analyzing for specific network characteris- characteris-tics and network context
6.2 Do national / regional HPH networks have es- es-tablished coordination structures and resources, es-tablished coordination structures and resources,
and are they functionally differentiated?
The development of explicit network governance or coordination mechanisms was shown to be another relevant aspect for advancing from networking towards full collaboration (or, following Fuhse’s group perspective, from mass towards organization). A research focus on network coordination was further supported by taking a “whole network” perspective on HPH (compare Provan et al. 2007), and by understanding “networking” as one distinct gov-ernance mechanism, next to markets and hierarchies27.
According to Milward & Provan (2006), network governance has to face the challenge of management or coordination on the basis of trust and reciprocity (as opposed to contracts or hierarchy which are usually found in organizations). However, as networks advance towards full collaboration, they too may take to using contracts or formalized coordination or govern-ance structures, since these appear helpful for at least two reasons: firstly, formalized coordi-nation structures help to secure a fair articulation and representation of the interests of partic-ipating organizations (compare chapter 3); and secondly, by providing fair conditions, formali-zation helps to support network attractiveness. In this sense, formalized network coordination structures have to be presumed as being supportive of network effectiveness.
Of the 28 HPH networks in the sample, 12 (43%) had their coordination affiliated to a health administration organization. In 9 cases (32%), coordination was based in a scientific or expert organization, and 7 networks (25%) had their coordination based at a hospital.
9 (32%) had no coordination structures in addition to the network coordinator (whom each network has to nominate according to international HPH regulations; compare constitu-tion and network agreement in appendix). Accordingly, about 32% of HPH networks in the sample did not dispose of functionally differentiated coordination mechanisms or specified opportunities for network members to articulate their interests or to engage in decision-making in the network.
Amongst those networks with specified coordination structures, a general assembly was most often reported (12 networks or 43%), followed by governance boards and chairmen / chairwomen (11 networks or 39% each), and advisory boards and secretary generals / CEOs (7 networks or 25% each) (compare Figure 12 below).
27 However, according to Kappelhoff (1999), markets and hierarchies, too, can be researched as networks.
Figure 12: Prevalence of 5 pre-defined types of network coordination structures in national / regional HPH networks (N=28)
With regard to resources for coordination, only a minority of four coordinators (14%) worked full-time in this function. Of the remaining coordinators, 1 (4%) could invest 85%, 7 (25%) were able to allocate up to 30% of their weekly working time to network coordination, and 5 (18%) used between 10 and 15% of their working time for coordination. In four networks (14%), coordinators used less than 10% of their weekly working time for coordination. 7 co-ordinators (25%) did not provide details on their working time (compare Figure 13 below).
Figure 13: Percent of weekly work time invested by HPH network coordinators for their coordina-tion role (N=28)
In total, only 9 coordinators (32%) – including those 4 working full-time – got paid for this function. Consequently, 25 coordinators (89%) reported to hold other bread-winning jobs.
These included management jobs on organizational (hospital) level (9 coordinators or 32%), public health and health planning jobs (6 coordinators or 21%), teaching jobs (6 coordinators or 21%), clinical jobs (5 coordinators or 18%), management jobs at health authority level (4 coordinators or 14%), research jobs (2 coordinators or 7%), counseling and training jobs (2 coordinators or 7%), and other coordination jobs, e.g. for smoke-free hospitals (3 coordina-tors or 11%) (compare also Dietscher et al. 2011a).
7 7
11 11
12
0 2 4 6 8 10 12 14
CEO / Secretary General Advisory Board Chair Governance Board General Assembly
100 100 100 100 85
30 30 30
25 25 25
20 15 15
10 10 10
7 7 5 5 0
10 20 30 40 50 60 70 80 90 100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
With regard to network budgets, of the 28 networks in the PRICES-HPH network sample, only 19 (68%) reported having a specified network budget. The amounts of these budgets varied widely from € 5 000 to more than € 540 000 annually (meaning that the annual budget of the richest network was about 109 times higher than the budget of the poorest), with a mean annual budget of € 102 600. These differences cannot be explained by network size alone, since differences between the networks remain high when calculating budgets per member (see Figure 14 below). The annual per-member budget of the richest network was € 12 500 and almost 45 times higher than the per-member budget of the poorest network (€
278). The mean annual budget per member was € 3 575, with 33% of networks having report-ed a budget above and 66% below this value (compare Dietscher et al. 2011a).
Figure 14: Amounts of network budgets per member per year in € (n=1828)
Explicit network offices were even less widespread despite a standard agreement between the international HPH network and the national / regional HPH networks that requires the net-works to nominate a coordinating institution. However, only 12 of the 28 netnet-works (43%) from the PRICES-HPH network sample reported having such an explicit coordinating office.
