ORIGINAL ARTICLE
What healthcare leaders can learn from research on dark networks H. Brinton Milward, PhD
Abstract—For 12 years, a research program has been conducted on “dark networks,” which are both illegal and covert. One of the major findings is that the structure of the network is conditioned by an existential dilemma—the need to act or exist. The more you do of one, the less you can do of the other. This article examines the findings of that research and applies it to the dilemmas of organizing healthcare networks.
I
n healthcare, if there is a problem that involves coordination of care, someone will surely suggest that a network is the solution to the lack of coordination. This in fact is the network value proposition. Because of this, we have tended to think of networks as the highest stage of organizing to solve collective problems like a strategy to better serve the needs of the mentally ill in a province or state. This article asserts that the assumption that networks are superior to organizations or markets as a means of coordination is wrong. If a problem can be dealt with effectively in a market or a single organization, healthcare leaders should do it, as it is much easier. Both organizations and markets have high-powered incentives like prices or commands to coordinate the activity. Networks should be reserved for problems that do not fit neatly into a market or organization, and because reciprocity based on trust is the adhesive that holds a network together, there must be adequate time for trust to emerge to facilitate the effective coordination of network activity. Leaders should choose networks when it is clear that markets and hierarchical organizations have failed and where there are problems that are complex and multifaceted and beyond the ability of a single organization or the price system to coordinate them effectively.
DISCUSSION There is certainly no shortage of research on networks in healthcare to illustrate their increasing use in dealing with problems of integrated services in vulnerable populations like children, the elderly, or the mentally ill.1,2 The author has From the School of Government and Public Policy, University Tucson, AZ. Correspondence: H. Brinton Milward, School of Government Policy, University of Arizona, Social Sciences Building, Room 315, 85721-0027. (e-mail: [email protected]) Milward is the Providence Service Corporation Chair Management.
of Arizona, and Public Tucson, AZ
in Public
Healthcare Management Forum 2014 27:136–138 0840-4704/$ - see front matter & 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2014.06.002
spent the past 38 years studying networks of organizations, and for most of that time, these were mental health networks or healthcare networks. After Al Qaeda's attack on the World Trade Center on September 11, 2001, that focus changed. Little was known about the organizational challenges of leading illegal and covert networks, which is how the “dark networks” research program began. Dark does not imply good or bad, but simply that, members of these networks must stay out of the light or they can be killed or captured. Given this definition, the African National Congress (ANC) under Nelson Mandela was a dark network under the South African apartheid laws. Other dark networks include Al Qaeda, the drug cartels in Mexico, or the Revolutionary Armed Forces of Colombia (FARC) that mixes grievance and greed by being both an insurgency as well as drug traffickers. One of the major findings of this research program is that the structure of the dark network is conditioned by an existential dilemma —the need to act or exist. To engage in overt acts against their opponent, the members of the network must coordinate their activities to plan, implement, and strike their opponent. At the same time, coordinating their activities increases the probability that an informant or phone surveillance will give their plans away and allow their opponent to strike them first. Thus, the process of engaging the enemy can threaten the network's existence. To increase the probability of continuing to exist, the solution is to lay low and go underground to increase the chance that their enemy cannot find the dark network. This is “the terrorist's dilemma.”3 Does the leader bring his people together to attack the government and expose the network to the risk that the government has prepared a trap or does the leader decide to decentralize his fighters and hope to live to fight another day? This binary choice allows us to consider a critical feature of any type of network—resilience. How resilient is the network to a shock like a financial meltdown that leads to a government losing a third of its tax base?4 One measure of resilience is how and whether the network survives over time. The second is how does it organize to respond to these attacks? Seeing how a network changes its form after a shock or attack allows us to understand what type of network structure is the most resilient under which conditions.
