NGOS AND STAKEHOLDER COOPERATION IN LONG TERM CARE ORGANIZING AND DELIVERY: AN EQUAL PLAYER OR AN OUTLIER?

: This paper summarizes the arguments and counterarguments within the scientific discussion on the issue of inter-sectoral and inter-organizational cooperation in long-term care service policy-making, organizing and delivery with a specific focus on NGO role in it. The main purpose of the research is to explore the current situation, with a specific focus on NGO role in it, and look into some drivers of stakeholder cooperation in LTC organising and delivery and to compare them across public and private LTC providers and NGOs. Systematization of the literary sources and approaches indicates that NGOs’ role in stakeholder cooperation is unique due to the nature of their non-profit philosophy. The relevance of this scientific problem decision is that inter-organisational LTC cooperation with and by tertiary sector organisations has to date received very modest research attention, and is inconclusive and fragmented. This leads to not meeting growing needs for LTC services and increasing public costs. Investigation of the topic first offers empirical evidence on stakeholder cooperation in LTC policy development, organising and delivery across multiple stakeholder groups in three sectors – public, private and NGOs. In addition, it pays specific attention to NGOs role and engagement in LTC and identifies stronger and weaker areas of cooperation with other stakeholders. The paper also identifies several cooperation drivers and measures them in LTC field. The study builds on the findings of a survey of key LTC stakeholders in Lithuania (n=215). Results show that current NGO engagement in cooperation is lower in comparison to public and private LTC service providers and their cooperation is mainly limited to the sphere of LTC service delivery at an individual level, and family members, social workers and other NGOs make key stakeholder groups they cooperate with. The research empirically confirms that NGOs are outliers in cooperation in long-term care policy development, organising and delivery across multiple stakeholder groups. The results of the research can be useful for all the stakeholders in LTC policy field and service provision.


Introduction
Demographic changes in Western societies are leading to an increasing demand for long-term care (LTC) services for older persons. In response to them, governments are developing and adopting various policies and practices to ensure effective functioning of sustainable LTC. A close inter-sectoral and organisational cooperation becomes essential in meeting these growing needs for LTC services and lowering public costs (Ailsa Cameron, Lart, Bostock, & Coomber, 2014). Inter-sectoral and organisational cooperation is also vital in meeting elderly people needs that are often complex and multiple and require services from various professional groups and organisations. In opposition to this, limited or weak cooperation leads to fragmented care (Sundström, Petersson, Rämgård, Varland, & Blomqvist, 2018). Such cooperation, especially between health and social care providers, is becoming a frequent phenomenon. At the same time, it faces more challenges than inter-sectoral and interorganisational cooperation in any other field since these organizations have different goals, varying levels of power and contrasting public images which results in conflicting roles, responsibilities and cooperation outcomes (Källmén, Hed, & Elgán, 2017).
Inter-sectoral and inter-organisational cooperation in organising and delivering LTC services has been researched extensively before (e.g. Clarkson Rothera et al., 2008, etc.) and numerous enhancers and barriers of this cooperation have been named; however, it is still inconclusive and fragmented. It has mainly focused on cooperation between health and social care providers, while studies on cooperation with other stakeholder groups and across public, private and third sectors are scant. Moreover, much of this knowledge is theoretical and lacking empirical evidence (Dowling, Powell, & Glendinning, 2004), or builds on the case study design and focuses on small-scale cooperation initiatives at a single or a small number of institutions, which calls for research on a wider range of stakeholders and larger scale cooperation.
To some extent, this lack of more systematic knowledge may be accounted by the conceptual ambiguity. Current LTC literature employs quite a number of concepts in regards to inter-sectoral and inter-organisational cooperation, such as partnership, collaboration, cooperation, joint-work, etc. (Dowling et al., 2004). Though some authors argue that they carry some subtle differences in their meaning, majority, however, tend to use them interchangeably as all of them imply different organisations working together and may refer to joint working activities, such as for instance information sharing, or delegation and integration of specific functions, which in turn may be associated with higher risk and require higher levels of trust (Glendinning, 2002). In this paper we use the concept of cooperation and define it in a broad sense as any form of different organisations working together to reach a common end, which in this case is sustainable LTC for older persons, but retain organisational autonomy.
Third sector organisations have a long history of involvement in the provision of social care services that dates before the times of well-fare state development and play an important role in it to date. As the term third sector is rather vague and used inconsistently in literature and may embrace such concepts as voluntary organisations, nonprofits, community-based organisations, charities, etc. (Bach-Mortensen & Montgomery, 2018), further on in this paper we use the term a "non-government organisation" (NGO), which in our research denotes non-profit voluntary organisations that are independent of the government. Research on NGO engagement in LTC services is still scant, much of it being policy documents or reports written by various organisations, and lacking theoretical foundation, empirical evidence or methodological rigour (H. Dickinson (Hoad, 2002;Thornton, 1991). Inter-organisational LTC cooperation with and by tertiary sector organisations has to date received very modest research attention, and is inconclusive and fragmented.
To address the above-mentioned gap in literature on inter-sectoral cooperation in LTC strategy development, organising and delivery, in this paper we seek to explore the current situation, with a specific focus on NGO role in it, and look into some drivers of stakeholder cooperation in LTC organising and delivery and to compare them across public and private LTC providers and NGOs. We use the term stakeholder rather than organisation, as we seek to differentiate between different professional groups, not just sectors and organisations, as they may diverge in their perceived public status, values, etc., which may have an impact on their willingness, ability and opportunity to engage in cooperation with members of other groups.
Our research seeks to contribute to the existing research. First, it offers empirical evidence on stakeholder cooperation in LTC policy development, organising and delivery across multiple stakeholder groups in three sectorspublic, private and NGOs (third sector). In addition, it pays specific attention to NGOs role and engagement in LTC and identifies stronger and weaker areas of cooperation with other stakeholders. The paper also identifies several cooperation drivers and measures them in LTC field.

