6. Buurtzorg nurse NL	BZ5	June 2017
7. NL national government	OFNL2	June 2017
8. BZ manager CH/	OFCH1	July 2017
9. Manager CH	EXP1	July 2017
10. Policy advisor local government	OFCH2	July 2017
11. Buurtzorg Nurse CH	BZ5	Dec 2017
12. Buurtzorg Nurse CH	BZ6	Dec 2017
13. Buurtzorg Nurse CH	BZ7	Dec 2017
14. Buurtzorg Nurse CH	BZ8	Dec 2017
15. Buurtzorg Nurse CH	BZ9	Dec 2017
16. Buurtzorg Nurse CH	BZ10	Dec 2017
17. Home care nurse CH	NU1	Dec 2017
18. Home care Nurse CH	NU2	Dec 2017
19. Home care Nurse CH	NU3	Dec 2017
20. Buurtzorg Manager CH	NU4	Dec 2017
21. Expert in Chinese long-term care insurance	EX1	Jun 2018
22. Expert in Chinese long-term care insurance	EX2	Jun 2018
23. Expert in Chinese long-term care insurance	EX3	Jun 2018

The scope of respondent backgrounds was kept broad to allow for an encompassing view of Buurtzorg’s development in the first three years, and the number of interviews was sufficient to reach a saturation point in data collection. The professionals interviewed were employed at different levels and in different positions, varying from nurses to nurse coaches to senior advisors and persons in higher management positions in the organization, either in Shanghai or the Netherlands. Additionally, with snowball sampling, people outside Buurtzorg, but having knowledge of diffusion, were interviewed, including professionals at other home-care organizations (defined as government-oriented non-profit organizations), local government officials in Shanghai and the Netherlands, and academic experts. Secondary literature comprised academic literature, web/media sources (Buurtzorg websites, newspaper articles in Dutch and Chinese media, and international press) and company material. Limited data triangulation was possible.

The research design has been approved by the ethical committee of the second author’s academic institution, and all respondents have consented to their collaboration in the research project and any subsequent publications. Between May and June 2017, the first round of interviews (European and Chinese respondents, N = 10) was conducted face-to-face, either in person or via Skype. In December 2017, a second round of face-to-face interviews (Chinese respondents, N = 10) was held. In June 2018, final interviews of the academic scholars (N = 3) specialized in Chinese healthcare and social-care regulations were held. Each interview lasted between 45 min and 1 h, and the Chinese interviews were conducted by a Chinese research assistant and the first authors. In this manner, the cultural differences and understanding of context could be discussed and interpreted. All interviews were transcribed, translated (Chinese/Dutch into English) if necessary, anonymized, and the method of qualitative content analysis was applied. The seven-step process of familiarization, condensation, comparison, grouping, articulation, labelling and contrasting of data according to Dahlgren and Fallsberg (1991) was conducted. Thematic coding was based on the three institutional isomorphic processes as the main categories, and it was further analysed with the labelling and contrasting of the findings.

4. Results

4.1. Institutional boundary conditions

The institutional boundary conditions in China drastically differ from the one in the Netherlands. One respondent (BZ1) refers to this difference by stating, ‘whereas the organization structure in the Netherlands is very flat and horizontal, the structure in China is very vertical, hierarchical and complex'. Both central-government control and the local governments’ influence are strong on all public-service providers. In addition to dealing with a city’s central-level authorities (who make general policies under the specific ministries), Buurtzorg Shanghai faced challenges in collaborating with the district-level government that makes the general decisions, and with the township-level government that makes the specific decisions on funding and actual care decisions for the elderly (BZ3, BZ4, OFCH1, OFCH2). The respondents (BZ3, BZ5) tell us that these three different levels of government welcome new organizations in very different ways: the city-government level is very keen on tapping into Western expertise in an area (as elderly care has a very high level in political urgency), but the operational levels are seen as less keen on collaborating with foreign organizations. As our respondent in Shanghai (BZ5) states, ‘street level […] gets the pressures from the society. They do not have a policy to back them. They want to find solutions, but they lack all resources. And also, transparency … ’ The strong guanxi traditions and super-stewardship relations of service providers and the local government (see also Jing 2012) were hampering Buurtzorg Shanghai. Local-level decision-makers commonly favoured existing Chinese companies (despite these companies often having little to no competence in the new service sector). The organization was seen as ‘foreign’ (BZ4, BZ5, BZ12) and, therefore – often by default –, it was not trusted. The healthcare industry, where home-care services operate, was also very competitive (BZ3, OFCH1, OFCH2, ACA1): ‘Most players think that elderly care will be the next “gold rush” and act extremely aggressively; pumped up with private equity/venture capital, their objective is to occupy as much “market share/space” as possible’ (BZ3). This left the organization, after two and half years in Shanghai, still searching for the right connections within the Shanghai government with whom to collaborate as reliable business partners.

