Place and the Structuring of Cross-Sector Partnerships: The Moral and Material Conflicts Over Healthcare and Homelessness

Abstract

Local places, such as communities, cities, and towns, host many cross-cross sector partnerships, many geared primarily toward alleviating local social and environmental issues. Yet, existing literatures focus predominantly on largescale systemic impact and global challenges such as climate change, paying scant attention to the role of local, geographically bounded dynamics in shaping these partnerships. In this article, I conceptualize places as geographic locations imbued with specific meaning systems and material resources to unpack how local embeddedness shape the structure of cross-sector partnerships. Specifically, I investigate how place-based conflict, arising from tensions between the moral and material aspects of a partnership, can shape formalized aspects of organizational structure. These include the scope of operations, partners’ roles, and shared resources. I unpack these relationships using a case study of Occupy Medical, a local partnership between the civic society and the local government in Eugene, Oregon, tackling the problem of providing healthcare to the homeless and other marginalized and disenfranchised communities. The analysis covers the nine-year period of 2011–2020 and spans three major restructurings of the organization, the latest prompted by the onset of the COVID-19 pandemic in March 2020. I theorize two forms of structural arrangements for cross-sector partnerships, confined and leveraged, and further elaborate on the role of cross-sector partnerships in crises response on the local level.

Cross-sector partnerships (CSPs) are “relatively intensive, long-term interactions between organizations from at least two sectors (business, government, and/or civil society) aimed at addressing a social or environmental problem” (Clark and Crane, 2018, p. 302). As an organizational form, CSPs are designed to facilitate joint deliberations, decision-making, and enforcement of multi-stakeholder agreements (Dentoni, et al., 2018; van Tulder & Keen, 2018). The collaborative and voluntary nature of these organizations underline their touted potential in tackling social and environmental issues (Bryson & Crosby, 2015). As such, a growing and informative line of research has generated valuable insights on partnership dynamics. This burgeoning literature primarily championed CSPs as vehicles for systemic change albeit with a skewed focus on the governance of public–private partnerships in symbolic market contexts (Branzei & Le Ber, 2014; Clarke & Crane, 2018; Ellersiek & Kenis, 2007). Conversely, the embeddedness of these organizations in local socio-political contexts embodied in many government–civic society collaborations received much limited attention (Awad, 2022; Cornelius and Wallace, Cornelius and Wallace, 2010; Powell et al., 2018; Slawinski et al., 2019). A recent review of one hundred published articles found only 13 studies with a local focus and seven particularly analyzing a public–nonprofit partnership. Critically, these studies conceptualized “local” largely as a static context for stakeholders’ interactions (Clark and Crane, 2018). Despite the increasing attention to the dynamic nature of CSPs (Gary and Purdy, 2013; Ryan & O’Malley, 2016), this “relatively static view of context still persists, which is limiting for studies of process and change.” (Nguyen & Janssens, 2019, p. 374).

However, emerging literature in organizing and entrepreneurship suggests a profound effect for bounded geographic spaces such as those of cities, towns, communities, and/or regions (Awad, 2022; Guthey et al., 2014). Such “local” environments are rife with conflict over political interests between stakeholder groups with varying levels of power (Amis & Greenwood, 2020; Trounstine, 2020) and shifting endowments symbolic and material resources (Cnosson and Bencherki, 2019). These dynamics are especially important for cross-sector partnerships as many social and environmental problems, the raison d’être for cross-sector partnerships, manifest and are managed at the local level (Brammer et al., 2019; Dentoni et al., 2018) in the contentious throes of urban local politics, social movements, and crises (Daskalaki and Kokkinidi, 2017; Trounstine, 2020). Thus, it is crucial to disentangle the impact of such localism on the emergence and evolution of CSPs (Seitanidi, 2008).

This study theorizes a more expansive role for local conflict in shaping cross-sector partnerships. I conceptualize local dynamics through the theoretical lens of “place,” defining it as a geographic location imbued with meaning systems, material forms, and resources (Gieyrn, 2000). These meaning systems—such as history, collective identities, public policy—and material forms—for example, physical spaces, technologies, buildings—enable and constrain different forms of organizing (Awad, 2022; Muñoz et al., 2020). I specifically focus on the effects of these dynamics on the organizational structure of cross-sector partnerships, prompted by field observations of the partnership in this study and the significantly different organizational forms it adapted over a decade of navigating and responding to local developments and shocks. Organizational structure is well established in the literature as a reflection of internal actors’ perceptions and best attempts to fit with dynamic external contexts (Joseph & Gaba, 2020; van de Ven et al., 2013), to manage multiple stakeholders and collaborations (Ashraf et al., 2017), and to assimilate environmental complexities (Schneider et al., 2017). Structure enables cross-sector partnerships to “organize tasks and allocate decision-making authority, establish standard operating procedures and practice conventions, and enshrine priorities and subgoals” (Soderstrom & Weber, 2020, p. 227). Surprisingly, despite being the carrier for governance mechanisms and collaborative action (Emerson et al., 2011), structure has received little attention in cross-sector partnerships research (Bryson & Crosby, 2015) with a few exceptions (Clarke, 2011; van Tulder & Pfisterer, 2013). Accordingly, the research question animating this inquiry is: how does the organizational structure of cross-sector partnerships emerge and evolve in response to place-based conflicts?

Empirically, I conducted a single-case qualitative study based on extensive data from in-depth interviews, traditional and social media, and site visits. Occupy Medical, the focal organization, is a government–nonprofit (sometimes referred to as public–civic) cross-sector partnership in Eugene, a mid-size city in the Pacific Northwest of the United States. The organization pioneered a unique free-healthcare-for-all-no-questions-asked model, servicing the unhoused, the poor, and other disenfranchised social groups in the city. The two main partners were the independent members of the local civil society and homelessness activists, representing the interests of the unhoused and local citizens and organizations concerned about the consequences of homelessness and access to healthcare, and the local city government, including officials in the city manager’s office, the elected city council, and the mayor’s office. The organization has its deep roots in the ethos of communal living and inclusion ingrained in the city’s legacy as a liberal mecca and a haven for alternative lifestyles dating back to the 1950s. Yet, the organization had to contend with the unique local challenges of the city: one of the highest homelessness rates in the country, lack of public funds, and strong discourses of stigmatization and marginalization for disadvantaged social groups, rooted in local ethos of self-reliance and socioeconomic strife. The partnership emerged in the wake of intense local social mobilizations in 2011 as a make-shift mobile clinic, moving to an apartment complex to mitigate socio-political issues in 2017—2019. When the coronavirus pandemic struck the city in 2020, local actors turned to Occupy Medical for expertise. The partnership expanded immensely, temporarily taking over a $5 million government building and an 11,000 sq. ft. pavilion in downtown Eugene.

This analysis contributes to the recent call to “emplace” cross-sector partnerships (Bryson & Crosby, 2015; Guthey et al., 2014; Powell et al., 2018) through capturing their long-term dynamics in the central elements of organizational structure: the scope of operations, partners’ roles, resource dependencies, and control over operations (Burton & Obel, 2018). Specifically, I unpack the role of place in shaping partners’ moral orientations and material interests, producing tensions and conflicts on courses of action. I theorize how cross-sector partnerships resolve these tensions through manipulating structural elements specifically partners’ roles, scope of activities, shared resources, and control. I identify two structural arrangements, confined and leveraged, that cross-sector partnerships employ to manage local dynamics. Additionally, I explore the potential of CSPs as a form of latent organizing on the local level that enables communities to respond effectively to crisis situations (Fenema et al., 2020).

Theory Development

Place-based Conflict: The Local Tensions of the Moral and the Material

Over the past decade, organizing research has been advancing more elaborate accounts of local embeddedness through the theoretical lens of sociology-of-place. Researchers examined “local” as a combination of a specific geographic location with unique endowments of meaning systems and material forms (Gieryn, 2000) to generate insights into communities (Dacin & Dacin, 2019), towns (Slawinski et al., 2019), cities (Lawrence & Dover, 2015), regions (Finch et al., 2017), and spatially bounded locations such as refugee camps (de la Chaux et al., 2018) and churches (Jones et al., 2019). These studies highlight a constitutive role for places: geographically bounded areas supply the symbolic systems, such as history, culture, and laws, and material resources such as technologies, market relationships, and physical spaces, with which embedded actors construct their social reality including moral stances (Lawrence & Dover, 2015) and interests (Cnosson and Bencherki, 2019; Powell et al., 2018).

Importantly, this approach provides a more sensitive lens to analyze the critical relationship between conflict and change for emplaced cross-sector partnerships. The very few existing studies on place foreshadow a fruitful research area. Slawinski et al., (2019) investigated the place-based tensions between the local and global goals of regenerative organizations, those aiming to “restore and replenish degraded natural ecosystems while building resilience in, and improving the well-being of, the communities that rely on them” (Slawinski et al., 2019, p. 1). Dorado and Fernandez (2019) examined a deeper tension arising from the conflicts in the symbolic meaning systems on which different stakeholders ascribe value to a venture. These nascent studies suggest that cross-sector partnerships—an innately collaborative, conflict-prone, and often tenuous form of organizing (van Tulder & Keen, 2018)—are especially sensitive to such place-based dynamics.

