Public-private collaboration in health and human service delivery: evidence from community partnerships

Government Health and Social Services Spending Show Evidence of Single-Sector Rather Than Multi-Sector Pursuit of Population Health

Population health improvements can be achieved through work made possible by government spending on health care, public health, and social services. The extent to which spending allocations across these sectors is synergistic with or trade-off against one another is unknown. Achieving a balanced portfolio with multi-sector contributions is key to improving health outcomes. This study tested competing hypotheses regarding achievement of balanced multi-sector resources for health. County-level U.S. Census Bureau data on all local governmental spending measured each county’s average per capita local government spending for public hospitals, public health, social services, and education. American Hospital Association (AHA) Annual Survey data on hospital community health service provision were used to calculate an index of hospital community service provision aggregated to county level by year. County Health Rankings data measured each county’s health outcomes and health factors. Longitudinal mixed-effects regression models (n = 1877 counties) predicted changes in spending for each government spending category based on two sets of predictors (government spending vs community health services and needs) from current and prior year. Models account for average spending in each category and county-, state-, and time-trends. Models showed that spending increases in each of the four spending categories examined (public hospitals, public health, social services, and education) were not associated with changes in spending across other categories in current or prior years. For all categories, an increase from baseline spending levels in Year 1 was always significantly associated with an increase from baseline spending level in that same category in Year 2 (ie, spending stayed above baseline in Year 2). Multi-sector initiatives to health outcomes require funding across sectors, yet there was little evidence to suggest that communities that invest in public hospitals, public health, or other social services see commensurate increases in other areas. Underlying funding decisions may reflect strategic decisions within a community to scale up single sectors, constrained resources for multi-sector scale up, or a host of additional factors not measured here.

A stakeholder analysis of community-led collaboration to reduce health inequity in a deprived neighbourhood in South Korea

Intersectoral collaboration amongst health and other sectors, as well as between government and non-governmental organisations, has been highlighted as a way to improve health equity. We used a mixed-methods approach to assess collaborative relationships between multiple government sectors and civil society and to suggest possible health promotion interventions and policy alternatives for the urban poor in deprived neighborhoods. A total of 18 participants involved in health promotion interventions and policy processes related to the inner-city area of Seoul were recruited using purposive sampling methods. Participants included stakeholders working for or engaging in governments (3), public health care institutions (5), social service providers (3), community-based organisations (CBOs) (4) and faith-based organisations (3). We conducted semi-structured, one-on-one interviews and then collected survey data. Quantitative data were analysed using social network analysis, and qualitative data were analysed through iterative and consensus processes. The social network analysis indicated that a CBO plays the most substantial role in sharing and controlling informational resources to promote health. A stakeholder analysis showed that the CBO neutrally and negatively viewed the possibility of collaboration with other stakeholders. Three themes related to challenges to intersectoral collaboration emerged: (1) lack of trust and communication, (2) need of a coalition with a committed leading actor for future collaboration and (3) organisational and political silos within and across public sectors. Increased understanding of the current status of and challenges to collaboration can inform the planning and implementation of complex intervening strategies and policies tailored to vulnerable people in deprived neighborhoods. Community-led collaborative actions empower people in marginalised communities to envision a healthier community.

Implementing Substance Abuse Intervention Services in New York City Sexually Transmitted Disease Clinics: Factors Promoting Interagency Collaboration

This report presents results of Project LINK, a Substance Abuse and Mental Health Services Administration (SAMHSA)-funded, 5-year collaboration (2007-2012) between New York City (NYC) health and NY State substance abuse disorder (SUD) agencies, an LGBT organization contractor, and multiple SUD, social service, and mental health referral agencies. LINK allowed the first ever SUD screening, brief intervention, and referrals to treatment (SBIRT) intervention services onsite in NYC Bureau of Sexually Transmitted Disease Control (BSTDC) clinics. Factors favoring collaboration were (a) joint recognition of substance abuse as an STD risk factor; (b) prior collaborations; (c) agreement on priority of BSTDC's mission and policies; (d) extensive SBIRT training, cross training on STDs; (e) a memorandum of agreement; and (f) mutual transparency of collaborative efforts, among others. LINK screened over 151,000 STD clinic patients and delivered brief interventions to 60% of positively screened patients and met a mandated follow-up target. Factors found to facilitate collaboration here may help screen prospective new health collaborations.