In line with coercive isomorphic processes, adopting to the Chinese context has meant that the organizational service model had to be adjusted from operating daily under (almost) no supervisory mechanisms in the Netherlands to operating under (dominant) supervisory mechanisms in China. This applied not only to how the organization accessed clients (local government/party provided access to the elderly instead of clients contacting the organization in the Netherlands), but also to what kind of care needs there were to be addressed. Respondents (BZ1, BZ3, BZ4, ACA1-3) told how the government gives very specific tasks or ‘descriptions of the type of care’. Also, the clients (families that arrange services for their parents) gave very detailed instructions on what they expected (BZ4) instead of a care professional determining the care needs together with the elderly. Although this fits the Chinese hierarchical culture of determining the duties between higher-ranked and lower-ranked persons, such work procedures were in strict contrast with how the organization operates in Europe: providing holistic care to address clients’ needs, tailored to their situation (BZ1, BZ2). Such a mandate violates the fundaments of the organizational care-work model ingrained in their slogan of ‘humanity over bureaucracy’.

Another major obstacle for the organization was that they were not granted a medical-treatment license that would have allowed them to operate independently. In this first three-year period, the organization applied various times for the medical nurse station license but failed to obtain it (they have received this finally in 2019). At the time of the interviews, all 41 licenses in Shanghai were granted to Chinese companies, many of them without any background in home nursing, but with the sufficient, right ‘guanxi’ (BZ4). Having the right guanxi was the key to success in dealing with the local government and to having access to resources (BZ3, BZ4, BZ5, ACA1, OFNL1). The government-purchased projects were allocated only to those with the right ‘guanxi’. The formal requirement is Shanghai to have a non-profit organization for contracting with the government was a major hurdle for all foreign operators, since no foreigner could set up a non-profit organization. Having no medical license meant that nurses were not able to give medications, nor could they provide medical treatment (without their partners’ licenses). For the organization’s philosophy, nurses’ own medical licenses were thus of the essence.

The institutional boundary factors were thus clearly a hindrance to the transnational diffusion process. Resources for the sector are highly centralized and given to trusted (government-oriented) non-profit organizations (Go-NGOs) (ACA1), leaving the foreign operator institutionally alone and dependent on Chinese partners on their guanxi, nursing stations and a medical license.

4.2. Deep core beliefs

The organization also faced difficulties relating to societal acceptance of the social innovation itself and the deep core beliefs that people shared about eldercare and care delivery in China. The elderly themselves were very unwilling to pay for ‘preventive’ care themselves: rather, they would save money for their children and grandchildren (BZ4, NU2). This problem was partially removed after the government launched the long-term care insurance (LTCI) experiments (BZ3, OFCH1, OFCH2, ACA1, EXP1–3), but this mended only a part of the problem. The model of delivering (integrated medical and social) care at home was at this moment of time new to China (BZ5–9, NU1–3, EXP1–3). It is a ‘forced’ innovation for coping with unprecedented ageing in China (see also Liu and Sun 2015; van Gerven 2019), and although long-term care is now embraced by the government (BZ9, NU4), the core idea of home care still remains in deep contrast with the Chinese deep core ideas of familial care provision: people go to hospitals and see a medical doctor if they require medical treatment (BZ1, BZ2, NU1, NU2, NU3, ACA2), but regular ‘home’ care is the responsibility of the family (child/children). Although the norm of filial piety is slowly eroding in big cities like Shanghai, some respondents (BZ4, BZ5, NU2) view that a long-term care system goes against the traditional values, and this hampers some families from considering the services provided (BZ1, BZ2, BZ4, NU1).