I build on this work to suggest three pertinent effects for “place.” First, place could shape the different, and often conflicting, moral frameworks through which local stakeholders engage with a potential cross-sector collaboration (Besio & Pronzini, 2014). These are “prescriptive judgments of justice, rights, and welfare pertaining to how people ought to relate to each other” (Turiel, 1983, p. 3). This partner-specific morality is constituted through place-based meaning systems and drives the material interests of the stakeholders (Powell et al., 2018). The complex nature of the social and environmental problems and crises which CSPs typically aim to tackle further amplify these tensions (Dentoni et al., 2018; Wexler, 2009). Such problems manifest on the local level prompting socio-political contentions and new forms of organizing and collective action in response to market failures, inequality, and marginalization (Brammer et al., 2019). The criticality of local cross-sector collaborations is emphasized in the 2015 UN’s Sustainable Development Goals aiming to eradicate urban poverty (SDG 1), improve access to health and well-being (SDG 3), and build sustainable cities and communities (SDG 11) (United Nations, 2023). Tackling these complex problems require actors to navigate an elaborate political process with multiple and often conflicting stakeholders’ interests, ideologies, and moral values (Ferraro et al., 2015; van Tulder & Keen, 2018).

Second, cross-sector partnerships are likely to emerge in social upheaval, as local responses to contentious social movements and crises (Hällgren et al., 2018). These disrupted contexts highlight the role of “place” in shaping the emergence and evolution of cross-sector partnerships. Dominant social and economic orders are legitimized and enforced through existing arrangements of local physical spaces and the relationships within them (Haug, 2013). Thus, social movements and other acts of resistance that aim to change or remedy existing market failures engage in the reconceptualization of local places through negotiating a clash of values, interests, and underlying ideologies (Daskalaki and Kokkinidia, 2017). Conceptualizing CSPs as products of resistance to local oppressive or damaging systems suggest a reflexive process, where place shapes organizations and practices while also being shaped by them (Cnosson and Bencherki, 2019; Courpasson et al., 2017). Local crises produce similar effects, challenging existing arrangements of power and resource distribution and prompting changes in cross-sector relationships (McNamara and Pazzaliga, 2018).

Lastly, places provide the material building blocks and constraints for organizing such as physical spaces, buildings, funding, relationships, and technologies (Jones et al., 2019). Current analyses, however, emphasize the process of governance and outcomes of CSPs with little attention to these material features (Bryson & Crosby, 2015). For instance, studies advance a dichotomy of collaboration outcomes as a result of conflicting material interests. Collaboration is either successful, i.e., collective, or it is a failure, one-sided and/or inaction (Powell et al., 2018; van Tulder & Keen, 2018). However, the depth and breadth of the collaboration could vary with the availability and accessibility of resources over time, leading to different levels of collaboration and outcomes.

So how would these place-based dynamics manifest in cross-sector partnerships? In the next section, I turn to the role of organizational structure as a dynamic reflection of fit between a cross-sector partnership and the local environment where it operates over time.

The Dynamic Structure of Cross-Sector Partnerships

Research on organizational structure, broadly defined as the “ways in which an organization divides its labor and integrates their efforts” (Joseph & Gaba, 2020, p. 3), has been experiencing a renaissance in recent years (Joseph et al., 2018). Structure, or structural elements, includes scope of organizations, partners’ roles, resources dependencies, and control over tasks (Burton & Obel, 2018), commonly referred to as the formalized aspects of design. The emergence of new organizational forms, such as strategic partnerships and hybrid enterprises (Pache and Santos, 2013), is partly driving this increased attention as researchers grapple with the new theoretical and empirical questions these forms pose to organizational decision-making (Burton et al., 2019). Cross-sector partnerships subsume many of these complexities. Many cross-sector partnerships emerge as social innovations bringing together a variety of stakeholders toward common long-term goals (e.g., Powell et al., 2018) thus needing to “hybridize” different and often competing demands (Pache and Santos, 2013).

Yet, despite its centrality, the role of structure in cross-sector partnerships has received little attention in the literature (Bryson & Crosby, 2015). In an early attempt, Clark (2011) examined key structural elements in 21 local partnerships suggesting a role for coordination, however, she focused mainly on outcomes as opposed to the internal structural elements of the organization. Van Tulder and Pfisterer (2013) expanded this inquiry in their analysis of the roles that partners can assume in a cross-sector partnership. The authors theorized four possible roles for the government: mandating, facilitating, partnering, and endorsing; civil society can engage in mutual-support, advocacy, partnering, and service provision; and the corporate sector can assume competing, delegating, partnering, and outsourcing roles. Lastly, a few studies have showed that higher mutual dependence and integration of resources between partners could lead to more value creation (Austin and Seitiendi, 2012) and organizational survival (Ashraf et al., 2017).

Accounting for dynamic external environments and demands, as conceptualized earlier in terms of “place,” requires a shift toward a more reflexive organizational structure to understand temporal changes especially since existing structures shape future reorganization (Raveendran, 2020). Research on business–nonprofit partnerships highlights their dynamic nature as evolving through interactions between the partners (Seitanidi, 2008; Seitanidi & Ryan, 2007). These changes can lead to positive outcomes (Ryan & O’Malley, 2016) or to conflict (Gray & Purdy, 2013), noncooperation (Chowdhury, 2021), and possible failure (Seitanidi, 2008). Existing studies, however, barely incorporated the structure of CSPs in these analyses (Bryson & Crosby, 2015; for an exception with a focus on partners’ interests, Powell et al., 2018). With many cross-sector partnerships emerging as social innovations, a few insights can be gleaned from entrepreneurship research where scholars are adapting more dynamic approaches to the structure of entrepreneurial ventures buoyed by questions of scaling (DeSantola et al., 2017), hybridity (Pache and Santos, 2013), and external fit (Burton et al., 2019). This emerging line of research portrays the organization as a dynamic interplay between formalized elements and actors (Mathias & Williams, 2018; Soderstrom & Weber, 2020). Similarly, research in hybrid companies investigated how managerial roles and formal goals maintain the organization mission and facilitate collaboration and stability (Smith & Besharov, 2019).

Importantly, most of this literature, including studies on hybrid and for-profits firms, engages with external demands as mainly institutional in the form of new regulations (Durand et al., 2019), competing logics (Pache and Felipe, 2013), and technological changes. These studies suggest that organizations can respond to normative pressures with the symbolic adoption of inefficient structures, roles, policies, and resource misallocation consequently leading to limited outcomes (Bromley & Powell, 2012; Durand et al., 2019). Such misalignment is more likely in contexts where internal actors champion contentious causes and/or hard-to-measure social/public outcomes such as that of cross-sector partnerships (Hallett, 2010). A place-based perspective further invites inquiry into this line of research as it surfaces the undertheorized interplay of material contexts, organizational structures, and the diversity of stakeholders in cross-sector collaborations (van Tulder & Pfisterer, 2013).

In summary, existing research suggests a potential effect for geographically bounded meaning systems and material resources on partnerships’ structures. I probe these dynamics with an in-depth analysis of Occupy Medical, a healthcare organization in Eugene, Oregon, in 2010 – 2020.

Methods and Research Setting

Elements of Place: Eugene, Oregon, and Local Homelessness

The city of Eugene sits on the Willamette valley in Oregon, a state in the Pacific Northwest of the United States. It is the largest city in Lane County with an estimated population of 172,622 in 2019. The city has a long history of inclusion and social activism dating to the counter-culture movements in the 1960s. Ken Kesey, a prominent figure in the movement, along with his followers the Merry Pranksters, called Eugene home and remains one of the city’s most influential figures. Ethos of universal love and peace live on in the city, manifested in the many intentional communities and the annual world-famous Oregon Country Fair (Vanneman, 1997). Importantly, this legacy of the counter-culture left the city with a local trove of experience in local activism and organizing, marshaled through the 1970 and 1980s for the peace and environmental movements, and the 1990s in the anarchist movement. On the other hand, the city is steeped in conservatism from Oregon’s long exclusionary history as a frontier state where people of color were barred from the new territory with legislations and forced displacement. The timber industry and agriculture were the major forces in the local economy until the environmental movement in the 1970–80 s. Local ethos of communal living and universal love co-exists with a culture of self-dependence and conservatism. The juxtaposition is evident in the socioeconomic state of the city with a high poverty rate reaching 24% in 2017 and a wide wealth gap between the rich neighborhoods in the South and the low-income ones to the West.

Case Study: Occupy Medical (October 2011–September 2020)

Occupy Medical is a cross-sector partnership between the local civic society and the local government in Eugene. Its mission is to provide free wellness and healthcare services to underserved social groups in Lane County, primarily in the major cities of Eugene and Springfield. It mainly serves the local homeless population (about 60% of the clientele), low-income individuals and families, those lacking access to health insurance, and other stigmatized groups such as undocumented immigrants and substance abuse patients. Unlike traditional hospitals, the clinic offers a broad set of services, one of the lead operators explained as follows:

It’s more than just a free clinic. It’s the model that we have of judgment-free, patient-centered care, integrated health, and community involvement, and recapturing your own body. (#SS1)

The clinic emerged out of a tumultuous social mobilization episode in October 2011. The Occupy movement originally aimed to protest global inequality however, in Eugene, the local chapter adopted the cause of homelessness. By November 2011, Occupy Eugene established a large camp in the Washington-Jefferson Park in the middle of the city providing food, shelter, safety, and community to more than a thousand of the city’s unhoused. The sheer number of those seeking shelter with Occupy was emblematic of the rampant homelessness problem that the city failed to address over the past two decades. The problem persisted following Occupy, culminating with Eugene earning the infamous title of the city with the highest number of homeless people per capita the United States in 2019 (Seccuity.org, 2020).

