Healthcare Co-production and the indirect governance toolkit: demystifying the organizational puzzle

Background The economic meltdown, coupled with the public-sector legitimacy crisis, forced public services to reconcile increasing demand with decreasing resources and, at the same time, unleashed a wave of criticism on traditional service delivery patterns. One remedy to this challenge that is gaining an increasing attention is co-production - defined as engaging citizens and, more generally, voluntary and non-profit organizations in the production of public services (Alford, 2009; Pestoff, Osborne, & Brandsen, 2006; Thomas, 2013; van Eijk & Steen, 2013). Social and health services are the most elective co-production practices in the public sector, but set the healthcare providers two major challenges. The first is to engage the patient, an ongoing process that calls for this latter to actively participate in their healthcare plan (Coulter, Parsons, & Askham, 2008). The second is to ensure that the patient engages with both their therapy and the hospital organizational system by managing the interdependency within and between ‘organizational production and client co-production’ (Alford & O'Flynn, 2012, p. 182) in order to govern the healthcare organization’s interactions (Alford, 2009; Brandsen & van Hout, 2008). Aim This qualitative study analyses and discusses the relevant organizational challenges of co-production for the public healthcare system at the micro-level, that of the providers – hospitals, trust, local health communities, etc. The paper highlights the implementation gaps and the as-yet unsolved organizational puzzles through an analysis and discussion of the scientific literature on the implications of co-production practices and on how they are managed in actual practice. Theoretical framework The co-production analysis is informed by the “indirect government” conceptual framework to gain access to the set of tools that ‘rely heavily on a wide assortment of “third parties” to deliver publicly financed services and pursue publicly authorized purposes’ (Salamon, 2002, p. 2). Unlike traditional direct-government methods, this approach to public problem-solving sets fresh, sometimes unprecedented challenges and brings into play new capabilities and tools. It is not, therefore, something that ‘self-implements’. On the whole, co-production is a form of indirect government requiring “concerted action across multiple sectors” (Kettl, 2006, p. 14) and actors and the taking on of new responsibilities. Kettl (2002) calls for a management approach that encompasses three key components: process (managing programs by structuring contracts and by tracking money); people (addressing people problems and the indirect government skill set); and performance (reinventing government and the performance puzzle). Research method The study was conducted in two phases. Phase one entailed an systematic interdisciplinary review of the public administration, management, and public policy literatures, mostly by trawling the main electronic databases to find scholarly articles on co-production in healthcare services. This first step enabled us to identify the theoretical and empirical contributions that investigate co-production from the specific viewpoint of the service providers. Phase two inventoried the themes, approaches and key findings of this subset of articles to draw a fairly clear picture of the conditions and capabilities needed by the healthcare providers to manage the organizational implications of co-production. Kettl’s conceptual framework is the basis on which the results are then discussed and compared. Contribution 1) Up-to-date overview of the research on co-production in healthcare services. 2) Analysis of the co-production organizational challenges and how these are addressed in the practice. 3) Insights and policy indications for public managers on how government can play a supportive role in the delivery of co-produced healthcare services. References Alford, J. (2009). Engaging Public Sector Clients. From Service-Delivery to Co-production. Basingstoke: Palgrave Macmillan. Alford, J., & O'Flynn, J. (2012). Rethinking Public Service Delivery. Basingstoke: Palgrave Macmillan. Brandsen, T., & van Hout, E. (2008). Co-Management in Public Service Networks. The organizational effects. In V. Pestoff & T. Brandsen (Eds.), Co-Production. The Third Sector and the Delivery of Public Services (pp. 45-58). London: Routledge Taylor & Francis Group. Coulter, A., Parsons, S., & Askham, J. (2008). Where are the patients in decision-making about their own care? Kettl, D. F. (2002). Managing indirect government. In L. M. Salamon (Ed.), The tools of government. A Guide to the New Governance (pp. 490-510). Oxford: Oxford University Press. Kettl, D. F. (2006). Managing Boundaries in American Administration: the Collaboration Imperative. Public Administration Review, 66(Special Issue), 10-19. Pestoff, V., Osborne, S. P., & Brandsen, T. (2006). Patterns of co-production in public services. Public Management Review, 8(4), 591-595. Salamon, L. M. (Ed.). (2002). The tools of government. A Guide to the New Governance. Oxford: Oxford University Press. Thomas, J. C. (2013). Citizen, Customer, Partner: Rethinking the Place of the Public in Public Management. Public Administration Review, 73(6), 786-796. van Eijk, C. J. A., & Steen, T. P. S. (2013). Why People Co-Produce: Analysing citizens’ perceptions on co-planning engagement in health care services. Public Management Review, 16(3), 358-382.