Tightening Networks and Deepening Co-Regionalism
The Evolution of Cross-Boundary Cooperation to Combat the Opiate Epidemic in Washington State
Lachezar G. Anguelov (The Evergreen State College)
Often, scholars investigate co-regional actions by evaluating them in their final form: an interlocal agreement, the charter of a regional authority, or the decisions of a Regional Intergovernmental Organization board. In this post, Lachezar G. Anguelov introduces us to an embryonic informal network addressing drug addiction and overdoses with stakeholders crossing jurisdictional, sectoral, and policy boundaries. In this case, the coordination that he observes between actors operating at different scales highlights how constellations of actors can leverage strengths to work across boundaries and generate effective solutions. A key point is that it is unlikely that the opioid crisis could be effectively tackled by a single organization operating at an “optimal” scale; therefore challenging the tendency in scholarship on regionalism to seek, promote, or critique ideal types of regional organizing and to dismiss entities that fall short (with respect to resources, authority, or reach, for example). Here there is power in truly shared, decentralized, flexible, and evolving collective action – a fact that could easily be overlooked in focusing solely on formalized entities and agreements. At present, it is not clear whether the networks he observes will crystallize into a more formally institutionalized structure. However, studying such cases and the genesis and evolution stories of networks are necessary to improve scholarly understanding of the final forms of co-regional action and to provide actionable recommendations for local leaders developing these networks in their communities.
As we seek a better understanding of how communities coordinate policies and projects across jurisdictional boundaries, we observe tremendous variation of solutions that coexist in any given region. Often our focus is on “visible” institutional arrangements, though many initiatives operate rather effectively in the shadows of formalization. Contributing to the conversation on regionalism approaches, this paper explores the prevalence and dynamics of complex network governance in the state of Washington.
The nodes and ties that form this co-regional network are not consistent in reach, form, or function. The cross-boundary cooperation depicted here consists of formal, as well as informal, working groups, and task forces. Some of these arrangements vary in terms of their formalization; in some cases, agencies sign MOUs, in others they partner informally on different projects. These issue-focused intergovernmental coalitions span sectors, levels of government, and operate across organizational and jurisdictional boundaries in a shared geographical space. Such ad hoc approaches may not be novel, but little is known about their histories, management, and effectiveness.
This article focuses on cross-boundary solutions to combating the opiate epidemic in the state of Washington. Though strategies for tackling the opiate crisis appear to be singular in purpose, many formal and informal efforts involve extensive coordination between the region’s health professionals, housing agencies, educational institutions, law enforcement agencies, workforce agencies, and, particularly in rural communities, transportation departments. Similarly, public works departments and business representatives often contribute to the proposed solutions. These types of intergovernmental coalitions tackling complex wicked problems could arguably be rather effective in our regions. Wicked problems are defined as “complex, involving multiple possible causes and internal dynamics that could not be assumed to be linear, and have very negative consequences for society if not addressed properly” (Peters 2017). Networks are important for resolving wicked problems. However, how information, knowledge, and resources are transferred and integrated across these networks is not easy and collaborative capacity builders are necessary (Weber & Khademian 2008).
Focusing on the efforts of workgroups in Mason County (Washington State), this blog post outlines the advantages and disadvantages of this type of informal cross-boundary, cross-policy, and cross-sector coordination. It further explores how this complex network approach has evolved over time, by focusing on the changes in the network of stakeholders. Subsequently, the post explores tensions related to responsibility, accountability, and autonomy, as well as ones associated with resource allocation (Bekemeier, B., Chen, A. L. T., Kawakyu, N., & Yang, Y. (2013). It concludes with a discussion of the potential – as well as the materialized – opportunities. Finally yet importantly, the article proposes questions and implications for future studies on regionalism in a US context.
