Communities, health‐care organizations and the contingencies and contradictions of engagement: A case study from Chile

Abstract

Context Despite a growing interest in service‐user involvement in mental health services, the interaction between health institutions and local groups is only beginning to receive attention, particularly in global south settings. Objective Looking at a participatory initiative in Chile, this study explores how, under unfavourable administrative conditions, health organizations approach and work with communities. Methods We interviewed policy‐makers (5), local professionals (10), service users and community representatives (6) linked to a concrete participatory initiative. Participant observation in relevant meetings helped to enrich the interpretations. Thematic analysis was applied to interview transcripts and field notes. Findings The findings present a sequence of actions starting with the creation of a network of community‐based groups. A set of problems ensued, related to the group's diversity, internal representation, decision‐making and funding processes. In response, processionals implemented simultaneously bureaucratic and democratic adjustments, developing a vision of community that ignored the particularities—including the motivations—of local groups. Discussion and conclusion Based on these findings, we argue that participatory initiatives should be studied as on‐going achievements shaped by broad policy orientations and local configurations of interest. In the process, they produce ad hoc forms of knowledge and visions of community that provide orientation to the agents involved.

Decision-Making Dilemmas within Integrated Care Service Networks: A Systematic Literature Review

“…The full-text review resulted in the exclusion of 37 articles for the following reasons: No sufficiently detailed information about decision-making (e.g., who is involved in what type of decisions) (n = 33); no full-text available (n = 3); or because another included article from the same author and project was already included and provided more details about decision-making (n = 1). This led to a final subset of 18 included articles [ 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 ].…”

“…Table 1 provides an overview of the 18 included articles in terms of authors, reference number, country and sector, methods, network stakeholders, network size, governance model, favoured decision-making way, and elements of decision-making dilemmas. The articles covered integrated care service networks in the United States [ 24 25 26 29 34 ], Afghanistan [ 27 ], New Zealand [ 28 ], England [ 30 32 36 ], Belgium [ 31 ], Australia [ 33 41 ], Central America [ 35 ], Sweden [ 38 ], Brazil [ 39 ], Chile [ 37 ] and Canada [ 40 ]. In all studies, except for one [ 34 ], some form of qualitative research methods were employed including interviews, focus group discussions (FGDs), observations and document analyses.…”

“…Twelve studies covered participant-governed networks and four studies focussed on networks governed by a lead-organisation [ 28 30 35 39 ]. One study included a NAO-governed network [ 37 ]. The remaining study included 2 participant- and 2 lead-organisation governed networks [ 25 ].…”

“…According to nine articles, another dilemma includes the search for coherence whilst facing a diversity between network stakeholders [ 25 28 29 34 35 37 38 39 40 ]. On the one hand, it seems easier to make decisions in a more coherent group as stakeholders try to achieve similar goals by finding common ground and shared understanding [ 34 ].…”

“…Such a diverse group may hamper decision-making due to differences in viewpoints, communication styles, historical relationships, and/or power. Four of these networks were participantgoverned [29,34,38,40], three were governed by a leadorganisation [28,35,39], one NAO-governed network [37], and one study covered a mix of 2 participant-and 2 lead-organisation-governed networks [25]. This dilemma seems to appear at similar levels as mentioned in dilemma 1: (1) operational decisions related to integrated care services, and (2) strategic decisions in which power imbalances come to play a role.…”