In the Literature
What does it take for government agencies to overcome the hurdles of limited time and resources, fragmentation, and bureaucracy and work together? A recent study addressing that question pointed to The Commonwealth Fund-supported Assuring Better Child Health and Development (ABCD) program as an example of successful collaboration among Medicaid and other state agencies.
In the initial phase of the ABCD program, which ran from 2000 to 2003, the Fund provided grants to four states—North Carolina, Utah, Vermont, and Washington—to enhance the delivery of developmental services to low-income children. In "Jump-Starting Collaboration: The ABCD Initiative and the Provision of Child Development Services Through Medicaid and Collaborators" (Public Administration Review, May/June 2008), researchers led by Carolyn Berry, Ph.D., of New York University find that the program was successful: all states made changes to their policies, regulations, or reimbursement mechanisms to achieve their goals. Beyond just paying for developmental services, the four state Medicaid agencies took active roles in partnering with child health professionals.
According to Berry and her coauthors, the states' successes were due to their willingness to work across agencies, including the departments of health, public health, and social services, as well as with professional medical groups. The analysis was based on an external evaluation of the ABCD program that was also supported by the Fund. The analysis included informant interviews and site visits, document reviews, and observation of meetings and conference calls among participants.
Motivations for Collaboration
Although the benefits of collaboration may seem clear, government agency leaders must choose to work together in the face of significant challenges. Recent examples, such as the federal government's response to Hurricane Katrina, demonstrate the perils of a lack of collaboration.
According to a framework set forth in a 1990 article by Christine Oliver and cited by the authors, government agencies might be persuaded to collaborate for the following reasons: 1) reciprocity, or collaboration for the purpose of pursuing a common interest; 2) efficiency, or the desire to take advantage of pooled resources and expertise; 3) legitimacy, or the desire to take part in a project deemed to be of prominence; or 4) stability, or the desire to share the risks of entering into a new arena.
The ABCD program fulfilled each of these motivating factors. While states had differing approaches, they had a common goal and were able to share resources to accomplish it. Furthermore, financing and technical support provided by the National Academy for State Health Policy (NASHP) helped states overcome resource constraints, lent legitimacy to the project, and mitigated the risks of a new venture.
Ingredients for Successful Collaboration
The authors conclude that Medicaid agencies were able to implement ABCD by developing working relationships among state agencies. Several of the key informants noted that, in all four states, the ABCD initiative catalyzed an unusual degree of cooperation.
"The ABCD initiative inspired a notable degree of interagency cooperation and coordination in all four states," the authors note. "Over the course of the three years, interagency barriers were broken down and often intractable bureaucracies changed their behaviors as a result of ABCD. . . . [T]he relationship between ABCD and interagency cooperation went both ways—it was necessary in many cases for interagency cooperation to occur in order to implement the ABCD projects, and ABCD itself spurred interagency coordination."
In addition, states that partnered with medical professionals during the planning stages achieved greater success; they developed more practical programs and had to devote less time soliciting the support of the medical community during the implementation process. All four states built on existing child development infrastructure or strategies, instead of starting from scratch. They followed a "pilot, refine, and expand" model in creating their programs, enabling them to gradually expand the circle of participants and build support for their efforts.
Finally, the role played by NASHP was critical in fostering collaboration. NASHP convened a consortium of program participants across the states, allowing them to share practical advice and information, discuss goals, and vent frustrations when confronting obstacles.
Implications
The ABCD experience demonstrates that it is feasible for states to play an active and effective role in strengthening child development services. The program also provides an example of a successful collaboration: with modest external support and technical assistance, state governments can take active roles in forging collaborations across public agencies to accomplish shared goals.
This article demonstrates the potential robust effects that external, incentive-based programs can have in precipitating collaboration among institutional entities in a highly-fragmented policy area," the authors conclude. "Future public administration literature should continue to focus on questions of how government leaders overcome the many obstacles to collaboration."