State of Washington Response to the Opiate Epidemic
As opioid overdoses continue to increase in most jurisdictions, “rapid response efforts and a multisectoral approach are needed to reduce and prevent overdoses and their associated morbidity and mortality” (Vivolo-Kantor et al 2018).Washington State has formally directed its agencies to implement a response plan with five key priority goals: (1) prevent opioid and other drug misuse, (2) identify and treat opioid misuse and stimulant use disorder, (3) ensure and improve the health and wellness of people who use opioids and other drugs, (4) use data and information to detect opioid misuse, monitor drug user health effects, analyze health effects, and evaluate interventions, and (5) support individuals in recovery.1 These are lofty goals. Implementation at the state level is done through six workgroups that coordinate action steps targeting the plan’s five key goals. The plan also explicitly states that it does not include efforts underway at the local and federal levels. But it is made clear that “[p]artners from all sectors on the local, state and federal levels are driving implementation of the strategies and activities in the response plan.” As with any challenge that does not recognize boundaries, this issue requires substantial coordination of efforts. The plan lists stakeholders who have “expressed a particular interest and commitment to addressing opioid misuse and overdose prevention.” There are federal and tribal partners, state partners, professional associations, academic institutions, as well as local entities. Missing are the state’s Regional Public Sector Organizations (Rickabaugh 2021). These regional entities, though listed as “interested stakeholders,” are not tasked with the lead in any of the goals’ actionable items.
In accordance with the state plan, counties develop their own response plans. Thurston County, for example, declared the opioid epidemic a public health crisis in June 2018 and developed its own response plan. A task force of thirty-eight organizations was convened and participated in the plan’s formalization and finalization. The participants of the Thurston County Opioid Response Task Force are mostly from the county, though a tribal nation, state agencies, and a crisis clinic spanning two counties are also involved. Though county efforts are examples of the need for localized solutions, this type of crisis necessitates co-regional coordination. It is not uncommon for these types of county task forces to share resources, information, and even patients. Yet, what brings them across the city/county/sovereign first nation line: Money? Resources? Evidence of effectiveness?
The Mason County Comprehensive Opiate Abuse Program (COAP)
Instead of focusing on the individual efforts of the state’s 39 counties, this blog post highlights workgroups that span all sorts of borders (geographic and otherwise) in Western Washington as they respond to the crisis. Even within singular counties, there are multiple, and yet often coordinated, efforts. The Mason County Opioid Stakeholders Group, for example, regularly brings together participants from various workgroups and programs (Substance Use Prevention, Prevention Coalition, Regional Communities Opioids Response Program, etc.). These endeavors require substantial efforts, and can be elusive when we study coordination across jurisdictional boundaries. Nonetheless, these are excellent examples of regional initiatives that need more attention and further study.
The Mason County Comprehensive Opiate Abuse Program (COAP) seeks to enhance communication and agency collaboration by implementing a “No Wrong Door” approach in efforts to eliminate deaths due to opioid overdose. Communication and referrals to appropriate resources and services throughout the network are an integral component of the “No Wrong Door” approach. Thus, many more stakeholders can be instrumental in supporting coordinated entry by relying on care coordination and peer recovery. This kind of program requires better understanding and coordination within the Mason County Behavioral Health Services System and the broader network beyond to provide the appropriate resources and treatment to all county patients.
The individuals working on the COAP program are some of the core members of the Mason County Opioid Stakeholders Group. Even though Mason County is the focus here, it is important to note that the work and coordination actually spans neighboring counties (Kitsap, Thurston, and Grays Harbor). However, this would be difficult to observe, and study, if the focus was just on overall efforts at county levels. My focus is on the projects undertaken by the workgroups, even if they span multiple counties.
Arguably, our units of analysis should not be organizations (formal or informal); we should be looking at projects, MOUs, agreements, and other tangible outputs. These truly reflect regional efforts that are often in the shadows because they may not have an “organizational home.” Or they may appear to be the work of a single organization or jurisdiction, but a closer look at the efforts of some of these workgroups reveals exceptional coordination that spans all types of boundaries. Figure 1 below provides an example of the network participants that are captured through formal referrals and exchanges. This is an early view of Mason County Behavioral Health Services network of partnerships.
Figure 1: Mason County Behavioral Health Services Network
Even this limited (data is only partially coded2) network visualization shows a range of actors who are tackling a multifaceted problem in an overlapping geographical space. These formal exchanges include agencies from three counties, the state, city, two Tribal nations, and a number of nonprofit organizations. The informal efforts are even larger (geographically speaking) and also worth exploring. However if we looked only at formalized organizations, we would miss out on a lot of regional efforts.
The conception of informal networks is difficult to track; the “when” and “why” this particular network developed might be easier to explain. The presence of a crisis that affects the entire region, in particular a crisis that respects no boundaries, naturally brings people to the table. Another incentive that brings people to the table is resources. Mason County has been instrumental in securing grants to address the opioid epidemic and has been able to capitalize on the informal networks serving the community.