WHAT HEALTHCARE LEADERS CAN LEARN FROM RESEARCH ON DARK NETWORKS
The first task is to consider resilience as survival. In a recent article on the resilience of dark networks, three responses to a significant shock are proposed. Non-resilient dark networks like Pablo Escobar's Colombian drug cartel5 are instructive for healthcare networks. Pablo Escobar was a drug kingpin, and he was killed by Colombian Special Forces, with help from the United States in the 1990s. Once Escobar was gone, the cartel fell apart as too much depended on one central actor. Nelson Mandela's ANC was almost destroyed for the same reason when he and most of his top assistants were arrested and jailed by the apartheid government of South Africa in the early 1960s. Like Pablo's cartel, the ANC too was centralized, and it took 13 years to rebound from the shock of the arrests. As a rebounding network, it became much more cellular so that the leadership tried to maintain a decentralized network to resist the armed forces and police of South Africa when it needed to, while having a survivable centralized structure to return to when the pressure from the government was intense. There is a clear tradeoff here: the network maintained a structure that allowed for rebuilding the opposition to apartheid but at the cost of quickly confronting the government. The last pattern of resilience is a robust response to a major shock. Here a network takes the best shot from their opponent and is so resilient that it does not slow down its operations. The Revolutionary Armed Forces of Colombia prior to 2005 is an example of this pattern. It was decentralized across a mountainous jungle territory into “fronts” and had money for arms and supplies from its drug trafficking operations allowing it to take the blows the government sent their way while having the resources to respond in kind.6 The second feature of resilience that has relevance to healthcare is that it is essential to organize and reorganize in response to changing conditions. It helps not to think of organizations and networks as distinct structures but rather focus on the process of organizing as the key management task. Al Qaeda before September 11 was a rather centralized network. It had a base of operations in Afghanistan, and it did not need to hide its existence from the Taliban government of Afghanistan as they were invited guests in the country. After September 11, when the U.S. and its North Atlantic Treaty Organization (NATO) allies invaded the country, it had to radically decentralize and hide in the caves of South Waziristan after the Battle of Tora Bora. This was Al Qaeda's only alternative, if it was not going to be completely destroyed. Rather than talking about organizations or networks as alternative solutions, consider the process of organizing as the critical management task. In mental health, mental hospitals once dominated the organizational landscape and provided housing, food, treatment, and recreation within the confines of a locked institution. Now, the same services are provided by mental health networks, which integrate services for clients in a deinstitutionalized setting. It can be argued as to which organizational alternative provided the best and
most consistent treatment; however, providing care in a deinstitutionalized setting comports far better with societal values than locking the mentally ill away in insane asylums.7 Based on the work the author has conducted on dark network resilience, it seems that the following factors can be applied to healthcare as a form of reasoning by analogy. (1) Networks viewed as legitimate both internally by their members and externally by their funders, clients, and political superiors are quite resilient. In many ways, for networks, legitimacy constitutes the stakes of the game for long-term survival as many networks are externally funded by governments. (2) Networks have a carrying capacity that is directly tied to resilience. Resources must be balanced against tasks, and a network that is highly effective for 3,000 clients will likely fail with 6,000 clients and no additional resources. (3) Over time, people and organizations come and go and the network must replace them. Maintaining network capacity is critical for maintaining resilience. A key task for network leaders is to “prune” the network of deadwood in the form of non-performing or overly demanding organizations as well as the more standard task of recruiting new organizational members. Trusted members whose values comport with the network's are highly valued. (4) The managerial implication of the “terrorist's dilemma” is that network leaders must quickly balance the structure of their network very skillfully to allow the network to adapt to the changing nature of the political and economic environment. At some point, it may make sense for a network to centralize and gain greater efficiency like Pablo Escobar's cartel if there are few environmental changes. If the environment changes, it may make sense to decentralize to better adapt to economic or political crises, even at the cost of some efficiency. (5) Organizing is a function of what is possible given the tasks a leader is trying to accomplish and the resources at one's disposal. Because networks are a weaker and slower form of collective action than organizations, leaders should use an organization if possible and a network if they must. It is important to recognize that moving from one form to another as the environment changes will enhance resilience.