Members’ Perceptions of Community Care Network Partnerships’ Effectiveness

Investment in voluntary partnerships raises important questions: Should we invest in collaboration in moving toward the goals of health system redesign? What makes collaborative groups effective? Given the voluntary nature of these partnerships, membership perceptions of their experiences and the partnership’s effectiveness should be important predictors of success. This article provides a preliminary analyses of perceived effectiveness of participants’ perceptions of their own partnership, particularly focusingon leadership, conflict management, decision-making dynamics, and the breadth and depth of partnership membership. Members’ perceptions that the partnership membership was “sufficiently broad to accomplish objectives” had a negative and highly significant relationship to perceived effectiveness. Members’ perceptions about leadership beingethical was positively related to perceived effectiveness while perceptions that the leadership was not effective a keeping the group focused was negatively related to perceived effectiveness.

Sustainability of Collaborative Capacity in Community Health Partnerships

Sustainability is a key requirement for partnership success and a major challenge for such organizations. Despite the critical importance of sustainability to the success of community health partnerships and the many threats to sustainability, there is little evidence that would provide partnerships with clear guidance on long-term viability. This article attempts to (1) develop a conceptual model of sustainability in community health partnerships and (2) identify potential determinants of sustainability using comparative qualitative data from four partnerships from the Community Care Network (CCN) Demonstration Program. Based on a grounded theory examination of qualitative data from the CCNevaluation, the authors hypothesize that there are five primary attributes/ activities of partnerships leading to consequential value and eventually to sustainability of collaborative capacity. They include outcomes-based advocacy, vision-focus balance, systems orientation, infrastructure development, and community linkages. The context in which the partnership operates provides the conditions for determining the appropriateness and relative impact of each of the factors related to creating consequential value in the partnership.

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Who's who in the crew? Exploring participant involvement in the Active Living Coalition

Health coalitions serve as an important "vehicle" to strengthen horizontal and vertical ties between organizations, community groups, and individuals whose intent and purpose is to improve wellness. Having a strong and diverse group of participants is essential for highly effective coalitions to carry out their mission in an organized and participatory manner. However, the extent that individuals become involved in coalition operations and activities remains ambiguous. A grounded theory approach was used to explore expressions of participant involvement of a local health coalition known as the Active Living Coalition (ALC). Open, axial, as well as domain and taxonomic coding were used to analyze transcripts from four focus groups (n = 37 participants) in order to develop a participant continuum that captured six network aggregates within the coalition. Findings suggest that participation, for the most part, was heterogeneous and ever-changing given the expectations of the level of partnership that best individuals' personal and professional interests. Differentiating the type of participants in health coalitions can help coalition leaders more successfully "manage" new and existing relationships. Findings imply that health coalitions can maximize coalition capacity by drawing upon the full range of potential human and material resources by further understanding the types of individuals that make up their network.

Implementation of collaborative governance in cross-sector innovation and education networks: evidence from the National Health Service in England

Background

Increasingly, health policy-makers and managers all over the world look for alternative forms of organisation and governance in order to add more value and quality to their health systems. In recent years, the central government in England mandated several cross-sector health initiatives based on collaborative governance arrangements. However, there is little empirical evidence that examines local implementation responses to such centrally-mandated collaborations.

Methods

Data from the national study of Health Innovation and Education Clusters (HIECs) are used to provide comprehensive empirical evidence about the implementation of collaborative governance arrangements in cross-sector health networks in England. The study employed a mixed-methods approach, integrating both quantitative and qualitative data from a national survey of the entire population of HIEC directors (N = 17; response rate = 100%), a group discussion with 7 HIEC directors, and 15 in-depth interviews with HIEC directors and chairs.

Results

The study provides a description and analysis of local implementation responses to the central government mandate to establish HIECs. The latter represent cross-sector health networks characterised by a vague mandate with the provision of a small amount of new resources. Our findings indicate that in the case of HIECs such a mandate resulted in the creation of rather fluid and informal partnerships, which over the period of three years made partial-to-full progress on governance activities and, in most cases, did not become self-sustaining without government funding.

Conclusion

This study has produced valuable insights into the implementation responses in HIECs and possibly other cross-sector collaborations characterised by a vague mandate with the provision of a small amount of new resources. There is little evidence that local dominant coalitions appropriated the central HIEC mandate to their own ends. On the other hand, there is evidence of interpretation and implementation of the central mandate by HIEC leaders to serve their local needs. These findings augur well for Academic Health Science Networks, which pick up the mantle of large-scale, cross-sector collaborations for health and innovation. This study also highlights that a supportive policy environment and sufficient time would be crucial to the successful implementation of new cross-sector health collaborations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0552-y) contains supplementary material, which is available to authorized users.

