Research protocol: a realist synthesis of contestability in community-based mental health markets

Abstract

BackgroundIn most developed nations, there has been a shift from public services to a marketisation of public goods and services - representing a significant reform process aiming to transform the way in which community-based human services, such as health, are delivered and consumed. For services, this means developing the capacity to adapt and innovate in response to changing circumstances to achieve quality. The availability of rigorous research to demonstrate whether a market approach and contestability, in particular, is a coherent reform process is largely absent. Contestability operates on the premise that better procurement processes allow more providers to enter the market and compete for contracts. This is expected to create stimulus for greater efficiencies, innovation and improved service delivery to consumers. There is limited understanding, however, about how community-based providers morph and re-configure in response to the opportunities posed by contestability. This study focuses on the effect of a contestability policy on the community-managed mental health sector.Methods/designA realist review will be undertaken to understand how and why the introduction of contestability into a previously incontestable market influences the ways in which community-based mental health providers respond to contestability. The review will investigate those circumstances that shape organisational response and generate outcomes through activating mechanisms. An early scoping has helped to formulate the initial program theory. A realist synthesis will be undertaken to identify relevant journal articles and grey literature. Data will be extracted in relation to the emerging contextual factors, mechanisms and outcomes and their configurations. The analysis will seek patterns and regularities in these configurations across the extracted data and will focus on addressing our theory-based questions.DiscussionIncreasingly, community-based mental health markets are moving to contestability models. Rigorous research is needed to understand how such markets work and in what contexts. The knowledge gained from this study in community-based mental health will provide valuable lessons in how contestability works, in what circumstances and who benefits when. The results of the proposed research will be useful to policy-makers and may be applicable in other contexts beyond the community-based mental health sector.Systematic review registrationPROSPERO CRD42015016808

A realist evaluation: how institutional entrepreneurs build adaptive not-for-profit healthcare organisations

“…The range of health services provided by NFPs may include [4,9]: The environment in which Australian NFPs operate is rapidly changing. In the past three decades, there has been a significant shift to the commodification of government-funded health services, through mandated reforms, new laws and regulations, and cuts to public sector funding [10,11]. The shift to a competitive market aims to identify providers who will deliver health services most competitively.…”

“…For NFPs, which have traditionally been cushioned from the competitive pressures of markets, the journey into a competitive market is filled with uncertainty. NFP service providers must adapt to constantly changing landscapes, including increasing demands for greater accountability and shifting client expectations [11,13,14]. As the boundaries between the various sectors become blurred, the "for-purpose" NFP sector is faced with the pressure to conform to the business principles of the public and for-profit sectors [5,13,15,16].…”

“…The response of NFPs to business-like pressures can mean that the sector is forced to reconfigure its operations in ways that compromise the not-for-profit mission in order to show economic efficiency with indicators traditionally used in the commercial sector [13,17]. Available data suggests that NFPs are attempting to address these challenges, yet many are having difficulty adapting [8,11]. As public-serving NFPs confront changed economic, political, and competitive environments, too little is known about the manner in which they can successfully grow in their altered external environment.…”

“…Rather, it is the mechanisms underlying the strategies that generate outcomes [11,40,143]. It is this notion of mechanisms that takes a step away from the positivist view of asking whether a strategy 'works' to understanding what it is about a strategy which makes it 'work' [18,42].…”

“…IEs are perceived as legitimate) [11,136,144]. that an outcome of one strategy can also become a context or mechanism that provides another outcome, creating a 'ripple effect' [145].…”