Integrating community driven care service in European welfare states – nonprofit institutional entrepreneurship as driver for expanding access

We review historic and contemporary cases of a surprisingly wide-ranging class of health care delivery, which we term Open Care. Examples includes historic friendly societies that provided insurance and medical services to members, co-ops, unpaid community clinics, patient groups, self-help support networks, crowdsourcing and the IT-based aggregation of medical data. The definition of Open Care is based on the production of health by communities rather than profit motives, and therefore also includes for-profit firms that rely on voluntary input. We attempt to analyze Open Care using the related literature on institutional economics in order to identify areas where community driven care projects are most likely to thrive, provide policy recommendations on how they could be integrated in the existing European health care system. The unorthodox features of open care also make it a valuable case that provides new theoretical insights in institutional economics. The concept of evasive entrepreneurship has previously been restricted to for profit firms that evade formal institutions. Reviewing Open Care however shows that the concept also fits for community based projects, though in sometimes different ways. For profit firms that evade institutions maximize profits, and often have incentives to corner evasion. By contrast non-profit evasive entrepreneurship that circumvent institutions to maximizes quantity have incentive to expand the evasion to others or remove the barriers entirely. We find that Open care tends to emerge when existing health system fails, when there are therapeutic advantages in co-producing health such as support and addiction care, or when knowledge is dispersed, such as patient knowledge about symptoms and side-effects.