Stakeholder cooperation in LTC: current research status
Over the past 25 years, stakeholder cooperation has become a significant part of economic development policy (Brooks, Liebman, & Schelling, 1984;Fosler & Berger, 1982;Walzer & Jacobs, 1998;Weaver & Dennert, 1987;Westeren, 2000). This has not escaped LTC sector as well. Gray (1985) speaks for many when she sees "a growing need to promote collaborative problem solving across various sectors of society" (p. 911). In the last years, more mainstream strategy scholars have adopted a stakeholder perspective (e.g. Barney Stakeholder cooperation in LTC service delivery is strongly encouraged and practiced in many countries throughout Europe. Research on stakeholder cooperation in LTC is however divided in regards to its effectiveness. Those following the pessimistic tradition doubt its feasibility, as cooperation in LTC requires representatives of separate professionsdoctors, nurses and social workersworking together, which is in contradiction to sociological arguments that propose each profession being a distinct self-interest group with varying levels of perceived public status (Loxley, 1997). Building on success cases, more recent research holds a more optimistic view to cooperation (Hudson, 2002) and has suggested a wide range of factors that enable and sustain stakeholder cooperation in LTC, which may be grouped under two major categoriesorganisational and national-policy level drivers (Table 1).    Literature suggests that NGOs' role in stakeholder cooperation is unique due to the nature of their non-profit philosophy. In many ways, NGOs share aspects of both public and private organizations. Although they lack the coercive powers of government, they also have fewer restraints than government organizations. NGOs are usually less secretive than private organizations and they are more open in sharing information with the public. Since they often possess tax-exempt status in return for a commitment to some public interest, they are also philosophically closer to government than private for-profit organizations. In other words, NGOs merge characteristics of public and of private for-profit organizations. This makes them potential partners for the public sector, especially in the area of policy partnerships (Lovrich, 2000). Hula, Jackson, and Orr (1997) state that "broad collective interests exist that are not adequately represented in current governing regimes" and that NGOs "can serve as a viable platform for the aggregation of collective interests, including under represented interests" (p. 460). In other words, NGOs often serve as effective coalition builders and policy initiators (Hula & Jackson-Elmoore, 2001; Cabral et al., 2019; Luo and Kaul, 2019)). To summarize, the nature of NGOscombining characteristics of public and private institutionssuggests that their collaboration levels might be higher in LTC organizing and delivery activities.

