Service fragmentation in social services - how can ecosystem orchestrators and outcomes contracts help?

What are ecosystem orchestrators and how can they help?

In his book “Measuring Social Change”, Professor Alnoor Ebrahim describes an ecosystem strategy as one where interactions between key stakeholders need to be reconfigured, not just coordinated, to produce better outcomes. As one approach to addressing service fragmentation, ecosystem orchestrators can help align and restructure the roles of the different organisations involved. This is important in ensuring that individual organisations are brought together in a coherent way, instead of operating in silos.

In practice, four key ingredients underpin the ecosystem strategy:

1) System framing: Map the existing system to understand which organisations exist in a certain policy or geographic area, and what their specific roles are.

2) Interdependent model of social change: Consider how interdependent models or theories of social change can be built by wrapping services around service users.

3) Accountability for collective outcomes: Identify a common outcome that stakeholders are working towards and align work around it across organisations.

4) New capacities for orchestration: Use “backbone organisations” to organise groups of key actors, participate in joint advocacy, and influence city budgets.

Impact bonds, pioneered in the UK, offer one mechanism that might bring these four ingredients together.

Kirklees Integrated Support Service- an example from the UK

A combination of social investment, cross-sector collaboration, and outcomes contracting, Kirklees Integrated Support Service supports adults who need assistance to live independently. Based in Kirklees Council in England, the project launched in 2019 as a social impact bond (SIB) and illustrates the added value of an ecosystem orchestrator.

An interim evaluation report from the Government Outcomes Lab finds that the service launched in a system of fragmented housing services. While several service contracts were in place, they faced significant challenges. These included limited market stewardship, limited contract and performance management, limited flexibility in service delivery, and limited collaboration across service providers. Introducing an outcomes contract through the social impact bond might address these challenges in two main ways. Firstly, it may offer system-level coordination through stewardship of the provider network and collaborative infrastructure. Secondly, it could facilitate more productive interactions with service users by offering responsive and reflexive services, combined with strong performance management.

While the project is still in implementation and final results are not anticipated until late 2024, promising changes have emerged from switching to the SIB contract. Sarah Cooke, Managing Director at Kirklees Better Outcomes Partnership (KBOP), suggested the SIB has helped put service users back at the centre of services. By paying for pre-agreed outcomes and bringing in careful but collaborative contract management, it has introduced greater accountability, flexibility, and innovation. In addition, the project uses an asset-based model, which focusses on service users’ strengths and what they want to achieve rather than ‘deficits.’ Instead of only addressing part of the issue, service providers are better able to understand the root cause and break the cycle of re-referral into services. Quality standardisation, shared data systems, and trusting relationships with partners have proved pivotal in supporting more than 2400 people so far.

Expanding malaria testing and treatment - an example from Nigeria

The use of these mechanisms is not limited to higher income countries like the UK. Richard Johnson, a senior consultant at the World Bank and the Global Fund, argues that performance- or outcomes-based payment and systems coordination is needed even more in low-income contexts. These systems are often characterised by constant change, misallocated resources, and siloed services. Ensuring the right outcomes and performance management are in place, and attaching the money to performance, can go a long way in improving services, as well as providing the flexibility to address constant change.

For example, informal pharmacies in Nigeria (known as proprietary and patent medicine vendors- PPMVs) are being brought into the formal system to increase testing, treatment and reporting of malaria. Single, disconnected interventions are often used to address similar problems in emerging countries, but do not change underlying behaviours. Instead, the Global Fund has partnered with the National Malaria Elimination Programme to contract with a facilitator. This organisation will act as an intermediary within a performance-based contract to provide PPMVs the right training, accreditations, advertising material, and supply of medicines. Building on these activities, the facilitator will encourage better testing, treatment and reporting around malaria – outcomes which will trigger payments and hence incentivise the facilitator. By acting as an ecosystem orchestrator, it will aim to improve performance and service integration in the system.

Facilitating ecosystem orchestration- what can policymakers do?

Ecosystem orchestrators can play a pivotal role in improving coordination and effectiveness of services in both high- and low-income contexts. Governments can support them in doing so, and also play this role themselves. Val Keen, Head of the UK Government’s Changing Futures Programme, highlighted that while policymakers are often distant from service users whom their decisions affect, they can narrow this gap by working closely with individuals with lived experience as well as local frontline organisations. They can act as coordinators themselves by encouraging more joined up working across central and local governments. By putting people at the centre of services, listening better, and aligning the constellation of key actors, they can foster fruitful partnerships across social services.