Community-driven network building in health care: creating an exploratory social space to pursue co-production following reforms

Community-driven network building in health care: creating an exploratory social space to pursue co-production following reformsIntroduction:Integrated care requires engaging and empowering people and communities to take an active role in designing and delivering health services (WHO 2019). Their capacities to co-produce health outcomes alongside formal providers are key to assuring sustainability and equity. However collaborative dynamics are compromised by power differentials that limit recognition of community capacities, and are vulnerable to system reforms. Much of the literature on co-production focuses on provider-side initiatives to engage communities. This paper provides an alternate view, exploring how community actors forge network alliances to gain legitimacy and power to co-produce care.Methods:We conducted a longitudinal case study of the network development efforts of a community working group (WG) concerned with access to health services following reforms in Québec, Canada. The WG brought together concerned citizens along with community organizations working with seniors, minorities, immigrants, youth, and people with disabilities. Data were collected over three years from observation, documents and interviews, and social network analysis was conducted to reveal the evolution of relationships among community actors, and between community and public actors. Actor-network theory (Callon) was used to distinguish stages of network maturation. These analyses explored how interactions contributed to identifying and opening pathways for co-production.Results:The WG pursued network building in two stages. A first focused on problem definition: WG members brought their existing networks together to validate access problems perceived in their constituencies, then reached out as a group to public sector contacts to achieve a better understanding of precisely what had changed in the system. In a second stage, the WG mobilized this network of community and public actors to equip a broader public to more effectively draw upon public and community resources to meet their needs. Two factors appeared to impede co-production: the limited influence of front-line actors on public system processes; and discrepancies between community priorities and system mechanisms for participation.Discussion:In the context of reforms, 'problematization' was an especially important stage in network development and showed signs of consensus development on 1. the existence and nature of problems, and 2. interdependencies between public and community actors in identifying and implementing solutions.Conclusions:Network development through the WG enabled community actors to gain the "organizational infrastructure" to participate in collaborative governance (Ansell and Gash 2008). Community efforts can open new spaces to enhance co-productive capacities of people and communities; public provider ability to integrate these capacities into processes is reduced by reforms.Lessons:Network interactions enable the recognition of interdependencies and the development of consensus, and in this way create conditions for collaboration even among actors of different strengths (Benson).The fragility and disruption through reforms of links between public and community actors impede co-production.LimitationsLonger follow-up and comparison with other community initiatives may have provided additional insight into community strategies for gaining legitimacy in co-production.Future researchResearch on factors limiting the effectiveness of longstanding 'concertation' venues after reforms would be helpful, as would exploration of territorial dimensions of co-production between public and community actors in healthcare services.

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