Stages of Stakeholders Cooperation in LTC
Researchers agree that stakeholder cooperation can be examined according to chronological stages, and a number of stage models have been proposed (Googins & Rochlin, 2000;Gray,1989; Waddell & Brown,1997; Westley & Vredenburg, 1997). However, the number of stages, variables examined within each stage, and nomenclature vary extensively and often depend on the geography of research. We apply three main fields of inter-sectoral and interorganization stakeholder cooperation in this paper. They are formation, implementation and provision.
The first field of formation encompasses a broad set of structural, political, cultural, historical and functional aspects of a social system that exert a powerful formative influence on patterns of social stratification, people's LTC opportunities and potential inequities in LTC. For instance, Kingdon's (1984) notion of a "window of opportunity" for policy change being composed of three streams (i.e., the identification of a problem, the formulation of policy options, and the influence of political events) is a central aspect of the context of initiation.
Westley and Vredenburg argue that "participants must first successfully identify the problem, which includes finding a common definition, generating a variety of information, making a joint commitment to collaborate, identifying and legitimizing critical stakeholders, finding an appropriate convener, and identifying initial resources" (1997: 382). Motivations often are perceived to be an important precondition to collaboration (Greening & Gray, 1994). For the purposes of this review, the relevance of context is limited to stakeholders cooperation in LTC policy formation at the national and/or municipal level and LTC quality improvement at the national and/or municipal level.
A second group of research clusters around implementation activities in inter-sectoral and inter-organization cooperation such as governance, structure, and leadership characteristics, as well as behavioral dynamics such as culture, communication, and relationship development. In this research, LTC governance, planning and management at the institutional level are allocated to formation activities of cooperation.
A third group includes provision activities that are especially important in LTC sector. The notion of process working and boundary-crossing in LTC organizations has attracted various labels including patient-centered care (Stewart, 2001), shared care (Hughes & Pritchard, 1995) and integrated care (Ekman & Huzzard, 2007). All of them imply organizational cooperation in LTC services provision. This in essence means boundary-crossing activities such as networking between different occupations, organizations and caregivers. In this paper, we consider provision activities to be assessment of a person's needs, LTC service provision at the institutional level and LTC service provision at the individual level.

Design and sample
Data for this study was collected through a national survey of key LTC service stakeholders in Lithuania including policy-makers (members of the Parliament and committees on health and social affairs, municipality council members, employees of the ministries of health and social security and labour), service organisers and administrators (municipality departments responsible for care services), and service providers (care homes (public, private and NGOs)). Invitations to participate in the survey were emailed either in person (Parliament and ministries) or to institutional heads (service administrators and providers), who were asked to share the link to the survey with members of their organisation, as we also wanted to address different professional groups such as doctors, nurses, social workers, administration, etc. If requested, respondents were provided an option of filling in paper questionnaires. In total around 375 invitations were sent out. At the end of the survey 347 questionnaires were returned, out of which 215 were used in further data analysis.

Measures
Dependent variable. Stakeholder cooperation was measured across 7 areas of LTC that were identified through LTC literature review and through consultation with LTC experts. These included LTC policy formation at the national and/or municipal level, LTC quality improvement at the national and/or municipal level, assessment of a person's needs, LTC governance, planning and management at the institutional level, LTC service provision at the institutional level and LTC service provision at the individual level. Respondents were asked to indicate in which fields they cooperate with each of the stakeholder group (1=yes, 0=no). Independent variables. The following drivers of stakeholder cooperation in LTC were included and measured in our survey: stakeholder trust and reciprocity; ability, motivation and opportunity (AMO) to cooperate and organisational practices of knowledge and information sharing.
• Ability-motivation-opportunity to cooperate with other stakeholders was measured with 10 items (1=totally disagree, 6=totally agree).