CONCLUSION The purpose of this short article is to ask healthcare leaders to conduct a thought experiment and think of networks very differently than they are portrayed in healthcare and in many other fields as kinder, gentler forms of organizing where consensus rules and goals emerge from the needs of the members. Think of networks engaged in an
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
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Milward
existential conflict with an opponent. In this world, power and conflict prevail, and networks are no longer viewed as a more humane alternative to bureaucracies. To rethink networks, rethink the alternative—organizations. Both networks and organizations are structural choices that human beings make as to how to achieve collective goals. Weick7 refuses to talk about organizations at all but only the process of organizing. This moves us towards a place where the choice of a network or an organization is based on the task at hand rather than a normative preference. Both are arrows in the quiver of healthcare leaders. If we are honest and look at public problems over time, it is clear that leaders have often chosen organizations at one time and networks at another for reasons unrelated to the problem they faced. It is not without irony that the United States created the second largest bureaucracy in its history when it created the Department of Homeland Security after September 11, when its opponent was not another organization but rather a terrorist network. Healthcare leaders must recognize that organizing involves a continuous process of balancing the benefits of centralization with its costs vs the costs and benefits of decentralized networks as they move from organizations at one time to networks at another based on the critical problems at
138
hand. For a healthcare leader, the key is knowing when and why to switch from one to the other so that whatever form is chosen, it is both resilient and effective.
REFERENCES 1. Hill C. Network Literature Review: Conceptualizing and Evaluating Networks. Calgary, AB: Southern Alberta Child and Youth health Network; 2002. Available at: 〈http://health-leadership-research. royalroads.ca/publications/〉. 2. Popp J, MacKean G, Casebeer A, Milward HB, Lindstrom R. Inter-organizational networks: a critical review of the literature to inform practice; 2013 (online literature review). Available at: 〈http://health-leadership-research.royalroads.ca/publications/〉. 3. Raab J, Milward HB. Dark networks as problems. J Public Adm Res Theory 2003;9(4):413–439. 4. Carboni J, Milward HB. Governance privatization and systemic risk in the disarticulated state. Public Adm Rev 2012;72(special issue):536–544. 5. Kenney M. From Pablo to Osama: Trafficking and Terrorist Networks, Government Bureaucracies and Competitive Adaptation. State College, PA: Penn State University Press; 2006. 6. Bakker R, Raab J, Milward HB. A preliminary theory of dark network resilience. J Policy Anal Manage 2012;31(1):33–62. 7. Weick K. The Social Psychology of Organizing, 2nd ed, New York: McGraw Hill; 1979.
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
What healthcare leaders can learn from research on dark networks H. Brinton Milward, PhD
Abstract—For 12 years, a research program has been conducted on “dark networks,” which are both illegal and covert. One of the major findings is that the structure of the network is conditioned by an existential dilemma—the need to act or exist. The more you do of one, the less you can do of the other. This article examines the findings of that research and applies it to the dilemmas of organizing healthcare networks.
I
n healthcare, if there is a problem that involves coordination of care, someone will surely suggest that a network is the solution to the lack of coordination. This in fact is the network value proposition. Because of this, we have tended to think of networks as the highest stage of organizing to solve collective problems like a strategy to better serve the needs of the mentally ill in a province or state. This article asserts that the assumption that networks are superior to organizations or markets as a means of coordination is wrong. If a problem can be dealt with effectively in a market or a single organization, healthcare leaders should do it, as it is much easier. Both organizations and markets have high-powered incentives like prices or commands to coordinate the activity. Networks should be reserved for problems that do not fit neatly into a market or organization, and because reciprocity based on trust is the adhesive that holds a network together, there must be adequate time for trust to emerge to facilitate the effective coordination of network activity. Leaders should choose networks when it is clear that markets and hierarchical organizations have failed and where there are problems that are complex and multifaceted and beyond the ability of a single organization or the price system to coordinate them effectively.
DISCUSSION There is certainly no shortage of research on networks in healthcare to illustrate their increasing use in dealing with problems of integrated services in vulnerable populations like children, the elderly, or the mentally ill.1,2 The author has From the School of Government and Public Policy, University Tucson, AZ. Correspondence: H. Brinton Milward, School of Government Policy, University of Arizona, Social Sciences Building, Room 315, 85721-0027. (e-mail: [email protected]) Milward is the Providence Service Corporation Chair Management.