Eliminating malaria in Malaysia: the role of partnerships between the public and commercial sectors in Sabah

BACKGROUND

Countries in the Asia Pacific region have made great progress in the fight against malaria; several are rapidly approaching elimination. However, malaria control programmes operating in elimination settings face substantial challenges, particularly around mobile migrant populations, access to remote areas and the diversity of vectors with varying biting and breeding behaviours. These challenges can be addressed through subnational collaborations with commercial partners, such as mining or plantation companies, that can conduct or support malaria control activities to cover employees. Such partnerships can be a useful tool for accessing high-risk populations and supporting malaria elimination goals.

METHODS

This observational qualitative case study employed semi-structured key informant interviews to describe partnerships between the Malaysian Malaria Control Programme (MCP), and private palm oil, rubber and acacia plantations in the state of Sabah. Semi-structured interview guides were used to examine resource commitments, incentives, challenges, and successes of the collaborations.

RESULTS

Interviews with workers from private plantations and the state of Sabah MCP indicated that partnerships with the commercial sector had contributed to decreases in incidence at plantation sites since 1991. Several plantations contribute financial and human resources toward malaria control efforts and all plantations frequently communicate with the MCP to help monitor the malaria situation on-site. Management of partnerships between private corporations and government entities can be challenging, as prioritization of malaria control may change with annual profits or arrival of new management.

CONCLUSIONS

Partnering with the commercial sector has been an essential operational strategy to support malaria elimination in Sabah. The successes of these partnerships rely on a common understanding that elimination will be a mutually beneficial outcome for employers and the general public. Best practices included consistent communication, developing government-staffed subsector offices for malaria control on-site, engaging commercial plantations to provide financial and human resources for malaria control activities, and the development of new worker screening programmes. The successes and challenges associated with partnerships between the public and commercial sector can serve as an example for other malaria-eliminating countries with large plantation sectors, and may also be applied to other sectors that employ migrant workers or have commercial enterprises in hard to reach areas.

EXAMINING HIGHER EDUCATION-COMMUNITY PARTNERSHIPS THROUGH HUMAN RESOURCE DEVELOPMENT: IMPLICATIONS FOR INNOVATION AND TECHNOLOGY MANAGEMENT

Higher education and community partnerships have transitioned from casual relationships to more of a mandate with the advancements in technology and globalization. The result of this large-scale change has led to an increase in these efforts, but the relationships are still emerging. Using survey research and the human resource development (HRD) perspective, we explore higher education and community partnerships, assesses their challenges, and discusses potential contributions of such partnerships in community development. This article contributes to our understanding of how these partnerships interact and what strategies the field of HRD may offer to advance such collaborative efforts.

Assessing the validity of self-reported community benefit expenditures: evidence from not-for-profit hospitals in California

CONTEXT

In its revised Form 990 Schedule H, the Internal Revenue Service requires not-for-profit hospitals to provide detailed financial information on their community benefits, yet no standardized reporting guidelines exist for how these activities should be quantified. As a result, little is known currently about whether a hospital's self-reported community benefit expenditures provide an accurate picture of its commitment to serving the community.

OBJECTIVE

To assess the validity of hospitals' self-reported community benefit expenditures.

DATA AND METHODS

Data for this study came from California hospitals. Self-reported community benefit expenditures were derived from hospitals' annual community benefit reports for the year 2009. Bivariate correlation analysis was used to compare self-reported expenditures to a set of indicators of hospitals' charitable activity. Of the 218 private, not-for-profit California hospitals that were required to submit community benefit reports for 2009, 91 (42%) provided sufficient information for our analysis.

RESULTS

California hospitals' self-reported community benefit expenditures were strongly correlated with indicators of charitable activity. Hospitals that reported higher community benefit expenditures engaged in more charitable activities than hospitals that reported lower levels of community benefit spending.

CONCLUSION

Expenditure information from California hospitals' community benefit reports was found to be a valid indicator of charitable activity. Self-reported community benefit spending may thus provide a fairly accurate picture of a hospital's commitment to serving its community, despite the lack of standardized reporting guidelines.