Occupy Medical started as a volunteer-based medical tent in the Occupy Eugene camp. The operators witnessed first-hand the scale of the homelessness problem and the need for basic healthcare services. After the end of the Occupy events in December 2011, the operators continued to offer their services to the local community, combining an inclusive and holistic approach to healthcare, a unique no-question-asked privacy model, and a local network of volunteers. One of the founders described the operations as follows:

You just show up. If you need care, everyone deserves care. Here is the care. And here is the care we can offer. And we're not the end all be all, like there's a whole bunch of other services that we're working with, dental. We send a ton of people to LCC Dental Clinic, we send a ton of them to White Bird Dental. And White Bird Dental is right now working on the stuff that they got from Cleveland clinic which is the Oregon Country Fair booth and they're gonna put that towards dentures for the unhoused (#SS1)

Thus, Occupy Medical with its deep local roots and mission, presents an exemplary case to investigate the role of place in cross-sector partnership dynamics. Such cases allow researchers to utilize “in-depth insights of empirical phenomena and their contexts” (Dubois & Gadde, 2014, p. 555) to drive theory development.

As I discuss in the Findings section, the partnership assumed different forms in the period of 2012–2020. Civic actors formed the core of partnerships drawn mainly from the homelessness activists’ community in the city and volunteers from the local healthcare and wellness communities. These civic actors worked closely with the marginalized communities in the city and represented their interests in the partnership. As the organization gained more recognition on the local level, it established collaborations with local nonprofits to connect patients to advanced services such as dental care and lab testing. The Eugene city government was the main partner through the city manager’s office and the elected city council. The local government of the neighboring city of Springfield joined in the partnership in the second phase when Occupy Medical expanded its operation in 2018. Additionally, Lane County government played a prominent role in the partnership following the COVID-19 pandemic in 2020.

Data Collection

The data for this case study were collected as a part of a three-year field research project on local responses to homelessness in Eugene, Oregon. Data collection aimed to capture few important strands of locally bounded knowledge: elements of place, the changes in the local problem of homelessness; and the inter-partner relationships. Such long-term dynamics required the collection of longitudinal and rich data (Langley et al., 2013). I collected data from multiple sources to triangulate the focal case study covering the period of October 2011 to September 2020, summarized in Table 1. The data collected included 42 in-depth interviews with locals from the civic society, the local city government, and the homeless community (Table 2). I used a theoretical sampling approach followed by a snowball approach to capture the voices and experiences of the major stakeholder groups involved with homelessness in the city. These included interviews with the founders of the Occupy Medical, key community leaders and social activists involved in the homelessness problem, the local government officials and liaison for homelessness, and city councils. The data were collected over three waves of interviews conducted in 2016–2019. I augmented these interviews with archival data from the four largest local newspapers, compiling a database of 275 articles on homelessness, the city responses, and the focal organizations. Twenty-seven of these articles focused primarily on the post-COVID-19 pandemic period. Lastly, I conducted field visits to the Occupy Medical clinic in Springfield in November 2019 to observe the internal operations of the organization.

Table 1.

Data collected

Data Source	Description
Interviews  42 in-depth interviews including 22 with social activists; 5 interviews with neighborhood associations leaders; 6 interviews with government officials; and 9 interviews with unhoused people; one interview from the business community  Total: 862 single-spaced pages	First Wave: 7 open-ended interviews, each lasting between 40 min and 1.5 h, conducted in 2016 and early 2017. All recorded, transcribed, and hand-coded Second Wave:19 semi-structured interviews with key informants in all five stakeholder groups. All recorded, transcribed, and coded in NVivo. All conducted in the years 2017 and 2018 Third Wave:16 semi-structured interviews with harder-to-access informants. recorded, transcribed, and coded in NVivo
Traditional Media  Covering the period 2011–2020, and using the keywords homelessness, homeless, occupy medical and occupy Eugene, Covid-19, Coronavirus	Register-Guard, Eugene Weekly, the Daily Emerald, and the Torch Total: 248 articles, 529 pages Additional 27 articles following the covid-19 pandemic February–September 2020
Official Government and Organizational Documents	A total of 17 documents from local government and nonprofits including reports, ordinances, and research studies

Table 2.

Summary of the Interviews Collected during 2016—2019

First wave	Duration (hr:min)	Second wave	Duration (hr:min)	Third wave	Duration (hr:min)
Social advocate	1:57	Government official	1:26	Homeless	0:16
Social advocate	0:46	Government official	1:05	Homeless	0:20
Social advocate	1:40	Government official	1:00	Homeless	0:23
Government official	1:08	Social advocate	0:51	Homeless	0:43
Business	0:32	Neighborhood	0:40	Social Advocate	1:12
Social advocate	1:25	Neighborhoods	0:40	Social Advocate	1:12
Social advocate	1:07	Neighborhoods	0:17	Social Advocate	1:12
		Neighborhoods	0:48	Social Advocate	1:10
		Social advocate	1:00	Social Advocate	1:01
		Neighborhoods	0:48	Social Advocate	0:48
		Social advocate	0:53	Social Advocate	1:13
		Social advocate	1:04	Homeless	0:46
		Social advocate	0:58	Homeless	0:46
		Social advocate	0:48	Homeless	0:46
		Social advocate	0:58	Homeless	0:46
		Neighborhoods	0:32	Homeless	0:46
		government official	1:03
		Social advocate	0:42
		Social advocate	1:08

Data Analysis: Case Study and Abductive Analysis

The theoretical goal of this analysis is to develop what can be described as a highly contextualized account of a dynamic phenomenon: the conflation of place with the structure of cross-sector partnerships. I employed two crucial approaches in my analysis to achieve this goal. First, I built on recent re-focus in case-study methodology on the explanatory power of context where a case study is analyzed holistically as a combination of multiple interdependent variables (Piekkeri and Welch, 2018). Second, the goal of the study, to bridge different theoretical frameworks, privileged an abductive approach to data analysis (Dubois & Gadde, 2002, 2014). Thus, the data analysis emphasized the process of systematic combination in abductive research where “the theoretical framework, empirical fieldwork, and case analysis evolve simultaneously” (Dubois & Gadde, 2014, p. 554).

The analysis process proceeded in three phases. First, I constructed a highly contextualized timeline for the focal organization, Occupy Medical, through the period of the analysis October 2011–September 2020. I developed a thick description of the partnership, delineated geographically and relationally within the boundaries of Eugene and Springfield. Next, I conducted an initial coding phase, focusing on descriptive and attribute coding to organize the voices of the two main communities, civic society and the local government, and to bracket the key events on the local level. Three main events were crucial: the Occupy Eugene camp and the ensuing local mobilization for the cause of homelessness; the Federal Administration’s campaign on undocumented immigrants in 2016–2018; and the COVID-19 pandemic in 2020. The dynamics and manifestations of these events triggered different inter-partner interactions and, consequently, shaped the organizational structure of the partnership. This thick description allowed me to identify the empirical puzzle in the focal case. Occupy Medical was puzzling as an innovative model for healthcare, however, the major restructuring of the partnership in response to the COVID-19 pandemic highlighted the peculiarity of the phenomenon and inspired the research question of this study.

In the second phase, I started the abductive analysis process with an in-depth analysis of the existing literatures on place, homelessness, and the organizational structure of cross-sector partnerships. As detailed in the previous review section, this literature failed to explain the phenomenon, implying the existence of “changed circumstances, additional dimensions, or misguided preconceptions” (Timmermans & Tavory, 2012, p. 189) worthy of further first-hand research. The existing literature, however, provided initial coding schemes to analyze the data. For instance, I coded my data based on patterns of organizational structure including scope of operations, roles of partners, and resource dependencies (Burton & Obel, 2018; van Tulder and Pfisterer. Tulder and Pfisterer, 2013). Similarly, I built on existing frameworks from Wexler (2009) and Powell et al. (2018) to engage with the moral and material components of social problems, respectively. I developed emergent coding schemes from the data to capture specific patterns such as the local elements of place.

Lastly, I engaged in theoretical coding to theorize the patterns of the organizational structure over time, building a process of systematic combining, a hallmark of theory building through abductive analysis (Dubois & Gadde, 2014). I theorized two types of structural forms between the partners, which I termed confined and leveraged, to explain how a cross-sector partnership responds to the place-based dynamics of the local problem (Table 4). Structurally confined partnerships are ones with limited scope of operations typically targeting a marginalized local cause, with one partner unevenly responsible for operational roles, resource acquisition and allocation, and managerial control. Structurally leveraged partnerships are ones with expansive scope of operations targeting a more critical local issues(s) with partners sharing operational roles, resource acquisition and allocation, and managerial control.

Table 4.