of Arizona, and Public Tucson, AZ
in Public
Healthcare Management Forum 2014 27:136–138 0840-4704/$ - see front matter & 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2014.06.002
spent the past 38 years studying networks of organizations, and for most of that time, these were mental health networks or healthcare networks. After Al Qaeda's attack on the World Trade Center on September 11, 2001, that focus changed. Little was known about the organizational challenges of leading illegal and covert networks, which is how the “dark networks” research program began. Dark does not imply good or bad, but simply that, members of these networks must stay out of the light or they can be killed or captured. Given this definition, the African National Congress (ANC) under Nelson Mandela was a dark network under the South African apartheid laws. Other dark networks include Al Qaeda, the drug cartels in Mexico, or the Revolutionary Armed Forces of Colombia (FARC) that mixes grievance and greed by being both an insurgency as well as drug traffickers. One of the major findings of this research program is that the structure of the dark network is conditioned by an existential dilemma —the need to act or exist. To engage in overt acts against their opponent, the members of the network must coordinate their activities to plan, implement, and strike their opponent. At the same time, coordinating their activities increases the probability that an informant or phone surveillance will give their plans away and allow their opponent to strike them first. Thus, the process of engaging the enemy can threaten the network's existence. To increase the probability of continuing to exist, the solution is to lay low and go underground to increase the chance that their enemy cannot find the dark network. This is “the terrorist's dilemma.”3 Does the leader bring his people together to attack the government and expose the network to the risk that the government has prepared a trap or does the leader decide to decentralize his fighters and hope to live to fight another day? This binary choice allows us to consider a critical feature of any type of network—resilience. How resilient is the network to a shock like a financial meltdown that leads to a government losing a third of its tax base?4 One measure of resilience is how and whether the network survives over time. The second is how does it organize to respond to these attacks? Seeing how a network changes its form after a shock or attack allows us to understand what type of network structure is the most resilient under which conditions.
WHAT HEALTHCARE LEADERS CAN LEARN FROM RESEARCH ON DARK NETWORKS
The first task is to consider resilience as survival. In a recent article on the resilience of dark networks, three responses to a significant shock are proposed. Non-resilient dark networks like Pablo Escobar's Colombian drug cartel5 are instructive for healthcare networks. Pablo Escobar was a drug kingpin, and he was killed by Colombian Special Forces, with help from the United States in the 1990s. Once Escobar was gone, the cartel fell apart as too much depended on one central actor. Nelson Mandela's ANC was almost destroyed for the same reason when he and most of his top assistants were arrested and jailed by the apartheid government of South Africa in the early 1960s. Like Pablo's cartel, the ANC too was centralized, and it took 13 years to rebound from the shock of the arrests. As a rebounding network, it became much more cellular so that the leadership tried to maintain a decentralized network to resist the armed forces and police of South Africa when it needed to, while having a survivable centralized structure to return to when the pressure from the government was intense. There is a clear tradeoff here: the network maintained a structure that allowed for rebuilding the opposition to apartheid but at the cost of quickly confronting the government. The last pattern of resilience is a robust response to a major shock. Here a network takes the best shot from their opponent and is so resilient that it does not slow down its operations. The Revolutionary Armed Forces of Colombia prior to 2005 is an example of this pattern. It was decentralized across a mountainous jungle territory into “fronts” and had money for arms and supplies from its drug trafficking operations allowing it to take the blows the government sent their way while having the resources to respond in kind.6 The second feature of resilience that has relevance to healthcare is that it is essential to organize and reorganize in response to changing conditions. It helps not to think of organizations and networks as distinct structures but rather focus on the process of organizing as the key management task. Al Qaeda before September 11 was a rather centralized network. It had a base of operations in Afghanistan, and it did not need to hide its existence from the Taliban government of Afghanistan as they were invited guests in the country. After September 11, when the U.S. and its North Atlantic Treaty Organization (NATO) allies invaded the country, it had to radically decentralize and hide in the caves of South Waziristan after the Battle of Tora Bora. This was Al Qaeda's only alternative, if it was not going to be completely destroyed. Rather than talking about organizations or networks as alternative solutions, consider the process of organizing as the critical management task. In mental health, mental hospitals once dominated the organizational landscape and provided housing, food, treatment, and recreation within the confines of a locked institution. Now, the same services are provided by mental health networks, which integrate services for clients in a deinstitutionalized setting. It can be argued as to which organizational alternative provided the best and