Public-private partnership as a solution for integrating genetic services into health care of countries with low and middle incomes

In recent years scientific progress has dramatically raised the potential of genetic services, but the actual benefits of these developments are not universally shared. In countries of low and middle incomes, improvements in genetic services frequently lag behind. Since this is generally caused by lack of resources and not by the lack of political will, the question arises, how can one most easily acquire the necessary capital to improve the health care in these areas. Public-private partnerships (PPPs) offer one approach to solve this issue, aiming at the inclusion of private enterprises in the realisation of public authority services. So far PPPs have been used exclusively in other health service areas. In this paper a first attempt is being made to discuss the feasibility of transferring the concept of PPP to genetic services, and consideration is given as to where the most promising starting point might be. We start by defining a multilevel structure that needs to be considered in providing comprehensive genetic care. We continue by explaining the concept of PPPs and their current types of implementation in medical services. We then examine how the PPP model could be applied to genetic services or sections thereof. We arrive at the conclusion that a likely starting point for PPP in genetic services is at the level of the infrastructure building service.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

How can insulin initiation delivery in a dual-sector health system be optimised? A qualitative study on healthcare professionals' views

Background

The prevalence of type 2 diabetes is increasing at an alarming rate in developing countries. However, glycaemia control remains suboptimal and insulin use is low. One important barrier is the lack of an efficient and effective insulin initiation delivery approach. This study aimed to document the strategies used and proposed by healthcare professionals to improve insulin initiation in the Malaysian dual-sector (public–private) health system.

Methods

In depth interviews and focus group discussions were conducted in Klang Valley and Seremban, Malaysia in 2010–11. Healthcare professionals consisting of general practitioners (n = 11), medical officers (n = 8), diabetes educators (n = 3), government policy makers (n = 4), family medicine specialists (n = 10) and endocrinologists (n = 2) were interviewed. We used a topic guide to facilitate the interviews, which were audio recorded, transcribed verbatim and analysed using a thematic approach.

Results

Three main themes emerged from the interviews. Firstly, there was a lack of collaboration between the private and public sectors in diabetes care. The general practitioners in the private sector proposed an integrated system for them to refer patients to the public health services for insulin initiation programmes. There could be shared care between the two sectors and this would reduce the disproportionately heavy workload at the public sector. Secondly, besides the support from the government health authority, the healthcare professionals wanted greater involvement of non-government organisations, media and pharmaceutical industry in facilitating insulin initiation in both the public and private sectors. The support included: training of healthcare professionals; developing and disseminating patient education materials; service provision by diabetes education teams; organising programmes for patients’ peer group sessions; increasing awareness and demystifying insulin via public campaigns; and subsidising glucose monitoring equipment. Finally, the healthcare professionals proposed the establishment of multidisciplinary teams as a strategy to increase the rate of insulin initiation. Having team members from different ethnic backgrounds would help to overcome language and cultural differences when communicating with patients.

Conclusion

The challenges faced by a dual-sector health system in delivering insulin initiation may be addressed by greater collaborations between the private and public sectors and governmental and non-government organisations, and among different healthcare professionals.

Whole of Client Health Care in a Gridlocked System: An Insider Dialogue Between the Theory and Practice of Community Case Management

This article blends theory with empirical qualitative research to investigate the present practices of Community Case Management and develop a new and informed model driven by a whole of client approach rather than agency ownership. The Case Management Society of Australia presents an idealistic model that has never been fully implemented. Our exploration of the gap between this theory and the actual real-world practice demonstrates that a whole of client focus has been marginalized and frustrates full implementation. Recent Australian government policy changes to the Home and Community Care program have encouraged competitive, market-oriented delivery in an attempt to reempower the client, but it has come at the expense of collaboration. Introducing competition has added another dimension to impediments to client-centered care that include funding pressures, turf wars, territorialism, and organizationally induced gridlocked systems, all of which shift the focus from the client to the organization. In the face of this, it is paramount that case managers remain client focused and be willing to collaborate/communicate with all parties involved in the cares of the client. Failure to do so may lead to the eventual failure of the Home and Community Care program.

Understanding the organization of public health delivery systems: an empirical typology

CONTEXT

Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.

METHODS

This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.

FINDINGS

Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.

