Governance of state and civil society mental health care collaboration
Globally, there is growing urgency to address mental, neurological and substance abuse disorders in integrated, cost-effective ways - especially in low- to-middle income countries (LMICs) (Jack et al. 2014; Ngo et al. 2013; Patel et al. 2007; Patel et al. 2013; Patel et al. 2015; Wainberg et al. 2017; World Health Organization 2008). In South Africa’s pluralistic, state-driven health system, close collaboration between public and private mental health service providers is a key strategy in addressing the burden of mental illness (van Rensburg & Fourie 2016). Private (non-state, non-government, or third- sector) organisations are an established and core component of local public service provision. However, research into their dynamics with public entities remains limited (Bovaird 2014). What is known is that the organisation of these relationships unfolds in hierarchies, markets, networks, or - in South Africa’s case - hybrid structures of service delivery (Markovic 2017). The inclusion of NGOs and other private partners in health care provision has gained traction due to weakening formal states and the loss of legitimacy in centralised state governance, as well as the gradual acceptance that complex social problems cannot be resolved by the state alone (Donahue 2004).
Similarly, mental illness cannot simply be resolved with pharmacology and psychotherapy, but requires collaboration across services to effectively address its devastating effects on both individuals and communities (Mechanic, Mcalpine, & Rochefort 2014; Millward et al. 2009; Thornicroft & Tansella 2002). Despite increased global efforts to achieve the ideal of comprehensive mental health care by integrating social and health services, success has been mixed (Butler et al. 2008; Butler et al. 2011; Maruthappu, Hasan, & Zeltner 2015; Mechanic 2003). Paradoxically, integrated care initiatives have been plagued by fragmented approaches, across different contexts, health systems, cultural and governance structures, and definitions of key terms (Kodner 2009; Kodner & Spreeuwenberg 2002; Ouwens, Wollersheim, Hermens, & Hulscher 2005). Indeed, collaboration and partnership across the structural and cultural boundaries of siloed approaches has become something of a unicorn, both attractive and seemingly unattainable (Fimreite & Laegreid 2009).
The division between health and social sectors particularly affects socially marginalised people, with chronic conditions including people with mental illness (PWMI) (Nicaise et al. 2013). In South African health care, “operational governance is embedded within and influenced by the organizational and system-level governance arenas”, and local service managers are often faced with constraints from broader organisational and system design issues (Scott et al. 2014, p. 67). The failure of national mental health policy implementation on district levels is an effect of decentralised governance to provinces, leading to fractured prioritisation, implementation and monitoring (Draper et al. 2009; Van Rensburg & Engelbrecht 2012a). In such settings, integrated systems of care become even more difficult to achieve (Mechanic 2003).
The fragmentation of care is a real and pressing concern for health systems. In the case of mental illness, the knocking down of the “Berlin Wall” between health and social care has been an persistent challenge (Dickinson & Glasby 2010). Across the past two decades, a wealth of literature has spawned addressing how to break down this wall and create integrated health systems, with governance highlighted as especially critical (D’Amour, Goulet, Labadie, Martin-rodriguez, & Pineault 2008; Janse van Rensburg & Fourie, 2016; Janse van Rensburg et al. 2016; Mitchell & Shortell 2000; Mur-Veeman et al. 2003; Pirn Peter Valentijn et al. 2015; Pirn P. Valentijn, Schepman, Opheij, & Bruijnzeels 2013). The dynamics of governance mechanisms in collaborative arrangements are crucial in fostering beneficial partnerships (Hill & Lynn 2003), but evidence of the particularities of the governance processes are lacking (Willem & Lucidarme 2014), as are questions on how to effectively govern networks geared towards ‘wicked problems’ (Cristofoli, Meneguzzo, & Riccucci 2017). Simply put, we cannot expect to begin to understand outcomes before opening up the black box of the social processes of governing public- private collaboration (Brazil et al. 2005). The governance of service delivery networks requires empirical insight into the processes of power and influence (Heen 2009), and herein lies our study focus. In this Chapter we interrogate the relations between state and non-state mental health service providers, in a South African district. Accordingly, the principle aim of this study was to understand the power dynamics in governance processes of district-level public mental health service provision.