Unexpected result was also that the integration of the family into care delivery (which is an essential aspect of Chinese filial piety and embraced by the organization’s service-delivery model in Europe) was seen in practice as more burdensome in China than in Europe. In China, clients’ families and near communities often had insufficient knowledge and skills (BZ3, NU4), and in a country with a long history of one-child policy, the number of carers was limited. Despite the model of home care including a strong conviction that care should be provided by the inner circle (a community nurse together with the extended family and community), and the strong familialistic ties in China, the translation of a Western model to Chinese society caused friction. Respondents believed that this friction was due to the fact that the organization was foreign. Having its roots and principles in the Western world, the organization was met with (deep) mistrust by the Chinese. This was felt from the moment that nurses (who also worked for a foreign company) entered the homes of the elderly (BZ1, NU4). In spite of this, the nurses employed by the organization in Shanghai felt strongly belonging to the ‘Buurtzorg’ family. In this way, the organizational identity was very much in line with the core beliefs of the mother organization (Sabatier 1988).

As for cultural influences, the Chinese traditions and norms like filial piety preserved the traditions, ideas and beliefs about elderly care and its delivery. This hampered the diffusion of Western innovation with divergent core ideas. The strong identity of a ‘Buurtzorg’ professional, however, was a factor that socialized the nurses from within, and this was further cultivated through managerial practices as discussed next.

4.3. Professionalism and management

Although the institutional conditions and cultural norms were largely hindering the diffusion of the Western model, the interviews gave indication of some normative isomorphic processes that may circumvent (some of) the negative effects of the organizational environment and traditional beliefs in China. These had to do with managerial aspects, the socializing of nurses into Buurtzorg professionals, and the inherent transformative management where this happens.

The starting point of the sector was not a problem for the studied organization only. Rather, the low status of home-care workers in the healthcare sector hindered the new industry (BZ3, BZ4, NU3). Whereas home care employed predominantly nurses with a bachelor’s degree (70%) in the Netherlands (BZ1, BZ2), Chinese home-care nurses were much less educated and many ‘nurses’ (or carers or domestic aids) had no formal education and merely a very short on-the-job training (NU4). The formally medically trained nurses in China, whom the organization predominantly hired, did not fit the same profile as in the Netherlands. The Chinese nurses were educated in clinical hospitals with highly standardized procedures and under a strict line of command. As a result, the nurses, although medically trained and competent, needed to be trained to work independently and make swift decisions on their own after they joined the organization. ‘Nurses in China are educated to follow the authorities’ instruction and follow certain procedures and not think for themselves, as autonomy is not a normal or part of their culture’ (BZ2). That nurses are ‘used to work[ing] with a supervisor who gives them a duty’ (BZ2, BZ4) goes evidently against the principles of the organization’s care-delivery model which necessitates its professionals to have a wide range of holistic and social skills, including skills in secondary preventive care and being attentive to all social, environmental and psychological factors that influence the health of the elderly. Training and human-resource management have been important tools in the organization. The management in Shanghai has gone to great lengths not only to train the nurses skills related to home-care delivery, but also how to work in (self-steering) groups and, importantly, to bring the nurses into the ‘Buurtzorg mindset’ (BZ2, BZ4). Changing the mindset of the nurses was seen as key, but professional turnover was reasonably high (due bad pay and low appreciation of the sector in China), and trained nurses often left for another job (in hospitals), leaving the organization to start the socialization process again with new nurses. Despite these difficulties, the study shows that, in this particular case, the role of managers has been crucial. Although ‘self-organizing teams [in China] without a manager are a burden’ (BZ2), the management(less) model had been adjusted to the system in China. They have had to loosen their intentions of operating with fully self-steering teams. Rather, the organization had added an extra layer to their management and institutionalized a head nurse into the teams. In the words of one of our respondents (BZ1), ‘there will be, from the start […], a sort of team leader or “head nurse” in each team in Shanghai’. The lead nurse helped the organization coordinate the tasks of the nurses and lead the way for the nurses. The Shanghai management, however, foresee that self-organizing teams are possible even in hierarchical China in the long-term. This requires, however, distributed heroism and continuous coaching.

Although the hierarchical way of how nurses operate in China hindered the implementation of self-steering teams, the normative pressures brought on by the managers helped socialize the organization from within to adhere to Western principles and develop the organization’s mindset.