Structural forms in local cross-sector partnerships

		Structural arrangement of partnership
		Structurally confined		Structurally leveraged
	Scope of operations	Targeted Minority		Expansive
Structural elements	Partners’ role	- Providing service	-Endorsing	- Providing service	- Partnering
		- Advocating		- Advocating	- Facilitating
	Shared resources and control	High	Limited	High	High

Findings

In this section, I detail the emergence and restructuring of Occupy Medical in 2011–2020, focusing on place-based dynamics as captured in the value conflicts between local stakeholders and the changes in the dynamics of the homelessness in the city. My analysis details three major cycles of change over nine years, each triggered by specific socio-political events and/or local crises. Each of these phases introduced different moral/material tensions, reconfiguring the partnership structurally to align its operations with the ongoing dynamics. Figure 1 summarizes the three phases and the local triggers of transitions.

Fig. 1.

The Evolution of Occupy Medical (2011 – 2020)

Phase 1: The Emergence of Cross-sector Partnership

Place-based Dynamics

Local Triggers of CSP Emergence: Occupy Movement and the Failure of Healthcare

The roots of what became Occupy Medical can be traced to the contentious social mobilizations of the Occupy Movement. As mentioned, Eugene have struggled over the past two decades with a homelessness problem. However, in 2011, the events of Occupy Eugene brought the scale and negative consequences of the problem to the public eye as many of the city’s unhoused joined the Occupy Eugene camp, seeking warmth, food, and shelter. One activist recalled their experience.

We had the protest camp, and what happened was it evolved into a homeless camp over time because the unhoused folks heard about it. “Great. Place I could go,” or “It’d be a safe place to be.” “Won’t be harassed by the police and get some food.” cause we set up a kitchen there as well. (#LC1)

Following a few contentious weeks, Occupy Eugene set up its largest camp in the Washington-Jefferson Park in late October 2011 with a medical tent to provide first-aid for the protesters. As more of the city’s unhoused joined the camp, the range of conditions requiring medical attention expanded from simple first-aid to include patients with HIV, diabetes, measles, hepatitis, and other morbidities. The tent expanded with volunteers from the healthcare sector with a core group of physicians, nurses, and herbalists dispensing free healthcare to the camp community.

Eventually, the medical tent diverged from the broader Occupy movement over issues of management. Occupy movement famously championed a consensus-based decision-making model which the medical tent operators were wary of applying to health management. One of the pioneers of the model explained as follows:

We already have insurance companies that make decisions for our patients. These people that don’t know our people, they're the last people that get to make those choices. We separated ourselves. We would just show up at the meetings and say this is what the medical tent is doing., and these are the supplies that we need so if anybody knows, we only asked permission to get ... we didn’t ask permission. We just asked for donations. That was it, and then said we’ve really been enjoying having support from you guys. (#SS1)

Seeking to break free from neoliberal, fee-based models of healthcare, organizers of the medical tent empowered patients to take full control of their health conditions which meant separating from the hierarchy of general assemblies and consensus decision-making. Patients were urged to explore other options beyond western, medication-based healthcare with herbalists, nutritionists, and reiki professionals consulted in designing treatment plans. The holistic approach and the no-judgment-free-healthcare-for-all mission formed the core of what became Occupy Medical.

Following the shutdown of Occupy Eugene, the medical tent moved to downtown Eugene where it operated every Sunday. On September 28, 2012, ex-occupiers and volunteers from the civic society started operating Occupy Medical out of a re-purposed blood donation bus that they bought through a grant from the Oregon Community Foundation. One of the founders of the clinic explained as follows:

We wanted to offer something else, and so we did. We had little tents, and that was everything that I could stuff in my car, and that was what we were. We wrote the grant for our community foundation and got the grant, and that paid for the bus. That was a 32 foot Bluebird bus that used to be a blood mobile, and we changed it up a bit to be a mobile clinic. Then it very quickly expanded. We got more and more volunteers, and more and more patients, and then we had to have another tent. Eventually, it was the bus and three garage tents that we set up every single Sunday no matter what the weather was like (#SS1)

The process of setting up the clinic every Sunday was extensive and hectic. Volunteers set up the bus and the tents, forming different stations for patient take-in, a waiting area, and consultations. The clinic also provided haircuts, massage therapy, and warm meals to the unhouse and low-income patients. All services were provided free of charge with no questions asked. Even real names were not required.

In the period of 2013–2017, Occupy Medical continued to provide its services out of the bus every Sunday. The wide range of services offered to an increasing clientele, however, was getting more difficult to maintain, especially with an all-volunteer team and one clinic manager.

It took two hours to set it all up, and then we had a four-hour clinic, and then an hour to break it down. And then if it rained you had to take it all over to a place where we would hang it up, which was another hour, come back, fold it up, and then put it back in the bus. So that’s another couple of hours right there. (#SS1)

This period coincided with a massive escalation of local protests and mobilization. Local activists, both housed an unhoused, organized grassroots campaigns to protest the criminalization of the homeless and push for more compassionate and better housing solutions. Occupy Medical participated actively in these protests, buttressed by the organization’s goodwill on the local level. Operators and volunteers championed the city’s obligation to its local unhoused and the dire health consequences of homelessness, stating in an op-ed in the Eugene Weekly in 2015.

There are those in the community who dispute the claim that homeless citizens are treated poorly. Those who question the persecution of the unhoused need only look at Kesey Square. Once a resting place for citizens housed and unhoused, this plaza is eerily vacant at night. Blaring stadium lights give the square a concentration camp image. The unhoused, after being menaced by police officers under the direction of aggressive business owners, moved to the sidewalks. Now we hear grumbling of government officials who, though they were instrumental in the trail that led the homeless to the sidewalk, are disgusted by their arrival. This is the criminalization of the homeless (Eugene-Weekly, 2015)

Local Moral and Material Conflicts

Occupy Medical presented a unique arena of conflict between the morality of a mission and the material and pragmatic interests of stakeholders, manifested in the partners’ relationship. Morality is at the heart of Occupy Medical, enshrined in the unwavering belief the healthcare-for-all model and the right of low-income and the unhoused to access to medical care. Many of the unhoused population lacked proper healthcare and, consequently, simple wounds and ailments are often left unattended, further complicating their lives on the streets. Thus, for the volunteer-based clinic, one of the most important goals of operation was to provide access and treatment for everyone at the intersection of two complex socioeconomic problems: inadequate healthcare and homelessness. A member of the organization described the absence of even basic healthcare for the unhoused as follows:

We had people coming to us that weren’t going to the hospital. We weren’t seeing them in clinics. They just weren’t getting care and it was horrible. The example that I use is, a gentleman who was on the way to dying of Hepatitis, and you don’t have to die of Hepatitis. We have fixes for that, but he didn’t have anything. His skin was orange, his eyes were orange, he was peeing brown, he was in extreme pain, losing a lot of weight. He’s dying of Hepatitis. Coming to us, a little free clinic, the combination of the prescription medication and then the herbal supplements helped support his liver and kidneys meant that he was able to recover from his Hepatitis and get his body under control. (#SS1)

Additionally, the embodied experience of the unhoused clientele shaped the structure of the organization with the latter’s core ambition to go beyond merely providing medical assistance to offering patients and marginalized group a holistic and respectful treatment. That included access to meals, haircuts, and a massage therapist, all free of charge with no discrimination. This holistic approach aligned with Eugene’s culture, a previously unhoused informant stated the following:

So, I also love the fact that they are open minded. While they’re like totally open with regular normal medicine, they’re also open to everybody's idea of alternative medicines, like you know, different methodologies.

However, the morality of the mission clashed with the material conditions in Eugene. First, contentions arose between the operators’ goals of reaching the unhoused where they are on the streets, and the material interests for local stakeholders in keeping public spaces homeless-free. Downtown Eugene was where many of the unhoused spent the daytime to be closer to social services such as public libraries, churches, and the courthouse. The clinic opted to open on Sundays in Downtown Eugene when all business and government employees were off, thus minimizing potential confrontations with disgruntled passersby. A long-time volunteer recalls these early days of the clinic as follows:

There was nothing but offices and stores that normally weren’t open on Sundays surrounding us. We didn’t really get any feedback reaction from neighbors there. Except sometimes, people would be walking by and they’d kind of look at you know like what is this? On the other hand, a lot of people, probably more people stopped and asked what it was and then came back the next week with donations. (#NN1)

However, when the clinic moved to another location downtown, the operators had to deal with pushback from neighborhood residents, rooted in the latter’s material interests to avoid the “ugliness” of homelessness. One of the lead operators described the conflicts as follows:

The community was not super excited about us for a long time. We got a lot of flack. I’m not sure why offering free medical care was an issue for them. You're Occupy, therefore you’re stupid. They would recommend that we would get a job or something. I already have. 60 hours a week I'm working, but thanks for the advice. They were really rude to us. The cops would come and there would be three groups of two cops that would circle like sharks at our little spot. (#SS1)

Eventually, the clinic moved to the Washington-Jefferson Park where they faced less confrontations from the neighborhood.

Organizational Structure: Structurally Confined Partnership

Scope of Operations

Occupy Medical had the goal of dispensing holistic healthcare and wellness services to the city’s marginalized communities focusing on the homeless population and low-income families in Eugene. However, the organization had to reckon with the material constraints that both the model and the nature of homelessness healthcare put on the scope of operations. Because the organization was run by an all-volunteer team of administrators and healthcare providers, it could only operate with a minimal cutoff of personnel and supplies to maintain the various stations (triage, examination, pharmacists, herbalists, etc.). These constraints limited the scope of operations to one day a week on Sundays. Given the extent of homelessness in the city and the limitations on public spaces, scope of operations was further limited by the location of the clinic. In 2013–2017, the operators opted to run the clinic in Whitaker neighborhood, a low-income part of town, as it provided more access to the target clientele. The choice was further sanctioned by the local city government as it minimized complaints from business owners and other community members with more unwelcoming views to the clinic and its target social groups.

