Bridging the Macro–Micro divide: Implications for the governance of pharmaceutical prescription

This PhD dissertation presents insights on the relevance of the macro–micro divide in public healthcare systems and policies, focusing on the challenges and implications of governing pharmaceutical prescription practices. Prescription represents the link between the patients and their access to care, specifically to medications in this context. Yet, while the act of prescribing may appear straightforward, the underlying decision-making process is complex and far from linear. Physicians are the primary focus of the dissertation, considering their central role in prescribing decisions in most countries. The factors influencing their prescribing have been explored in the literature and can be linked to multiple sources, including interactions with patients and the resulting pressures, the intrinsic characteristics of the physician, as well as interactions with colleagues or specialists and the regulatory and institutional context.The thesis adopts a multilevel perspective to analyze the governance of prescriptions, also addressing the need to move away fromsiloed visions and towards a more comprehensive allignment of macro, meso, and micro levels. By disentangling the interplay across these levels, the dissertation conceptualizes prescription as a complex interaction between individual decision-making, organizational constraints, and system-level governance. The first chapter of the dissertation provides an overview of pharmaceutica prescription practices through a systematic review of the literature and meta-analysis, addressing the determinants that impact macro, meso, and micro levels prescription behaviors. The second chapter presents an empirical analysis of the short- and medium-term impact of a governance tool aimed at controlling drug prescriptions defined at national level. The analysis assesses the effects at the macro level and at meso level considering variability among groups of prescribers. The third chapter presents both empirical and theoretical contributions at the meso level. Using general practitioner networks as the unit of analysis, we develop a taxonomy of networks based on different prescription influences upon general practitioners, and their characteristics are assessed to understand the different meta-governance approaches deployed. With this disseration, we demonstrate how governance policies must account for the interplay of the multi-level dynamics, adapt to local contexts, and move beyond one-size-fits-all approaches. The multilevel framework also offers a foundation for future research on emerging challenges, such as digital health technologies, personalized medicine, and the governance of networks.