CONCLUSIONS

Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Contractual design and PPPs for hospitals: lessons for the Portuguese model

Recently the Portuguese Government announced the launching of public-private partnerships (PPPs) to build hospitals with the distinctive feature that infrastructure construction and clinical activities management will be awarded to separate private parties. Also, one of the parties will be in charge of providing soft facilities. We explore alternative configurations of contracts and assess whether the equilibrium allocations attain the first-best solution.

Effectiveness of a grant program's efforts to promote synergy within its funded initiatives: perceptions of participants of the Southern Rural Access Program

BACKGROUND

Foundations and public agencies commonly fund focused initiatives for individual grantees. These discrete, stand-alone initiatives can risk failure by being carried out in isolation. Fostering synergy among grantees' initiatives is one strategy proposed for promoting the success and impact of grant programs. We evaluate an explicit strategy to build synergy within the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), which awarded grants to collaboratives within eight southeastern U.S. states to strengthen basic health care services in targeted rural counties.

METHODS

We interviewed 39 key participants of the SRAP, including the program director within each state and the principal subcontractors heading the program's funded initiatives that supported heath professionals' recruitment, retention and training, made loans to health care providers, and built networks among providers. Interews were recorded and transcribed. Two investigators independently coded the transcripts and a third investigator distilled the main points.

RESULTS

Participants generally perceived that the SRAP yielded more synergies than other grant programs in which they had participated and that these synergies added to the program's impact. The synergies most often noted were achieved through relationship building among grantees and with outside agencies, sharing information and know-how, sharing resources, combining efforts to yield greater capacity, joining voices to advocate for common goals, and spotting gaps in services offered and then filling these gaps. The SRAP's strategies that participants felt fostered synergy included targeting funding to culturally and geographically similar states, supporting complementary types of initiatives, promoting opportunities to network through semi-annual meetings and regular conference calls, and the advocacy efforts of the program's leadership. Participants noted that synergies were sometimes hindered by turf issues and politics and the conflicting perspectives and cultures of participating organizations and racial groups. Inadequate funding through the SRAP, restricting program involvement to only a few needy counties, and instances of over- and under-involvement by the program's leadership were sometimes felt to inhibit synergies and/or their sustainability.

CONCLUSION

Participants of the SRAP generally perceived that the SRAP's deliberate strategies yielded synergies that added to the program's impact.

Partnership lessons from the Global Programme for Health Promotion Effectiveness: a case study

It is an article of faith in health promotion that health challenges cannot be confronted successfully by actors working in isolation. The synergy produced through collaboration is seen as vital. Yet, collaboration is arduous and many collaborations fade before their goals are met. Research is needed to identify factors and processes that promote as well as inhibit the production of synergistic outcomes. To this end, a case study was undertaken of the Global Programme for Health Promotion Effectiveness (GPHPE). The GPHPE reviews and disseminates evidence for the effectiveness of health promotion. Interviews with 20 GPHPE participants were conducted, transcribed and analyzed, and GPHPE documentation provided additional data. The results were used to develop the Bergen Model of Collaborative Functioning. It is a systems model (input, throughput, output) building on earlier research, that adds three new elements suggested by the findings of this study. First, the partnership's mission--to disseminate evidence of effectiveness--was identified as a significant input (alongside the conventional inputs of partner resources and financing) that affected the GPHPE's functioning in fundamental ways. Second, positive and negative cycles of interaction were identified that simultaneously strengthened and weakened the GPHPE's ability to sustain itself and produce the desired outcomes. Third, the construct 'antagony' was introduced as a unique type of output, in addition to synergy and additive results, representing unwanted and disturbing outcomes. The Model is constructed to have wide applicability, and further research now underway tests its utility in the study of local and national collaborations.

Promoting community coalition functioning: effects of Project STEP

There has been relatively little research on effects of interventions aimed directly at improving internal community coalition functioning, particularly in the area of planning for adoption of evidence-based prevention programs. The current study investigated the effect of Project STEP, a prevention diffusion trial, on three factors hypothesized to improve coalition prevention planning (quality of coalition plans, extent of plan implementation, and committee internal functioning in meetings). Cities were randomly assigned to one of three conditions (televised training with limited technical assistance, televised training alone, or control; n = 24). Results demonstrated that at 1.5 year follow-up, coalitions in the two intervention groups showed more effective prevention plans, plan implementation, and functioning in meetings than control coalitions. Group differences were maintained at 3-year follow-up, albeit at decreased levels, for quality of planning and implementation. The findings suggest that building coalition capacity to diffuse evidence-based prevention programs works at least partially by increasing the effectiveness of coalition functioning, and that booster training may be warranted within 3 years after initial training.