5. Conclusions

This article proves that much can be learned when it comes to social innovations and their transnational diffusion. The article provides substantial empirical support for extending the diffusion theory to account for a broader range of contextual factors. The exploration of the transnational diffusion process of social innovations (an ‘oriental version’ of a Western home-care delivery provider from the Netherlands) provides evidence of a hampering effect of the environmental context, notably the coercive isomorphic processes stemming from strong hierarchical steering in China and limited autonomy of the non-profit sector. In line with expectations from the literature, coercive isomorphism hinders social innovations in authoritarian China through the supervisory presence of the Chinese government and cultural mechanisms of the exclusion of outsiders from in-group guanxi networks. This leaves social innovations often lacking crucial resources and organizational autonomy required for making progress in their mission. This coerces innovation to adjust to the local context, as expected. Also as expected, Chinese core beliefs about filial piety and the duty of children hampered the diffusion of Western innovation cultivating ‘Western’ ideas of elderly care bringing professionals and medical care to households. Although deep core beliefs are expected to be reasonably stable (Sabatier 1988), they may be subject to change as the problem load (ageing) rises in China, and new political ideas, with help from strong advocacy for them, may converge the ideas towards a new paradigm of (integrated health and social) long-term care (see, e.g. Béland 2016; Kingdon 1995)

The study shows that the localization of Western social innovation happened to a great extent at the level of organizational daily practices. Many of the daily practices were (coercively) adjusted for survival in the demanding Chinese context. Nevertheless, and as our contribution to public-management research, we raise the notion of normative pressures within an organization being a powerful driver in transnational diffusion. In between the hindrance of the institutional (political-administrative) context, uncertainty and ambivalent cultural beliefs, the transformative management factors seemed to aid in the survival of the foreign social innovation in question. With its managerial practices, balancing between hard steering and enabling coaching, the organization was socializing from within and was seeking a ‘golden middle ground’ of adjusting to the Chinese context and to transforming the sector and the profession. It is therefore that avenues of further research should be expanded to examine normative isomorphic pressures through education and professional networks, as socialization within sectors and business is crucial to establishing a shared understanding and legitimation of goals and practices. In our case of social innovation, the organization was affected by institutional mechanisms of the drastically different context of China (cf. Pawson and Tilley 1997). The diffusion of social innovation is restricted by the limitations of the institutional setup and the isomorphic coercion that boundary conditions create. Nevertheless, even within authoritarian China, there is room for normative processes of professionalism and transformative management. Our findings suggest that the theory of transnational diffusion of social innovations should be more sensitive to normative isomorphic changes. This explorative case study has empirically shown how socialization and localisation as part of public-management practices can help to build bridges between negative institutional boundary conditions and ambivalent cultural norms.

To conclude, the article took a novel look at the classic work on institutionalism to study how social innovations evolve in a new environment and how contextual factors enable or disable the transnational diffusion process of social innovation. It took an empirical stance at a social innovation that sparks social action by bringing in new ideas, models or practices, and at the same time fuels inclusiveness and sensitivity to social needs (Voorberg, Bekkers, and Tummers 2015). The study of transnational diffusion showed that social innovations face diverse pressures of isomorphism that necessitate their convergence with their institutional environments. However, it was also found that some of the isomorphic processes within the organization could counterbalance some of the external pressures in the long run. It is here that our study can spark new empirical investigations to engage in the broader debate. The findings of a case study need further validation by other research, preferably with a wider research population and in other innovation contexts and with different kinds of innovation, as local adoptions may vary. The case study is specific to the Chinese case but can potentially serve as a reference to other transnational diffusion cases from the West to Asia or to other authoritarian regimes. This exploration is also a snapshot of the very first period of organization. A later study should evaluate these findings again. In due time, Buurtzorg may find its way to an inner circle and become of one of the government-supported champions that Zhu (2014) has written about. Also, things change quickly in China, and with strong governmental commitment to home care, the social norms and attitudes around it are prone to change.

Acknowledgements

This work was supported by the KNAW under Grant 530-5CDP11. The data collection was partly done by Bachelor students of University of Twente, incl. Pascal Alscher, Denys Frijters, Lukas Kögel and Lorina Whittaker. The authors acknowledge their help in the data collection process. The authors want also to thank Dan Xiao and dr Yangyang Cui for their help in interviewing and translating the Chinese data and Prof Yijia Jing and Fudan University for hosting the first author during the visits. Cordial thank you also for the social innovation Buurtzorg for their collaboration in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Koninklijke Nederlandse Akademie van Wetenschappen: [Grant Number 530-5CDP11].

Notes on contributors

Minna van Gerven

Minna van Gerven is professor of social policy at Faculty of Social Sciences at University of Helsinki.

René Torenvlied

René Torenvlied is professor of public management, Faculty of Behavioural, Management and Social Sciences at University of Twente.