most consistent treatment; however, providing care in a deinstitutionalized setting comports far better with societal values than locking the mentally ill away in insane asylums.7 Based on the work the author has conducted on dark network resilience, it seems that the following factors can be applied to healthcare as a form of reasoning by analogy. (1) Networks viewed as legitimate both internally by their members and externally by their funders, clients, and political superiors are quite resilient. In many ways, for networks, legitimacy constitutes the stakes of the game for long-term survival as many networks are externally funded by governments. (2) Networks have a carrying capacity that is directly tied to resilience. Resources must be balanced against tasks, and a network that is highly effective for 3,000 clients will likely fail with 6,000 clients and no additional resources. (3) Over time, people and organizations come and go and the network must replace them. Maintaining network capacity is critical for maintaining resilience. A key task for network leaders is to “prune” the network of deadwood in the form of non-performing or overly demanding organizations as well as the more standard task of recruiting new organizational members. Trusted members whose values comport with the network's are highly valued. (4) The managerial implication of the “terrorist's dilemma” is that network leaders must quickly balance the structure of their network very skillfully to allow the network to adapt to the changing nature of the political and economic environment. At some point, it may make sense for a network to centralize and gain greater efficiency like Pablo Escobar's cartel if there are few environmental changes. If the environment changes, it may make sense to decentralize to better adapt to economic or political crises, even at the cost of some efficiency. (5) Organizing is a function of what is possible given the tasks a leader is trying to accomplish and the resources at one's disposal. Because networks are a weaker and slower form of collective action than organizations, leaders should use an organization if possible and a network if they must. It is important to recognize that moving from one form to another as the environment changes will enhance resilience.
CONCLUSION The purpose of this short article is to ask healthcare leaders to conduct a thought experiment and think of networks very differently than they are portrayed in healthcare and in many other fields as kinder, gentler forms of organizing where consensus rules and goals emerge from the needs of the members. Think of networks engaged in an
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
137
Milward
existential conflict with an opponent. In this world, power and conflict prevail, and networks are no longer viewed as a more humane alternative to bureaucracies. To rethink networks, rethink the alternative—organizations. Both networks and organizations are structural choices that human beings make as to how to achieve collective goals. Weick7 refuses to talk about organizations at all but only the process of organizing. This moves us towards a place where the choice of a network or an organization is based on the task at hand rather than a normative preference. Both are arrows in the quiver of healthcare leaders. If we are honest and look at public problems over time, it is clear that leaders have often chosen organizations at one time and networks at another for reasons unrelated to the problem they faced. It is not without irony that the United States created the second largest bureaucracy in its history when it created the Department of Homeland Security after September 11, when its opponent was not another organization but rather a terrorist network. Healthcare leaders must recognize that organizing involves a continuous process of balancing the benefits of centralization with its costs vs the costs and benefits of decentralized networks as they move from organizations at one time to networks at another based on the critical problems at
138
hand. For a healthcare leader, the key is knowing when and why to switch from one to the other so that whatever form is chosen, it is both resilient and effective.
REFERENCES 1. Hill C. Network Literature Review: Conceptualizing and Evaluating Networks. Calgary, AB: Southern Alberta Child and Youth health Network; 2002. Available at: 〈http://health-leadership-research. royalroads.ca/publications/〉. 2. Popp J, MacKean G, Casebeer A, Milward HB, Lindstrom R. Inter-organizational networks: a critical review of the literature to inform practice; 2013 (online literature review). Available at: 〈http://health-leadership-research.royalroads.ca/publications/〉. 3. Raab J, Milward HB. Dark networks as problems. J Public Adm Res Theory 2003;9(4):413–439. 4. Carboni J, Milward HB. Governance privatization and systemic risk in the disarticulated state. Public Adm Rev 2012;72(special issue):536–544. 5. Kenney M. From Pablo to Osama: Trafficking and Terrorist Networks, Government Bureaucracies and Competitive Adaptation. State College, PA: Penn State University Press; 2006. 6. Bakker R, Raab J, Milward HB. A preliminary theory of dark network resilience. J Policy Anal Manage 2012;31(1):33–62. 7. Weick K. The Social Psychology of Organizing, 2nd ed, New York: McGraw Hill; 1979.
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