The remaining 16 networks (57%) seemed to use some form of functional equivalent to a specified office (e.g. the possibility to use rooms, equipment, infrastructure or personnel of the organization employing the coordinator) to meet the demand of having a coordinating institution.
For a further differentiation of structures and resources of network coordination, Milward
& Provan (2006) suggest three types of governance for interorganizational networks, each of which comes along with specific advantages and disadvantages:
28 Of the 19 networks with a budget, one had not specified the amount.
278
Self-governed networks: These, typically, do not have an administrative entity, which makes the commitment of members their main adhesive mechanism. Because of their informal cooperation structures, they are usually rather small. The decentralized deci-sion-making associated with this type of structure holds the risk of inefficiency be-cause of the need for frequent meetings and difficulties in reaching consensus. For ex-ternal network environments, this form is problematic because, following sociological systems theory terminology, self-governed networks lack an “address” to approach.
Lead organization-governed networks: Coordination in these networks is taken by a “primus inter pares”. Because of the clear responsibilities and more centralized structures asso-ciated, this type of network can cope with bigger numbers of network partners. The risk, however, is that the network is dominated by the strong central lead partner, with a potential for reduced commitment from the other members.
Government by a “network administrative organization (NAO)”: Networks of this type are characterized by a distinct administrative entity, e.g. a hired network manager. So as lead organization-governed networks, NAO-governed networks can deal with larger numbers of network partners. Because of the explicitly managed network coordination they offer, they are better apt to guarantee an involvement of members in decision-making and a fair representation of the interests of all network members. According to Milward & Provan, while NAO-governed networks may be more costly in administra-tion, they also have a higher chance of efficiency and sustainability.In relation to Nutbeam & Harris’ (2004) hierarchy of cooperation (from networking to full collaboration), self-governance would be located at the network end of the hierarchy, NAO at the full collaboration end. If applying this distinction of governance types to HPH, the inter-national level of the network, with its established interinter-national secretariats, its membership fees, and established coordination structures, would clearly fall in the last category. But what about the national / regional HPH networks?
By taking the above-introduced characteristics of coordination as surveyed by the PRICES-HPH network questionnaire – i.e., the organizational affiliation of the network coordination, the existence of coordination structures in addition to the coordinator, and resources and in-frastructures for coordination (such as network budgets and offices) – HPH networks can be allocated to the three network governance types defined by Milward & Provan (2006) as fol-lows:
Self-governed HPH networks: Independently of the organizational base of the coordinator, this label was used for networks characterized by no explicit governance mechanisms and no coordination infrastructures other than the coordinator, thus characterized by rather weak coordination structures.
Lead organization-governed HPH networks: This framing was assigned to networks whose coordinators were based at an organization within the health system, e.g. a health ad-ministration unit (local, regional or national) or a hospital, if they also disposed of specified coordination structures and resources.
NAO-governed HPH networks: A network was allocated to this group if it was coordinat-ed by a non-healthcare organization and if it also disposcoordinat-ed of specificoordinat-ed coordination structures and resources.A description of the 28 HPH networks in the PRICES-HPH network sample, and their al-location to a governance type according to the criteria specified above, is given in Table 23 below:
Table 23: Location of network coordination, functional differentiation of network coordination29, network infrastructures (office and budget), and governance type assigned, for 28 HPH networks
Network30
Location of coordi-nation
Functional
differentiaton Network office Network budget
Governance type assigned
NW11 Health administration --- --- --- SG
NW13 Hospital --- --- --- SG
NW17 Hospital --- --- LOG
NW18 Non-healthcare --- --- --- SG
NW19 Hospital --- LOG
NW24 Non-healthcare --- --- SG
NW28 Non-healthcare NAO
NW35 Health administration --- --- --- SG
NW36 Non-healthcare NAO
NW37 Non-healthcare NAO
NW41 Hospital --- LOG
NW43 Health administration ~ LOG
NW47 Health administration ~ LOG
NW48 Non-healthcare NAO
NW53 Health administration --- LOG
NW54 Hospital ~ LOG
NW55 Non-healthcare --- NAO
NW56 Health administration --- --- --- SG
NW59 Health administration LOG
NW60 Non-healthcare --- --- --- SG
NW63 Health administration --- --- --- SG
NW65 Non-healthcare NAO
NW69 Health administration --- LOG
NW75 Hospital ~ --- LOG
NW80 Hospital ~ LOG
NW81 Health administration --- LOG
NW85 Health administration --- --- SG
NW86 Health administration ~ --- LOG
Accordingly, 9 (32%) networks were self-governed, 13 networks (46%) lead organization-governed, and only 6 networks (21%) were network administration-governed.
29 --- = 0 coordination structure in addition to the coordinator; ~ = additional structures but no governance board or general assembly; = additional structures including governance board or general assembly
30 As PRICES-HPH had granted anonymity to participating organizations, random numbers were allocated to each network.