Results
First, to explore stakeholder cooperation in LTC service policy-making, organising and management, and delivery and understand the role of NGOs in it, we compared the levels of their cooperation by looking into the average number of fields of cooperation per each stakeholder ( Table 2). Overall cooperation in seven fields was measured (see methods section for a full list); therefore, the score could range from 0 (do not cooperate in any field) to 7 (cooperate in all seven fields). Here we report findings for aggregated stakeholder groups: 1. ministry/municipality officials, 2. public LTC providers, 3. private LTC providers, and 4. NGOs. Results show that stakeholder cooperation in LTC is not intense. Table 3 shows how many cooperation activities in the last 12 months had ministry/municipality officials, public and private LTC providers and NGOs with important stakeholders in the LTC field.
Maximum number of cooperation activities observed is three (between ministry/municipality officials and municipality and social workers' groups). This indicates that most cooperation happens at the decision-making level and not the applied side of stakeholders' cooperation. Ministry/municipality officials are more actively engaged in cooperation, and NGOs the least. Results also show that these four aggregated groups most actively cooperate with municipalities, social workers and nurses, and the least with the policymakers (the Parliament) and researchers. NGOs have encountered the largest number of cooperation activities with other NGOs and social workers (around two per 12 monts)); and not even one full activity has happened between NGOs and Parliament, ministry of health, ministry of social security, doctors, nurses and researchers. We can conclude that in general NGOs have cooperated at the minimal level with other stakeholders. Next we looked into the three fields of activity that stakeholders are most active in -old person's needs identification, LTC service provision at an organisational level and LTC service provision at an individual level.
Here we present results on five stakeholder groups (four most active and NGOs). Results show that in all three fields of activity the largest percentage of respondents cooperate with old persons' family members and social workers, and the least with NGOs (Tables 3-5). Speaking about NGOs, this group cooperates mostly in service delivery at an individual level, where they work close together with family members, nurses, social workers and other NGOs.
In cooperation in elderly person's need identification for LTC, NGOs mostly cooperate with social workers and family members, and least with municipality officials and other NGOs. This finding is logical since it is the family and social workers that know the most about the person's individual situation.
An interesting finding is that private LTC providers portray significantly more cooperation with nurses when identifying elderly person's needs than do public LTC providers (doctors vs nurses 50.1 and 55.6 in public sector; and 23.1 vs 48.1 in private sector). Also, it is noteworthy that family spends most time with ministry and municipality officials when sharing specific needs of the elderly relative. It means that most time is spent filling papers and understanding the procedures and not discussing the actual situation with the care providers. After the old person's needs have been identified, general service provision follows at the organizational level and individual level. Table 4 summarizes the findings for organizational level cooperation. In general, social workers and family members spend most time cooperating with every other stakeholder in service provision at the organisational level. The stakeholder that cooperates the least is NGOs. When looking specifically at the NGOs cooperation, we observe that mostly NGOs cooperate with social workers (32.4%) but that it still low-level cooperation when compared to ministry and municipality officials (54.25), public LTC providers (71.6%) and private providers 55.8%). NGOs cooperate the leat with municipality employees, doctors and family members. In Table 5 we take one more step in analysing the cooperation and look through the lenses of service provision at the individual level. Here we observe higher level of NGOs engagement than at the institutional service provision level. NGOs spend more time cooperating at the individual service provision level with every stakeholder (municipality, doctors, nurses, social workers, NGOs and family members). However, still NGOs show the lowest level of engagement when compared to other three groupsministry and municipality officials, public and private LTC providers. Specifically, NGOs cooperate the most with family members, other NGOs and social workers in service provision at the individual level and the least with doctors and municipality employees.
Overall, public LTC providers spend most time in cooperation about provision of the service at the individual level in comparison with other stakeholders. Also, every stakeholder of the main four dedicates most of the time to family members. In two less active cooperation fields of policy formation at the national and/or municipal level and LTC quality improvement at the national and/or municipal level (Tables 6 & 7) we still observe minimal levels of NGOs cooperation. Respondents cooperate mostly with municipality representatives in these areas. Table 6 summarizes four main stakeholders' cooperation in LTC policy formation at the national and/or municipality level. The most active stakeholder here is ministry and municipality officials. They mostly cooperate with municipality employees and doctors. The least active stakeholder in LTC policy formulation is NGOs. NGOs spend comparatively a lot of time with other NGOs in cooperating in LTC policy formation however their involvement with other members of the system is very low. It can be stated that the cooperation in policy formation is limited to that between NGOs themselves. Source: compiled by the author.
The same can be said when discussing cooperation in LTC quality improvement activities. The least active stakeholder is NGOs and their cooperation is mostly limited to other NGOs. It should be noted that NGOs portray zero cooperation with family members in this area. The most active stakeholder in quality improvement activities is ministry and municipality officials. Public and private LTC providers show a very similar level of cooperation when compared with other players of the LTC system. To better understand the current cooperation situation, we also compared stakeholders in regards to their ability, motivation and opportunity to cooperate, knowledge and information sharing and trust in other stakeholders. Results in Table 8 show that NGOs score lower than the other stakeholders in regards to ability, motivation and trust and reciprocity, while all stakeholders perceive the level opportunity for cooperation as rather low. The results show that NGOs is the stakeholder that demonstrates the lowest level of cooperation in areas of elderly person' needs identification, service provision at the organizational and individual level, policy formation and service improvement. When cooperating, NGOs do that mostly with other NGOs and do not engage with other players in the LTC system.

