The impact of central government steering and local network dynamics on the performance of mandated service delivery networks: the case of the Primary Health Care networks in Flanders

This paper focuses on the impact of central – local relations on the performance of local service delivery networks set up by central government. Analyzing network literature leaves us with some questions about the impact of coordination strategies of central government as a possible determinant of network-level effectiveness for this type of network and the possible interaction between central government coordination (as part of the network context) and internal network dynamics and the combined effects hereof on the effectiveness of mandated service delivery networks in particular. Our analysis shows that both levels are important to explain the outcomes of the Primary Health Care networks in Flanders. Our study also leads to some important observations about the meaning of ‘central government coordination’ in this context

Rescaling the state in Flanders: new problem or old solution?

The rescaling of state emphasizes the rise of the regional and the city-regional scale in particular, as a new unit for policy making. The new governing strategy is referred to as regional governance, were both governmental and / or nongovernmental entities work together for the purpose of joint policy making or service delivery. This paper focuses on the operationalization of regional governance and links those findings to the actual debates surrounding the institutional organization of Flanders. A quantitative analysis of regional arrangements in Flanders and in the area of Mid-West Flanders, helps to clarify the nature of the rescaling of the state: the rescaling is the result of bottom – up and top – down initiatives and covers as well joined government arrangements as collaborative governance arrangements integrating public and private organizations. Further, we notice different roles of the Flemish government, as she is present at the regional level both as a meta-governor, actor and financier. By showing the nature and the content of regional governance, this paper helps to clarify the political debate that is going on now in Flanders. A debate dominated by classical institutional discussions and related to the issue of institutional fuzziness, efficiency and accountability. It is argued however that the political discussion and the organization of the public sector in Flanders should be renewed and should be inspired by this relatively new phenomenon. The rescaling of the regional state should be understood by using concepts, theories and instruments inspired by the literature on networks and collaborative governance

De Vlaamse stadsregio vanuit internationaal perspectief bekeken: aanzet tot een onderzoeksagenda

In deze paper geven we een aanzet tot een onderzoeksagenda naar stadsregio’s en stadsregionale samenwerking in Vlaanderen. In het eerste deel van de paper gaan we in de literatuur op zoek naar voor ons interessante concepten, inzichten en opvattingen over deze problematiek. We streven vooreerst naar een duidelijk begrip van de stadsregionale schaal. Literatuur over city-regions en functional urban areas vormt hierbij onze leidraad. Daarna geven we een overzicht van mogelijke drivers en barrières voor de ontwikkeling van stadsregionale samenwerking. In een derde onderdeel focussen we op literatuur die ons inzicht geeft in praktijken van beleidsvoering en bestuurlijke organisatie op een stadsregionale schaal. Het gedachtegoed van het New Regionalism biedt ons hiervoor een kader. In het tweede luik maken we de vertaalslag van de literatuur naar de praktijk van stadsregionale samenwerking in Vlaanderen. We plaatsen de stadsregionale problematiek in de Vlaamse context: een regio waar gemeenten (in vergelijking met andere landen) over beperkte bestuurlijke bevoegdheden beschikken en waar de centrale (Vlaamse) overheid bevoegd is voor heel wat beleidsdomeinen waarbinnen lokale en dus ook stadsregionale vraagstukken zich situeren (bijvoorbeeld ruimtelijke planning, huisvesting en openbaar vervoer). We laten ons leiden door het analysekader van Voets en De Rynck (2008) en de zeven bestuurlijke strategieën voor stadsregionale samenwerking die deze auteurs onderscheiden

Lokale netwerken als instrument voor centraal beleid?

A

Implementation of Point-of-Care Diagnostics Leads to Variable Uptake of Syphilis, Anemia and CD4+ T-Cell Count Testing in Rural Maternal and Child Health Clinics

Introduction: Anemia, syphilis and HIV are high burden diseases among pregnant women in sub-Saharan Africa. A quasi-experimental study was conducted in four health facilities in Southern Mozambique to evaluate the effect of point-of-care technologies for hemoglobin quantification, syphilis testing and CD4+ T-cell enumeration performed within maternal and child health services on testing and treatment coverage, and assessing acceptability by health workers. Methods: Demographic and testing data on women attending first antenatal care services were extracted from existing records, before (2011; n = 865) and after (2012; n = 808) introduction of point-of-care testing. Study outcomes per health facility were compared using z-tests (categorical variables) and Wilcoxon rank-sum test (continuous variables), while inverse variance weights were used to adjust for possible cluster effects in the pooled analysis. A structured acceptability-assessment interview was conducted with health workers before (n = 22) and after (n = 19). Results: After implementation of point-of-care testing, there was no significant change in uptake of overall hemoglobin screening (67.9% to 83.0%; p = 0.229), syphilis screening (80.8% to 87.0%; p = 0.282) and CD4+ T-cell testing (84.9% to 83.5%; p = 0.930). Initiation of antiretroviral therapy for treatment eligible women was similar in the weighted analysis before and after, with variability among the sites. Time from HIV diagnosis to treatment initiation decreased (median of 44 days to 17 days; p\u3c0.0001). A generally good acceptability for point-of-care testing was seen among health workers. Conclusions: Point-of-care CD4+ T-cell enumeration resulted in a decreased time to initiation of antiretroviral therapy among treatment eligible women, without significant increase in testing coverage. Overall hemoglobin and syphilis screening increased. Despite the perception that point-of-care technologies increase access to health services, the variability in results indicate the potential for detrimental effects in some settings. Local context needs to be considered and services restructured to accommodate innovative technologies in order to improve service delivery to expectant mothers