In my experience as the COAP action researcher/external evaluator, I have seen the table grow. With every workgroup meeting, the number and type of stakeholders increased. I guess word spread that this was a worthwhile initiative or it could have been just FOMO (fear of missing out). Nonetheless, more and more stakeholders started to attend. It felt that with every meeting, there was a new participant who wanted to share how they were impacted and wanted to contribute to the solution. From June 2018 to July 2021, the program has seen a steady increase in the number of stakeholders who have taken a seat at the table (physically or virtually). It was possible to track this growth through the data collection instruments distributed to community agencies. The entries for “Another Agency” in the “Participant Referred by” section of the client intake forms reveal a steady growth of agencies. In the first year of the data collection period the number of entries for this category was 15, at the end of the data collection period that number was 29! The social network surveys also indicate that community stakeholders are reaching out to more agencies for information, discussions, support, and resources. In its first iteration, the list included 26 agencies. This list was expanded to 30 (by participants taking the survey and indicating the need to add additional stakeholders).
Clearly, there is something that is working here. Stakeholders are actively trying to contribute to the solution, and are exchanging resources. All that is needed sometimes is just a little leadership and a vision. Coordinating across these multiple, nested networks of targeted workgroups is confusing at times, but bringing them together is powerful. For example, as I was sitting in at one of the smaller workgroups, I witnessed an exchange that was so simple, yet so powerful. All stakeholders at the table posted their resources on a giant board, as well as their needs. After a bit of sorting, pieces of the puzzle were put together and agencies were matched with resources based on their needs and other participants’ available assets. This type of exchange materialized numerous times. The benefits produced through these interactions were many. For example, agencies were able to quickly acquire information on space availability, and were also able to identify a key barrier for patients. In one instance, a person could not complete a treatment program because the agency did not allow animals on the premises. As a result the patient would have to be separated from their pet for a month. Since the client was not willing to abandon their pet and had no means to provide alternative care, they instead opted not to receive treatment. When this story was presented as an example of the challenges faced by one agency, another offered to provide complimentary pet boarding services for the duration of the treatment. In the end, the patient completed the month-long program. As participants saw benefits from these meetings, the desire for more of these increased in order to find out how resources sharing can be strengthened.
Why does it work? From my perspective, this works because it is a small community. Mason County is one of the smaller counties in Washington in terms of population (65,726 inhabitants). Mason County Public Health is also the smallest grant award recipient among those delivered by the Bureau of Justice Assistance to tackle this crisis. As the opioid pandemic has been ravaging the region for years, all stakeholders realized its impact. Many were impacted personally. Though a “singular” issue, this wicked problem has brought together public servants from all policy arenas and governments: sovereign nations, county commissioners, sheriffs, police chiefs, corrections staff, city managers, hospital administrators, educators, mental health professionals, fire chiefs, and so on, all working together across four counties. It is certainly beautiful to see, yet invisible. Studying how informal (and formal) networks operate to help address regional challenges is important. While it is easier to study the formalized structures (organizations), being able to layer how informal exchanges complement these efforts would be vital for our understanding of cross-boundary coordination. So much of these informal relationships evolve over time, yet it is difficult to capture their growth or even presence. But they produce tangible outputs, and these can help us identify the multitude of efforts that are simultaneously operating in various regions.
As policy tools that address regional problems informal workgroups are often classified as instruments that allow autonomous actors to coordinate efforts towards a narrow policy issue. This may not be the case; the opioid pandemic definitely spans multiple policy arenas. We think about it singularly “the opioid epidemic,” but its impact and solutions are not singular. The multiple nested work groups specialize in various solutions: some address transportation challenges for rural residents, others address recovery support services, yet others focus on mental health, or how afterschool programs can complement the efforts of school districts.
Though the actors in these work groups maintain autonomy, they are heavily dependent on each other. It is possible that this dependence is what brings regional stakeholders to the table. The common challenge is powerful. The myriad of work groups evolve into social welfare networks, handshakes become MOUs, and joint grant applications form partnerships. Even something as “simple” as the network depicted in Figure 1 is actually itself a part of an even greater informal network. These informal networks often are parts of various formalized regional mechanisms. Understanding how these formal and informal networks function, either as complements or substitutes, will be essential for our understanding of cross-boundary coordination mechanisms. The state has a plan and every county also has a plan; yet work groups spanning these boundaries are doing a lot of heavy lifting in the background.
