Abstract
Professional autonomy has long been regarded as a defining feature of the medical profession, yet contemporary healthcare systems are increasingly shaped by managerial and market-oriented reforms. While existing debates often frame these developments as an erosion of professional discretion, less attention has been paid to how autonomy is enacted within concrete organizational arrangements, particularly in rural contexts characterized by resource scarcity and territorial constraints. This study examines how institutional differences shape the organization of general practitioners (GPs) in rural primary care and how these arrangements orient the perception and enactment of professional autonomy.
Adopting a multi-level framework, the paper conceptualizes primary care as a nested institutional field in which macro-level governance arrangements, meso-level organizational structures, and micro-level professional practices interact. Drawing on a qualitative, case-oriented comparative design, the study analyzes three rural regions embedded in distinct healthcare systems: Sondrio (Italy), Cornwall (United Kingdom), and Zeeland (the Netherlands). Data were collected through semi-structured interviews, non-participant observation, and document analysis, and analyzed using the Gioia methodology combined with cross-case comparison.
The findings identify three ideal-typical configurations of professional autonomy. In the United Kingdom, autonomy is embedded within vertically integrated networks that align clinical discretion with standardized governance frameworks. In Italy, autonomy is isolated, formally preserved but enacted within fragmented organizational infrastructures lacking stable coordination. In the Netherlands, autonomy is negotiated within a regulated market system characterized by horizontal collaboration and contractual interdependence. Across cases, autonomy emerges not as an individual professional attribute but as an organizationally mediated mechanism shaped by governance architectures and collective infrastructures.
The study challenges assumptions that treat autonomy and coordination as opposing forces, demonstrating instead that they are interdependent dimensions whose balance depends on organizational design. By conceptualizing autonomy as an emergent relational mechanism, the paper contributes to research on institutional logics, professional work, and organizational governance in contexts marked by institutional complexity.