The Water in Which We Are Swimming - Introduction to the Special Issue - Developing a Common Understanding of Networks of Care

Jul 19, 2026

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This introduction frames “Networks of Care” as the often-overlooked system context shaping clinical communication, continuity, and quality of treatment. Drawing on a parable about “the water,” it argues that networking requirements are frequently handled ad hoc, producing gaps that undermine coordinated care and contribute to preventable deaths. The article presents a definition of Networks of Care as intentionally interconnected service sites supported by administrative and clinical management that enables collaborative learning and shared responsibility for outcomes.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages5

Reading Time13 min

Introduction

Networks of Care as the “water”

Definition and expected value

Maternal and newborn health as a lens

Public Disclosure Authorized Public Disclosure Authorized AUTHOR ACCEPTED MANUSCRIPT FINAL PUBLICATION INFORMATION The Water in Which We Are Swimming Introduction to the Special Issue-Developing a Common Understanding of Networks of Care The definitive version of the text was subsequently published in Health Systems and Reform, 6(2), 2020-11-17 Published by Taylor and Francis and found at [http://dx.doi.org/10.1080/23288604.2020.1834304](http://dx.doi.org/10.1080/23288604.2020.1834304) THE FINAL PUBLISHED VERSION OF THIS MANUSCRIPT IS AVAILABLE ON THE PUBLISHER’S PLATFORM This Author Accepted Manuscript is copyrighted by World Bank and published by Taylor and Francis. It is posted here by agreement between them. Changes resulting from the publishing process—such as editing, corrections, structural formatting, and other quality control mechanisms—may not be reflected in this version of the text. You may download, copy, and distribute this Author Accepted Manuscript for noncommercial purposes. Your license is limited by the following restrictions: (1) You may use this Author Accepted Manuscript for noncommercial purposes only under a CC BY-NC-ND 3.0 IGO license [http://creativecommons.org/licenses/by-nc-nd/3.0/igo](http://creativecommons.org/licenses/by-nc-nd/3.0/igo). (2) The integrity of the work and identification of the author, copyright owner, and publisher must be preserved in any copy. (3) You must attribute this Author Accepted Manuscript in the following format: This is an Author Accepted Manuscript by Chopra, Mickey; Pate, Muhammad Ali The Water in Which WeAre Swimming © World Bank, published in the Health Systems and Reform6(2) 2020-11-17 CC BY-NC-ND 3.0 IGO [http://](http://)[ ](http://)[creativecommons.org/licenses/by-nc-nd/3.0/igo](creativecommons.org/licenses/by-nc-nd/3.0/igo) [http://dx.doi.org/10.1080/23288604.2020.1834304](http://dx.doi.org/10.1080/23288604.2020.1834304) © 2021 World Bank 1 2 3 4 5 6 The Water in Which We Are Swimming: 7 Introduction to the Special Issue: Developing a Common Understanding of Networks of Care 8 9 10 Mickey Chopra 1 and Muhammad Ali Pate2 11 12 13 14 15 16 Corresponding Author: 17 Mickey Chopra 18 The World Bank 19 1818 H Street, NW 20 Washington, DC 20433 21 [Email: mchopra@worldbank.org](Email: mchopra@worldbank.org) 22 23 24 25 Author Affiliations: 26 1. The World Bank, Health Nutrition and Population, Washington, D.C., USA 27 2. The World Bank, Health, Nutrition and Population and the Global Financing Facility for 28 Women, Children and Adolescents (GFF), Washington. D.C., USA 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 A famous parable tells of two young fish swimming along. An older fish, swimming the other way, 48 nods at them and says,“Good morning, boys. How’s the water?” The two young fish swim on for 49 a bit, and then eventually one of them looks over at the other and asks,“What the hell is water?”1 50 51 Many of us, reading the collection of papers in this series on “Networks of Care,” may well start 52 out identifying with the bewildered young fish. Nearly all clinical care is conducted in the context 53 of a network, whether among care providers working within the same facility, across teams based 54 in facilities and the community, or vertically among different levels of care. Clinicians, 55 administrators and other health workers spend large amounts of time communicating across teams 56 and levels of care. Yet because we generally fail to pay attention to the networking requirements 57 of health care, these functions tend to be ad hoc and unreliable. A major source of frustration for 58 patients is frequent breakdowns in continuity of care. And the gaps and failures of networks are a 59 major cause of sub-optimal quality of care and hence a leading cause of the 15.6 million 60 preventable deaths estimated to have o

FAQs

Why does the introduction use the fish parable and the question “What the hell is water?”

It illustrates how networks of care are essential to clinical practice yet often taken for granted, remaining vague and hard to analyze. The metaphor highlights the need to understand the underlying system context shaping care.

What problem does the article link to failures in networks of care

Frequent breakdowns in continuity of care are presented as a major patient frustration. The gaps and failures are also described as contributing to sub-optimal quality of care and preventable deaths.

How does the article define a network of care

A network of care is defined as a group of public and/or private service delivery sites deliberately interconnected through an administrative and clinical management model. The model prioritizes client-centered effective and efficient operation and collaborative learning to enable team-based shared responsibility across care levels.

Jul 19, 2026

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