Hospital Responses to the Leapfrog Group in Local Markets

The Leapfrog (LF) initiative, directed at improving patient safety in hospitals, may be the most ambitious, coordinated attempt to date on the part of large employers to shape the delivery of health care in America. This article assesses the role of market conditions and other factors in influencing hospital responses to LF activities at the community level. Community characteristics were found to be important in explaining hospital participation in a LF safety standards survey at the study sites. However, characteristics of the individual hospitals, and of the LF goals themselves, were more important in explaining the relatively limited progress by hospitals across all sites in achieving those goals over a 5-year period.

Are joint health plans effective for coordination of health services? An analysis based on theory and Danish pre-reform results

Background

Since 1994 formal health plans have been used for coordination of health care services between the regional and local level in Denmark. From 2007 a substantial reform has changed the administrative boundaries of the system and a new tool for coordination has been introduced.

Purpose

To assess the use of the pre-reform health plans as a tool for strengthening coordination, quality and preventive efforts between the regional and local level of health care.

Methods

A survey addressed to: all counties (n=15), all municipalities (n=271) and a randomised selected sample of general practitioners (n=700).

Results

The stakeholders at the administrative level agree that health plans have not been effective as a tool for coordination. The development of health plans are dominated by the regional level. At the functional level 27 percent of the general practitioners are not familiar with health plans. Among those familiar with health plans 61 percent report that health plans influence their work to only a lesser degree or not at all.

Conclusion

Joint health planning is needed to achieve coordination of care. Efforts must be made to overcome barriers hampering efficient whole system planning. Active policies emphasising the necessity of health planning, despite involved cost, are warranted to insure delivery of care that benefits the health of the population.

Case study of capacity building for smoke-free indoor air in two rural Wisconsin communities

BACKGROUND

Despite national declines in smoking prevalence, disparities that pose challenges to tobacco control efforts exist among rural manufacturing populations. This community case study sought to better understand the dynamics and nuances that facilitate or impede capacity-building efforts in rural communities.

CONTEXT

Two rural manufacturing communities in Wisconsin with similar demographic characteristics were chosen for study. One represented farming communities with close proximity to a metropolitan area, and the other represented more isolated communities.

METHODS

The qualitative case study used a collaborative approach to collect data in four areas of research: 1) community context, 2) coalition functioning, 3) partnerships, and 4) strategy implementation. Data were analyzed using standard content analysis and triangulated for clarity and consistency.

CONSEQUENCES

Although not all the factors found to influence capacity-building efforts were unique to rural environments, the effects were impacted by rural isolation, small population sizes, local attitudes and beliefs, and lack of diversity and resources. Differences in coalition leadership and strategy implementation influenced the effectiveness of the capacity-building efforts in each community, bringing attention to the unique nature of individual contexts.

INTERPRETATION

Implementing capacity-building efforts in rural communities requires skilled and dedicated local leaders who have ready access to training and support (i.e., technical, emotional, and financial). Pairing of rural communities with greater use of distance technologies offers a cost-effective approach to reduce isolation and the constraints of financial and human resources.

The impact of state community benefit laws on the community health orientation and health promotion services of hospitals

This study examined the effect of state community benefit laws and guidelines on the community health orientation and the provision of hospital-based health promotion services in hospitals. The sample included all not-for-profit and investor-owned acute-care hospitals in the United States during the year 2000. Multiple regression procedures were used to test the effect of community benefit laws and type of ownership while controlling for organizational and environmental variables. The results of these procedures indicated that, on average, not-for-profit hospitals in the ten states with community benefit laws/guidelines reported significantly more community health orientation activities than did not-for-profit hospitals in the forty other states. The results of the multiple regression procedures also indicated that, on average, the investor-owned hospitals in the ten states with laws/guidelines reported significantly more community health orientation activities than did the investor-owned hospitals in the forty other states. The study found that community benefit laws had the effect of decreasing ownership-related differences in reported community health orientation activities. Further, Levene's test of equality of variance showed that the not-for-profit hospitals in community benefit states exhibited significantly lower variance in the community health orientation activities when compared with the not-for-profit hospitals in non-community benefit states. However, none of the statistical tests supported the hypotheses that community benefit laws compelled or induced hospitals to offer significantly more health promotion services. The study concluded that coercive measures such as community benefit laws were effective in compelling not-for-profit hospitals to report increased community orientation activities, and it also concluded that the mimetic pressures associated with these laws were effective in inducing investor-owned hospitals to report increased community orientation activities.