Partners’ Roles

Designing the partnership at this stage was contingent on the interplay between the moral and material interests of the local government and the operators of the clinic from the civic sector. To operate in the city, it was crucial for the nonprofit to engage with the local government to gain a minimal level of collaboration to access public spaces. The government, however, was reluctant to engage directly with the new organization. The city had to balance its duty to provide public services with its material interests in maintaining its political cache with powerful stakeholders in the community. This manifested in a pragmatic approach to the partnership: as a partner, the city endorsed Occupy Medical and provided support when called upon for help but otherwise preferred a hands-off approach, contributing minimal resources beside public space and police sanctioning. This is rooted in the limited impact that Occupy Medical had on the political interests of city officials as well as the fact that, through providing healthcare for low-income and homeless individuals, Occupy Medical saved the city some of the expenses associated with caring for these communities. A long-time resident of the city and early volunteer explained the balance as follows:

We had good local government support. You kind of need that in certain ways just to get permission to be on the park box. Set up your tents. Don’t go up to water. We had to have water or else people couldn’t wash up after getting urine samples. We had to have electricity. (#NN1)

On the other hand, civil society was exceedingly dominant: the clinic operated and provisioned the service with support of local partners in the healthcare and other homeless services agencies.

Shared Resources and Control

In line with its role, the local government was barely involved in provisioning resources for the organization. The hands-off approach from the city limited the resources and support the clinic received. One of the volunteers lamented the following:

The city of Eugene was very reticent to help us. I just came once a month and would, during public comment, give a report, as if they were part of our problem-solving team. That’s okay. I just say, “Well, it’s occupy medical, and these are the amount of patients that we served, and what we have noticed is that we have a lot of respiratory distress right now,” … After a while, [I ask] “What we would like is to have the bathroom open, and barring that, I would like to have the City of Eugene offer a public bathroom, and then a hand-washing station for our doctors. H1N1 is coming through, and you need to wash your hands for that. The hand sanitizer is just not going to do it.” After three asks, so that, and they provided that. That's what they offered. Their big thing that they offered was that they wouldn't charge us for being there. (#SS1)

Civil society partners, on the other hand, provided the volunteers and medical supplies to operate the organization through donations and grants. The organization relied completely on volunteer healthcare professionals. Driven by a moral imperative to the humanity of all patients, the clinic was intentionally designed as a low-barrier organization where no patient is excluded from accessing the provided services. Patients entering the clinic pass through a triage desk where they check-in and have their vitals recorded before being assigned to the suitable healthcare professionals. Many medications are provided directly to patients at the clinic, however, for more advanced treatment, the clinic provided vouchers for discounted generic products and referrals to local partner agencies and clinics. Additionally, the clinic relied on a host of collaborations with local nontraditional health providers to fulfill the high demand for alternative wellness, a local unhoused person explained the following:

I don’t trust western medicine at all anymore. They harmed me really bad. I have been trying to heal myself from the damage that professional allopathic doctors did to me. (#KH1)

The roles of partners and the shared resources were critical to the structure of control in the partnership. Occupy Medical championed a model of empowerment where the patients were highly involved in the choice and administration of the services. Through restricting the role and power of corporate and government partners, the nonprofit organization managed to continue to offer its brand of healthcare independently without any restrictions or rules on accessibility. A volunteer explained the rationale as follows:

I think the feeling was as far away from the government as you can stay, the better off you were. We’re trying to set an example here. We’re trying to show that you could do Medicare for all without anybody having to exchange money. Everything is free. The donor’s time is free. All the donations are free. And we give as much as people want to carry away with them kind of thing. That's the way we think it should go (#NN1)

Phase 2: Expansion of Scope and Control—Office Clinic

Place-Based Dynamics

Local Triggers of Change in CSP: Exacerbating Homelessness and Political Triggers

Two shifts in local dynamics in the city triggered the second major structural change for Occupy Medical. First, the success of Occupy Medical coincided with a surge in the number of unhoused and low-income patients seeking the clinic’s service overwhelming the operational capacity of the organization. The fluctuation in the number of available healthcare professionals began to take a toll on the clinic, with a few people putting in more hours or quitting due to burnout. A volunteer with Occupy Medical recalls a particularly bad winter in the first location in Downtown Eugene as follows:

the doctors and the nurses and the herbalists were freezing their butts off for four hours and they couldn’t deal with it. Especially aging people. At that point in time, I was okay as long as I was just dressed well, but we had one woman who we helped to start the place and she finally stopped coming to Occupy. The body just can’t tolerate the cold. So, she dropped out for probably six months (#NN1)

Occupy Medical continued to operate out of the bus till mid-2018, yet it was becoming increasingly clear that the sustainability of operation was in jeopardy.

The second trigger was a result of increasing ideological tensions between local and national stakeholder groups. Following 2016 presidential election, the new federal administration championed a more active role in prosecuting and deporting undocumented immigrants. An executive order issued in January 2017, empowered federal immigration officers from Immigration and Custom Enforcement (ICE), known as ICE agents, to override police operations on local levels. The order triggered national and local confrontations. States, counties, and cities across the United States refused to cooperate with what they believe to be a discriminatory overreach (Cameron, 2017, washingtonpost.com). The Federal government intensified its operations with threats to cut federal funding to these so-called sanctuary cities (Alvarez, 2020, CNN.com). The executive order was blocked in November 2017, however, the tensions continued as cities in Oregon, California and other states fought the indiscriminate crackdown as reports showed that “of 50,000 people in immigrant detention facilities on the last day of April 2019, nearly two-thirds had no criminal record” (Jordan, 2020, The New York Times).

Scale of the Local Problem: Homelessness, Healthcare, and Undocumented Immigration

Occupy Medical was proven to be highly popular and the increasing demand for services required an expansion of operations to accommodate patients with more complicated conditions. The clinic helped an estimated 9000 patients in 2013–2018, however, the weekly, temporary setup was proving to be unwieldy in servicing the increasing need in the community. As the cost of living and rents in the city continued to trend upward, coupled with the economic slowdown in the city, many low-income and at-risk families succumbed to homelessness and the health challenges of living on the streets. An unhoused person described her experience following the loss of a partner and having to live in her vehicle during the Eugene winter as follows:

when you’re on the street, one, you’re not eating properly. Let’s just face facts. Two, you’re not safe, and you know you're not safe, so you don’t sleep well. You spend the whole night one ear open and open eye cocked because you don’t know what's going to happen. When you do not eat properly and you do not sleep properly, you become susceptible to everything that comes down the road and you get sick a lot more (#GA1)

Importantly, besides operating at the intersection of homelessness and healthcare, the mandate of the partnership expanded to include certain patients that would rather not come to an open space location. The lead operator offered the rationale for the expansion as follows:

And there was so many segments of the population that needed to be served that we were serving poorly. Like, for instance, the undocumented. They are in a dangerous position right now... so for this situation we expand our hours and we offer appointments and people can come in and then leave quickly and we've got a back entrance et cetera that will make it easier for people no matter what their citizenship status is to get the care that they need. (#SS1)

Local Moral and Material Conflicts

These political contentions re-shaped the goals and mission of Occupy Medical. The free-healthcare-for-all model was a refuge for many undocumented immigrants in the county, in addition to the homeless, the poor, and those with criminal records. Patients were not required to furnish any personal records or their real names. The organization, thus, had to reckon with these contentions on the local level, acting as a proxy and a representative for these marginalized communities in political negotiations with local stakeholders. As mentioned, Occupy Medical was supported by the self-sufficient efforts of the clinic operators and volunteers and admired by the local city and the Whiteaker, the low-income neighborhood where the clinic operated every Sunday servicing families and unhoused individuals. However, the moral mission of the organization was hard to separate from the political and material conflicts between the law enforcement agents and the state. An operator described these conflicts for the clinic’s patients as follows:

We had some constant tension in Eugene. For example, if a police officer decided he was gonna come walking through the middle of the crowd, that could trigger a lot of people to leave. 'Cause they had warrants out for their arrests because they'd gotten no camping tickets and they'd never paid them and they didn't want to go to jail and they still couldn’t pay them. (#NN1)

The moral imperative to serve more of the local clientele, especially those becoming increasingly vulnerable to the political situation, further strained the material limits of the organization. The open space setup was proving to be rather unconducive to the purposes of the clinic. Maintenance costs were a drag on the organization’s limited finances. A local unhoused activist with strong ties to the program explains as follows:

And one of the other things I had learned was, like the equipment, they were spending too much money on fixing things. Like all the tents necessarily, people don’t realize all these tents coming up and down, up and down, up and down, wear and tear and thousands of thousands of dollars where those thousands and thousands of dollars can be going towards medicine. (#LW1)

The harsh winters of Eugene were also taking a toll on the operators, volunteers, as well as the patients, as a volunteer observed.