Conclusions
The aim of this paper was to explore stakeholder cooperation situation in Lithuania with a specific focus on the role of NGOs in it, and measure some drivers of stakeholder cooperation in LTC policy-making, organising and delivery. Our results show that stakeholder cooperation in LTC field is not very active in Lithuania and mainly concentrates on its delivery at organisational and individual levels; stakeholders working together in LTC policymaking, governance, quality improvement, planning and management at the national and/or municipal level is less pronounced. Our results also show that current NGO engagement in cooperation with other LTC stakeholders is lower in comparison to other groups, and their cooperation is mainly limited to the sphere of LTC service delivery at an individual level, and family members, social workers and other NGOs make key stakeholder groups they cooperate with.
The perceived level of motivation to cooperate is also lower among NGOs in comparison to other stakeholders. These results, at least to some extent, maybe explained by prior research findings. NGO reservation in regards to cooperation may stem from their apprehension of likely increased levels of bureaucracy that partnering with others, especially public authorities and organisations, may introduce and subsequent loss of autonomy and flexibility (Abendstern et al., 2018). Effective inter-sectorial partnerships also necessitate an appropriate legal basis and formal arrangements, as well as funding (H. Dickinson & Neal, 2011), which in Lithuania are still lacking. Co-location was found to be another driver of successful NGO partnerships with other stakeholders (H. Dickinson & Neal, 2011). In Lithuania, however, NGOs either operate in their own premises or deliver services at old persons' homes.
In addition, results revealed that NGOs are willing to share information with other stakeholders more than private organizations. This finding is in line with previous research discussing that NGOs are usually less secretive and are more open to share information than other, especially private, organizations (Lovrich, 2000). However, another notion that while possessing characteristics of both public and private organizations NGOs make strong partners for the public sector, particularly in the area of policy partnerships (Lovrich, 2000) is not supported.
In general, NGOs are outliers in cooperation in long-term care policy development, organising and delivery across multiple stakeholder groups. Innate benefits that NGOs possess like being a source of credibility, having greater public trust on health and social issues (Wootliff & Deri, 2001) are not observed in Lithuania. At the same time, NGOs are not benefiting from the economic capital that may be leveraged by cooperation with public and private stakeholders to fund programs, market their organization and/or social initiatives they are engaged in.

Conflicts of Interest:
The author declares no conflict of interest.

Data Availability Statement:
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.