How do we study these phenomena? How do we replicate them? Do we need a crisis and grant money before we see successful coordination that spans boundaries? Hopefully not. As we continue our studies of regionalism, we should look at projects or other outputs and work backwards. How did these come to be? Some might be fairly straightforward. Others could be years in the making, and could have evolved from a simple lunch at a convention and exchange of a business card. However they were formed, focusing on the genesis of programs and projects will shed light on regional initiatives. These types of studies can complement efforts that focus on organizations themselves. It is also possible that there is a progression of formalization. For example, some work groups might over time evolve to agreements with other regional entities. Understanding how coordination is formalized (if it is) would be a vital endeavor. Many initiatives are agreements between public and private organizations, and they might not be visible if we only focus on how governments work together. Also frequently missing from the discussion on cross-boundary coordination is the relationship with Tribal governments. By definition they are not local governments but sovereign nations. Yet they are a crucial regional partner, and must be involved. This can be difficult, but not impossible. We have examples of alliances in rural areas that have brought neighbors together to tackle a common challenge.
Finally yet importantly, what brings organizations together across boundaries and jurisdictional borders? Is it a crisis? Is it money? Is it FOMO? Is it trusted leadership? In my experience, the answer to all of these is “yes.” Does a crisis create an opportunity for unlikely alliances? Yes it does. More importantly, when wicked problems do not have a simple organizational nor policy solution we can expect increased coordination. Resources also drive participation. The grant funding that was awarded to Mason County was a catalyst for at least half a dozen programs, and additional grant awards! Most of these are examples of cross-boundary coordination, both organizational and jurisdictional. FOMO can be a factor, particularly if the efforts are perceived as effective and are building momentum. Additionally, leadership, a champion, and political savvy is also needed. It is particularly important to have community leaders who are skilled negotiators and are trusted by all stakeholders. The important role of trust and trustworthiness cannot be overstated for the study and understanding of regional solutions to wicked problems. Repeated interactions, most importantly repeated positive interactions, are essential for relationship building across organizational and jurisdictional boundaries.
What can we learn from this network about regionalism, or effective management of boundary-spanning “wicked problems?” First, many questions remain unanswered – and this is the exciting part for theory-building scholars. A genuine desire for solutions by all stakeholders – regardless of their policy arenas – appears to be a necessary condition, though not in itself sufficient. A challenge bigger than the existing institutions and their organizations’ capacities for solutions seem important as well. Wicked problems are complex, the opioid pandemic is complex, and the solutions will be complex. Social network analyses are a great first step to understanding the formation and effectiveness of complex formal and informal networks. Additionally, configurational approaches such as qualitative comparative analysis (QCA) can help us identify numerous complex solutions to regionalism’s biggest questions. Understanding which necessary and sufficient conditions create paths to successful cross-boundary cooperation can be important for both theories and practice of regionalism.
Notes
2021-2022 Opioid and Overdose Response Plan by Washington State. The five priorities are updated from the four listed in the earlier 2018 plan: https://www.hca.wa.gov/assets/program/WashingtonStateOpioidandOverdoseResponsePlan-final-2021.pdf
The data collection process was halted multiple times due to unforeseen circumstances. At the time of publication, a number of social network survey responses are yet to be digitized and analyzed. A more detailed analysis of the data would provide information regarding the network structure before as well as during COVID. Many organizations adapted their communications and exchanges.
References
Bekemeier, B., Chen, A. L. T., Kawakyu, N., & Yang, Y. (2013). Local public health resource allocation: limited choices and strategic decisions. American journal of preventive medicine, 45(6), 769-775.
Peters, B. G. (2017). What is so wicked about wicked problems? A conceptual analysis and a research program. Policy and Society, 36(3), 385-396.
Rickabaugh, J. (2021). Regional Public Sector Organizations: A broader taxonomic classification to cross-pollinate empirical research. Public Administration.
Vivolo-Kantor, A. M., Seth, P., Gladden, R. M., Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2018). Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017. Morbidity and Mortality Weekly Report, 67(9), 279.
Weber, E. P., & Khademian, A. M. (2008). Wicked problems, knowledge challenges, and collaborative capacity builders in network settings. Public administration review, 68(2), 334-349.