People come in with frost bite and in danger of losing their toes if not their entire feet. Just all kinds of stuff that you and I probably wouldn’t have to go to see anybody about because we're protected by being in a house or being well-clothed. Being able to go in a store or warm bathroom without having to answer a ton of questions (#NN1)

Thus, in June 2018, Occupy Medical made the decision to move its operations to an office building in the neighboring city of Springfield. The move was rather surprising, given the stable arrangements Occupy Medical had with the city of Eugene and the neighborhood.

Organizational Structure: Structurally Confined Partnership

Scope of Operations

The move from a mobile bus to an office building precipitated a restructuring of the organization’s operations to capitalize on the new space. It also epitomizes the central tension at the heart of the cross-sector partnerships’ operations, that is between the moral mission and the material constraints affordances of organizational structure. The move allowed the organization to expand the scope and quality of operations. Working out of building offered more protections and privacy to marginalized or prosecuted clientele. For instance, when ICE officers rented a jail cell in Springfield, the clinic was able to adjust its operations to continue serving this clientele.

So for this situation we expand our hours and we offer appointments and people can come in and then leave quickly and we've got a back entrance et cetera that will make it easier for people no matter what their citizenship status is to get the care that they need. (#SS1)

Additionally, the new space allowed for an expansion of the types of services while decreasing volunteer burnout. Working with marginalized and stigmatized communities, especially for medical students with little experience, is mentally and physically taxing. In the conversation with one of the administrators, they expressed such gratitude for the affordances that having material walls provided such as bathrooms, private examination rooms, and even a space for volunteers to regroup.

We usually have a crying stool in here. I don’t know where it went to, but it’s nice now. Before when someone was having a little problem, then they would go into the back of the bus and then crouch down. There’s a little closet there and they’d hang there for a little bit to collect themselves, because some of the stories that we hear are problematic, especially when you have context. (#SS1)

On the downside, the relocation out of the Whiteaker and into Springfield limited access to other patient groups. A formerly unhoused person explained as follows:

I’ve been a supporter of Occupy Medical as soon as they came out. My only criticism is that they’re not in the park blocks anymore. They’re in Springfield, in the office, so all the people in Eugene now don't have access to that because how do they get to Springfield? (#LW1)

Clinic visits in the early months for relocation reflected this effect: “It was really low for a while even though we were trying to put as much information out on the streets as we could.” (#SS1).

Partners’ Roles

The relocation had a major effect on the roles in the partners. The choice to move to Springfield was prompted by the exorbitant rents in Eugene. As before, the local government maintained its arms-length approach to the organization. The lead operator explains the tension around the move as follows:

City of Eugene asked to have me in a meeting, and you know, what’s going on with Occupy. I brought them up-to-date and said, “We’re not serving people in Eugene anymore, it’s too expensive. You guys have to fix the affordable housing issue, and you also ... I need a runner, like a sprinter van, and you guys have a bunch of vehicles. So, why don’t you give us one?” They were like, “Oh, okay. We'll write that down.” (#SS1)

The exacerbating homelessness in the city further soured the partnership between Eugene and the operators of the organization, many of the latter believing the city relies more on criminalizing homelessness than providing rehabilitation services (Perese, 2019, Eugene Weekly).

Shared Resources and Control

The move to Springfield allowed the organization to enhance its control over the operations. While support from the local city government dwindled, the county became more involved with the cross-sector partnership, in addition to an increasing support from the local government in Springfield. This was most evident when Occupy Medical officially denounced the operation of ICE agents in Springfield, arguing that it is negatively affecting the public health of the citY. Springfield and the county halted the operations in response. These interactions represented an endorsement from the city of Springfield who were happy to partner with the clinic, so long as the partnership did not require diversions of city funds. The organization continued to build further partnerships with other nonprofits and community members in Eugene. The network of civil society partners exemplified the bond between the organization and Eugene, a formerly unhoused local explained as follows:

We have a network of people in this community growing things specifically that they need: medicinal herbs, vegetables, different things that we can grow. And all these people do it to support Occupy Medical. And like when people are planting their gardens, they actually say this is the row for, this is my Occupy Medical row, or this one here, or these, this whole half of my garden is, things like that. (#LW1)

Thus, civic society maintained operational control allowing the organization to dispense healthcare in line with its core moral mission, free-healthcare-for-all. However, this level of control had to reckon with the material constraints as well. Now operating in a business/residential area, the organization faced the typical opposition from neighbors who believed the clientele was unsightly or a disturbance to the neighborhood. Appeasing these concerns required tighter controls of the physical spaces in and around the clinic which taxed the administrative capacity of the clinic. The reliance on volunteers and a few full-time personnel resulted in miscommunication issues and delays in processing volunteer applications and other aspects of operations. A volunteer described the concern with this arrangement as follows:

Because we don’t have an administration. We don’t have an executive director, we don’t have, these are administrative positions that nobody would necessarily need to know anything about medicine or whatsoever to do. And I really think, we've talked about this. We have a retreat every year and we’ve talked about it in terms of what could we get done better if x? And I always brought up the administrative staff to help out and take things that other people don’t have to deal with (#NN1)

By the end of 2019, the organization have been in the new space for a year with established operations and clientele base funneled every Sunday through a network of services and a stable structure. The onset of COVID-19 pandemic in March 2020 upended this local order.

Phase 3: Re-Organization for the COVID-19 Pandemic

Place-Based Dynamics

Local Triggers for Change in CSP: COVID-19 Pandemic

On December 31st, 2019, the Chinese government announced that doctors in the State of Wuhan were grappling with dozens of cases of an unidentified disease with pneumonia-like symptoms. The first case was reported in The United States less than a month later. By the end of February 2020, the world was unrecognizable as The World Health Organization (WHO) declared the Coronavirus Disease 2019 (COVID-19) a global health emergency, millions quarantined-at-home in countries all over the world, and all economic and social life came to screeching halt. By April, the United States became the country with the highest cases with at least 81, 321 confirmed infections and more than a thousand mortalities, climbing to 100,000 by the end of May. The first COVID-19 case in Oregon was reported in early March reaching 20,000 cases in August, and 34,000 by October (Granillo & Selier, 2020, Portland Monthly). A historically disastrous wildfire season in September exacerbated the public health crisis (Baker, 2020, The New York Times) as the air quality in many parts of the state hit extremely toxic levels prompting the state to declare an emergency (Winters, 2020, grist.com).

Scale of the Wicked Problem: Homelessness, Healthcare, and a Public Health Crisis

Eugene fared relatively better at the onset of the pandemic. The city went on lockdown in March following the declaration of a statewide emergency. Eugene remained a “cool spot” for the coronavirus in March–May. June saw a surge in cases, exploding in September and early October reaching a height of 400 cases a day. The state of emergency continued throughout the county with its two largest cities Eugene and Springfield at the epicenter of the surge. A massive wildfire tore through the forests on the edge of the county, burning 500 homes and engulfing the two cities in thick clouds of smoke and ashes (Dixon-Kavanaugh, 2020, the Oregonian).

COVID-19 is particularly hazardous to the homeless and the poor, the two main target groups of Occupy Medical. Many federal agencies including the Center for Disease Control and Prevention (CDC) and the National Alliance to End Homelessness promptly issued guidelines and frameworks for to mitigate the risk of these vulnerable groups. Cities with large number of unsheltered homelessness faced specially complicated challenges in “trying to contain COVID-19 and addressing homelessness, with the potential for both issues to exacerbate one another” (Tsai & Wilson, 2020). The high poverty rate in Eugene, at 27% in 2017, complicated the problem as low-income individuals were more vulnerable to contracting the disease and to become homeless (Buheji et al., 2020). The toxic air quality in September compounded the risk given the nature of the disease as a severe respiratory infection.

Thus, June–October period plunged Eugene and Springfield at a storm of local crises with unprecedented proportions. The normally intractable problem of providing healthcare for the homeless developed into a public health crisis. The severity of the situation was not lost on county authorities, a local official described it as follows:

Not only is it more difficult from unhoused people to maintain the good hygiene and social distancing that is critical to slowing the spread of COVID-19, but many of the social services they depend on for meals are not able to operate right now, or operating at a much smaller scale.” (Kate Gaffney, quoted in the Daily Emerald)

As the county scrambled for responses, Occupy Medical, the small free clinic in Eugene, was abruptly sprung into the spotlight as a local center for expertise on healthcare and vulnerable communities in the county. The limited partnership between the county and the nonprofit organization shifted drastically with two major developments. In late March, the county established a temporary respite site at the Lane County Fairgrounds in Eugene, contracting with Occupy Medical to dispense health services related to COVID-19. This was followed with a more extensive move to a $5.2 million dollar county-owned facility in Eugene on June 2nd with 44 rooms specifically designated to those suffering from COVID-19 cases while experiencing homelessness. Additionally, Occupy Medical partnered with a local nonprofit to open a new location on Wednesdays in its old location in the Whiteaker, the low-income neighborhood in West Eugene (Parafiniuk-Talesnick, 2020a).

Local Moral Versus Material Tensions

The local public health crisis at the conflation of an uncontrollable pandemic and toxic air quality brought the core tension at the heart of the wicked problem of homelessness into full relief. The public health implications of homelessness became a major concern for the county, catapulting the former’s moral right to basic material needs over the material interests of the elite majority and budget constraints. The urgency was more pertinent as the pandemic “gutted some organizations’ capacity to provide shelter and meal programs, pressure cooking those providers still serving on the frontlines” (Nyakanen, 2020, Daily Emerald). These developments were evident in two major points. First, the pandemic triggered increased funding from the federal and state to support emergency action on the county level (Eckert, 2020, KLCC). The county moved swiftly to supply the basic-level services that have long been denied to the unhoused. For instance, in Eugene,

seventy three portable restrooms and fifty eight handwashing stations, which for decades homelessness activists have advocated for, have been installed across the city (Nyakane, 2020, Daily Emerald)

Second, and more problematically, the escalating dynamics of the problem amplified the moral imperative for shelter as a universal human right and its contention with the privatization of local spaces. One of the main proscriptions to curb the spread of COVID-19 was to shelter-in-place, an unavailable option for most of the homeless population in the county. However, Eugene, home to 75% of the county’s unsheltered homeless population, lost 45% of its temporary shelter capacity due to the pandemic (McDonald, 2020, Register-guard). The battle lines were drawn between the County Response Team and the civic society on the one side, and the local city commissioners and the business communities on the other. As many cities worked to relocate their homeless residents to empty hotel rooms, local vendors around the county were “adamantly opposed to any attempt to commandeer hotel property, but we want to be proactive partners in dealing with the health emergency” (DuVernay, 2020, The Register-guard). The county moved to introduce micro-sites, temporary spaces on county-owned land with a maximum capacity of 10 persons. These initiatives had limited impact on the problem, however, especially as the ban on camping in public spaces was reinforced in July with police evicting more than 90 campers in a public park. In response, a four-page document protesting these evictions and recommending better courses of action was submitted to the city council, endorsed by more than thirty service providers, neighborhoods associations, and other groups in Eugene.

Organizational Structure: Structurally Leveraged Partnership

Scope of Operations

Occupy Medical’s scope of operations expanded immensely in this phase, moving to the forefront of the battle against the pandemic. This is evident in the operations of the organization. While limited to operating on Sundays at its office building in Springfield, the organization operated daily out of the Wheeler Pavilion at the Lane County Fairgrounds in Eugene. The site was a center for screening suspected cases of COVID-19, isolating those with mild symptoms till recovery, or re-directing severe cases to local hospitals if needed. The Pavilion added 14 beds as respite following the wildfires in September as the toxic air quality threatened many of the elderly unsheltered homeless population (Parafiniuk-Talesnick, 2020a). The volunteers continued to provide healthcare services for those with other conditions. The move to a county-owned building in July allowed up to 44 beds and a wider scope of services. However, one of the organizations operators explained as follows:

But there was still this nagging feeling that we really were missing our people where they were,“ Ní Flainn said. ” There’s a lot of people falling through the cracks (Parafiniuk-Talesnick, 2020c, The Register-guard)

Accordingly, the organization partnered with a local nonprofit to open another weekly temporary location in the Whiteaker, to continue providing non-COVID-19 healthcare services to the low-income and homeless individuals.

Partners’ Roles, Shared Resources, and Control

The enormity of the challenge altered the roles of the partners in Occupy Medical. The local government, which typically maintained an arms-length approach, was galvanized by the local escalation of the problem from a homelessness-focused problem to that of a global and local public health crisis. The lead operator of Occupy described the switch to a local newspaper as follows:

Barriers are starting to melt, it’s been encouraging. It’s particularly encouraging because many of us that have been working with this issue (of homelessness) for a long time have been tired.” (Parafiniuk-Talesnick, 2020b, The Register-guard)

The developments were evident in two major aspects of the cross-sector structure. First, the level of collaboration was significantly altered as the local county assumed a much larger role through providing funds, physical spaces, and resources to the partnership. Second, the cross-sector partnership was legalized further with Occupy Medical becoming a contractual partner to the county government. These advances cemented the role of the government beyond merely endorsing and sanctioning the operations of the organization. The new structure was contingent on an increase in shared resources between the two partners. However, Occupy Medical maintained its control over the operation. The partnership, thus, continued to enforce the free-healthcare-for-all-no-questions-asked model.

To summarize, Occupy Medical underwent a few major changes in its structure and operations from October 2011–November 2020. Local forces including shifting goals and interests and local crises triggered cycles of inter-partnership conflict over the moral and material aspects of the organization, summarized in Table 3.

Table 3.

Place-based dynamics and the structure of cross-sector partnership for occupy medical

Local dynamics of healthcare for the unhoused (2011–2020)		Local partners
		Phase 1		Phase 2		Phase 3
		Civic society	Local government	Civic society	Local government	Civic society	Local government
Moral dimension	Responsibility of the issue	Systemic	Systemic	Systemic	Systemic	Systemic	Systemic
	Responsibility to act	All sectors	Market Civil society	All sectors	-Civil society	All sectors	All sectors
	Urgency	High	Low	High	Low	High	High
	Tractability	High	Low	High	Low	High	High
Material constraints	Capacity to act	High	Low	High	Low	High	High
	Resource availability	High	High	High	High	Low	Low

		Mobile Clinic	Office Building	Wheeler Pavilion
Organizational structure of occupy medical	Form	Operating out of a bus and a few tents	Operating out of an a building in a business district	Operating the 11,000 sq ft. county/City-owned property
	Location	Low-income neighborhood: The Whitaker	Neighboring city: Springfield	Downtown Eugene
	Operation time	Sundays	Sundays, occasional mobile bus ventures	Everyday operations, clinic on Sundays
	Main clientele	The unhoused, low-income locals	Unhoused, low-income locals, undocumented immigrants,	COVID-19 patients, unhoused, low-income locals, undocumented immigrants,

Concluding Discussion

An increasingly fruitful line of research showcases the critical role of cities, communities, and towns, in shaping many organizational phenomena. This attention has mostly been missing in current research on cross-sector partnerships (Branzei & Le Ber, 2014; Bryson & Crosby, 2015). I analyzed the emergence and evolution of a local government-nonprofit partnership in the city of Eugene, Oregon over the course of nine years, 2011–2020. The findings disentangle the role of place in shaping cross-sector partnerships through (1) delineating the complexity of local dynamics and how it shapes, (2) the conflict between the partners’ moral claims and local material opportunities and constraints, and, ultimately, (3) how the structure of cross-sector partnerships changes in response. I discuss these dynamics and how the findings of this study contribute to the growing literature on cross-sector partnerships, place, and organizational structure.

Organizational Structure and the Contentions of the Moral and the Material

The main contribution of this analysis is unpacking how cross-sector partnerships change in response to place-based conflict. I proceeded from a synthesis of two major theoretical arguments. First, a focus on local dynamics of cross-sector partnerships emphasizes the inevitability of conflict inherent in stakeholders’ evaluations of local problems, their interests, and knowledge (Gary and Purdy, 2013; Ryan & O’Malley, 2016). Second, this place-based conflict is dynamic: changes in local conditions can disrupt existing arrangements and prompt renewed contentions over moral and material aspects of the core problem (Wexler, 2009) and stakeholders’ interests (Powell et al., 2018), and ultimately new organizational arrangements. Thus, this study embraces a more dynamic and embedded analysis of cross-sector partnerships to theorize how these cycles of conflict shape the formalized organizational structures of cross-sector partnerships. My analysis contributes to the interconnectedness of places, cross-sector partnerships, and local problems.

First, I unpack the dynamic and shifting interests of partners in local cross-sector partnerships, a research gap recently lamented in organization studies (Amis & Greenwood, 2020; Powell et al., 2018). Emplacement in geographically bounded moral and material systems allows for a deeper analysis of these shifts. Healthcare for the homelessness was a problem that the government acknowledged as systemic and intractable. Thus, the city was reluctant to divert any tax-payers funds to maintain the political cache with the elites, who typically oppose spending on such issues. However, COVID-19 pandemic aligned the interests of the civic society and the government as providing healthcare for the unhoused became a public health issue, as opposed to a niche wicked problem. The morality of the issue shifted in two major ways: higher urgency to act and a wider scope of those affected. This magnification of morality was enough to overcome the material constraints posed by political interests and limited capacity to act as more resources were directed to manage the urgent local situation. Attending to these dynamic interactions of the moral and the material offers a more nuanced grounding to the emergence and evolution of cross-sector partnerships as local solutions to local problems (Awad, 2022; Bryson & Crosby, 2015; Dentoni et al., 2018).

Crucially, the structure of the cross-sector partnership reflects these tensions/settlement patterns of interaction between the partners. I identify two types of structural forms, confined and leveraged, that a cross-sector partnerships employ to manage the dynamics of local places (Table 4). Structurally confined partnerships are ones with limited scope of operations typically targeting a marginalized local cause, with one partner unevenly responsible for operational roles, resource acquisition and allocation, and managerial control. Structurally leveraged partnerships are ones with expansive scope of operations targeting a more critical local issues(s) with partners sharing operational roles, resource acquisition and allocation, and managerial control. The findings suggest that cross-sector partnerships that emerge to serve a legitimate but marginalized cause are more likely to be structurally confined with uneven partnership involvement (van Tulder & Keen, 2018). These partnerships can still achieve outcomes, however, not the full potential of their moral mission due to the material constraints imposed by managerial and physical resources and the arms’ length instrumentality of other partners’ engagement (Powell et al.,; 2018). However, as the complexity in the external environment increases, i.e., changes in place-based dynamics, the organizational structure could respond with more internal complexity (Schneider et al., 2017). The partnership will shift to a more structurally leveraged form with increasing shared resources and larger role for other partners such as the local government, allowing for more expansive goals.

This finding is particularly informative for local governments and nonprofits, especially those operating under the resource constrained conditions of smaller cities and counties. My analysis showcases a pathway to identify new opportunities for more social and environmental impact through expanding homegrown and marginal partnerships. van Tulder and Pfisterer (Tulder and Pfisterer, 2013) argued that these bilateral partnerships, i.e., those involving only two of the three sectors, can only achieve optimality if they are independent of the third sector. Any less integrative (partial) arrangement would be rather transactional with limited effect. Ashraf et al. (2017) suggested a similar effect, arguing that cross-sector partnerships with low mutual resource dependencies and high power differences are more likely to fail. In contrast, the two types of organizational structures presented in this study nuances these arguments through demonstrating that successful operations and impact are achievable on different levels. Additionally, this suggests that cross-sector partnerships on the local level need to adopt more localized ambition and structurally confined forms as opposed to systemic change goals which could stretch the resources and lead to a misalignment between means and ends (Bromley & Powell, 2012).

Secondly, this study complements recent insights on the nonpath dependencies of cross-sector partnerships (Branzei & Le Ber, 2014; Powell et al., 2018). These studies suggest that collaborations can move toward better performance and patterns, despite past difficulties or failures, if new partners are recruited with potentially more aligned interests (Ryan & O’Malley, 2016; Seitanidi, 2008). I complement these findings through expounding the role of co-location and local events as external mechanisms for aligning interests. Importantly, crises are not guaranteed to trigger more pro-social collaborations, especially in the context of marginalized or stigmatized organizations (Rao & Greve, 2018). Rather, the relationship between the local manifestations of external shocks and local conditions is pivotal in triggering a shift from arm’s length instrumentality (Powell et al., 2018) toward more elaborate collaborations. The case of Occupy Medical captures these critical shifts. COVID-19 pandemic aligned the knowledge frames and the interests of the local stakeholders, transforming “healthcare for the homeless” from a niche local problem to an urgent public health crisis. This switch was directly related to local factors such as the high number of unsheltered homeless in the city and its small size. The tenure of Occupy Medical allowed the civic society partner in the cross-sector collaboration to accumulate a wealth of expertise on the problem over a decade of operations. This knowledge and expertise translated into more leverage and capacity to act locally, which allowed the civic to maintain operational control, even as the partnership moved to more leveraged structure. Broadly, this analysis advances our understanding of the evolutionary nature of cross-sector partnerships through theorizing the critical role of organizational structure in change processes (Gray & Purdy, 2013; Seitanidi, 2008).

Practically, these findings suggest a need for investing in better knowledge/expertise management approaches, beyond simply dispensing services. The increasing access to cheap digital systems and infrastructure allows for better long-term impact and preparation for future events (McNutt, 2020). Such repositories of local knowledge can allow civic society partners, to maintain better control over operations and preserve the moral mission at times of change.

Cross-Sector Partnerships as Latent Organizing

Additionally, this study explores the potential of local cross-sector partnerships in crises response as a form of latent organizing, “resources and capabilities that remain dormant in the context of the regular task domain A of host organizations, until they are activated by an emergency or crisis situation (the non-A domain) that cannot be addressed within task domain A” (Fenema et al., 2020, p. 5). This form of organizing is particularly crucial in responding to urgent and novel crises on which local governments and stakeholders have little guidance for action (Ansell et al., 2010). The COVID-19 pandemic in 2020 was just the latest in a long string of such crises over the past two decades including 9/11 attacks, Hurricane Katrina, the refugee crisis in Europe, and the SARS epidemic. These crises tax the capabilities and resources of local government, prompting more cross-sector collaborations (Lu and Li, Lu and Li, 2019). Emergency activities will thus depend on community resilience, the capacity of the local civic community to organize on existing local resources “including experienced founders and workers, dense social connections, and trust of others” (Rao & Greve, 2018, p. 9). For local government, these crises present many challenges on many fronts, three of which are particularly pertinent to this analysis: “coping with uncertainty; providing surge capacity; organizing a response” (Ansell et al., 2010, p. 197). Yet, the form of these potential collaboration in times of crises, while acknowledged, have rarely been investigated (Lu and Li, Lu and Li, 2019).

Based on this study, I advance this line of work through arguing that cross-sector partnerships with confined structures can act as a local repository of latent organizing as their existing structures, expertise, and knowledge allow them to overcome many resource and organizing limitations. Fenema et al. (2020) argue that latent organizing for emergency crises responses faces three main challenges: acquiring resources from local stakeholders; developing and integrating the urgently needed capabilities in short time periods; and leveraging the organizational arrangements to facilitate the efficient coordination and communication needed for a surge response. Structurally confined cross-sector collaborations, such as Occupy Medical, provide existing organizational arrangements where the required capabilities and coordination are already established. As such, as a crisis response injects more resources on the local level, these organizations can re-organize effectively toward new strategic outcomes and absorb the urgent local needs.

Local Embeddedness and the Dynamics of Wicked Problems

One of the major driving dynamics in this analysis was the conflicts inherent in wicked problems and the unfolding moral tensions between local stakeholders, a dimension of complexity rarely analyzed in the existing literature (Dentoni et al., 2018). This lack of attention is justified with the concept of wicked problems being introduced as an amoral technical term to describe certain types of policy problems (Wexler, 2009). Yet, for a cross-sector partnership aiming to tackle a specific wicked problem, these thorny ethical tensions are unavoidable: problem-solvers must establish and take responsibility for their claims regarding the problem, engage in politics of urgency to capture attention and resources, and argue for their methods and solutions (Wexler, 2009). Attending to these tensions in bounded local contexts can surface potential conflicts between how partners understand and define the problem and what goals/interests are prioritized in possible solutions. The findings in this study highlight the need to unpack these dynamics empirically to understand the emergence and evolution of cross-sector partnerships. Yet, current literature on cross-sector partnerships and wicked problems have typically conceptualized the latter as totalizing, “intractable masses of complexity, so conflict-prone and/or knotty that they defy definition and solution” (Alford & Head, 2017, p. 399).

Conversely, this analysis provides a fine-grained account for the evolution of wicked problems as a product of local history and events as opposed to the high-level global problems such as climate change and inequality, the typical targets for cross-sector partnerships. I find that local problems promote the emergence and evolution of local cross-sector partnerships with limited goals as opposed to the more elaborate goals of systemic change common for the highly complex super-wicked problems (Clark and Crane, 2018; van Tulder & Keen, 2018). This analysis thus informs the dynamic complexity of wicked problems, as proposed in Dentoni et al (2018) framework through analyzing degrees of “wickedness” over time (Alford & Head, 2017). A wicked problem can evolve into a less complex problem as shifts in the different interests of stakeholders align, as shown in Table 5. The impact of COVID-19 turned what was a typically wicked problem, healthcare for marginalized and at-risk social groups, into a more urgent and manageable complex problem. The shift was precipitated through aligning the divergent stakeholders’ interests, the conflicting framings of the problem, and redistributing resources and power on the local level, thus allowing for more consensus and courses of action. Such a shift, however, is not automatic nor inevitable. While the findings in this study point to the role of local material conditions, future studies can offer more insights into this process.

Table 5.

The dynamic complexity of wicked problems in Eugene, Oregon (2011–2020): homelessness and healthcare

	Local components	Criteria	Phase 1	Phase 2	Phase 3
Wicked problem	Knowledge	Technically Complex	Y	Y	Y
		Unknowable	Y	Y	Y
		Fragmented	Y	Y	Y
		Multiple Framing	Y	Y	N
	Stakeholders interests	Wide Interest-differentiation	Y	Y	N
		High Power Distribution	Y	Y	N
	Complexity		Wicked Problem	Wicked Problem	Complex Problem

Limitations and Future Research

The study is subject to a few limitations. Emblematic of theory development through abductive analysis, the findings represent a middle-way between inductive and deductive research. Thus, future research is needed to further validate these findings. The focus on a specific place invites challenges to possible generalizations. Additionally, the dynamic relationship between confined and leveraged structures is especially inviting for future research. For example, this study focused on the shifts precipitated by a crisis, the COVID-19 pandemic. Future research could examine the possibilities of such restructuring through other local dynamics such as advocacy and incremental political engagement (Awad, 2022). Future studies could also investigate these place-based dynamics in tripartial partnerships (van Tulder & Keen, 2018). Data collection also presented a challenge for this project as the urgency of the COVID-19 pandemic limited access to first-hand interviews with the partners in March 2020–September 2020, leading to more reliance on secondary data. Lastly, this analysis contends with the common limitation of many longitudinal research inquiries: while scientific analysis is bounded, the empirical reality is ongoing (Dubois & Gadde, 2014). The COVID-19 pandemic remains a pressing in many parts of the globe at the time of this writing.

Funding

The author hereby asserts that this manuscript does not pose any potential conflicts of interests. No funds, grants, or other support were received.

Declarations

Conflict of interests

The authors have no relevant financial or nonfinancial interests to disclose.

Ethical Approval

Approval was obtained from the Institutional Research Board of the University of Oregon. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Participants signed informed consent regarding publishing their data and photographs.