What explains community coalition effectiveness?: a review of the literature

Community coalitions have become popular vehicles for promoting health. Which factors make coalitions effective, however, is unclear. The study's aim was to identify coalition-building factors related to indicators of coalition effectiveness through a review of the empirical literature. Published articles from 1980 to 2004 that empirically examined the relationships among coalition-building factors and indicators of coalition effectiveness were reviewed. Two indicators of coalition effectiveness were examined: coalition functioning and community-wide changes. A two-phase strategy was employed to identify articles by reviewing citations from previous literature reviews and then searching electronic reference databases. A total of 1168 non-mutually exclusive citations were identified, their abstracts reviewed, and 145 unique full articles were retrieved. The review yielded 26 studies that met the selection criteria. Collectively, these studies assessed 26 indicators of coalition effectiveness, with 19 indicators (73%) measuring coalition functioning, and only two indicators (7%) measuring changes in rates of community-wide health behaviors. The 26 studies identified 55 coalition-building factors that were associated with indicators of coalition effectiveness. Six coalition-building factors were found to be associated with indicators of effectiveness in five or more studies: formalization of rules/procedures, leadership style, member participation, membership diversity, agency collaboration, and group cohesion. However, caution is warranted when drawing conclusions about these associations due to the wide variations in indicators of coalition effectiveness and coalition-building factors examined across relatively few studies, discrepancies in how these variables were measured, and the studies' reliance on cross-sectional designs.

Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership

BACKGROUND

To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery.

METHODS

In this single case study, we retrospectively explored how local health-care providers in Amsterdam collaborated for more than 30 years, interacting with the changes to the national health-care system. In-depth analysis of interviews, documents and literature focused on the complex relationship between the activities of this health partnership, its nature and its changing context.

RESULTS

The findings revealed that the partnership itself was successful and sustainable over time, although the partnership lost its initial broad explorative nature and narrowed its strategic focus towards care of the elderly. Furthermore, the realized projects--although they enforced integrated care--lost their community-based character. This declining scope of community-based integrated care seems to have been influenced by the incremental introduction of regulated competition in Dutch health care. This casts doubts on the ability of health partnerships to apply a vision of community-based integrated care within the context of competition.

CONCLUSION

Collaborating health-care providers can build seamless continuums of care in a competitive environment, although these will not automatically maximize community health with limited resources. Active policies with regard to health system design, incentive structures and population-based performance measures are warranted in order to insure that community-based integrated care through health partnerships will be more than just policy rhetoric.

Exporting the Buyers Health Care Action Group purchasing model: lessons from other communities

When first implemented in Minneapolis and St. Paul, Minnesota, the Buyers Health Care Action Group's (BHCAG) purchasing approach received considerable attention as an employer-managed, consumer-driven health care model embodying many of the principles of managed competition. First BHCAG and, later, a for-profit management company attempted to export this model to other communities. Their efforts were met with resistance from local hospitals and, in many cases, apathy by employers who were expected to be supportive. This experience underscores several difficulties that appear to be inherent in implementing purchasing models based on competing care systems. It also, once again, suggests caution in drawing lessons from community-level experiments in purchasing health care.

Communities and hospitals: social capital, community accountability, and service provision in U.S. community hospitals

OBJECTIVES

The study related community social capital to the level of community accountability and provision of community-oriented services in U.S. community hospitals.

STUDY SETTING

The sample included 1,383 community hospitals that participated in the 1997 American Hospital Association's (AHA) Hospital Annual and Governance Surveys.

DATA SOURCES

(1) The 1997 AHA Annual Hospital Survey, (2) the 1997 AHA Hospital Governance Survey, (3) the DDB Needham Market Facts Survey, (4) the 1996 County Election Data File, and (5) the 1998 Area Resource File.

RESEARCH DESIGN

The study used a mix of longitudinal and cross-sectional data.

KEY FINDINGS

We identified two distinct indicators of social capital-community participation and voting participation. Community accountability in hospitals was unrelated to either indicator. Hospitals' provision of community-oriented health services was negatively associated with community participation but unrelated with voting participation. The interaction between voting participation and community representation on hospital governance was positively associated with community accountability and provision of community-oriented health services.

CONCLUSION

Neither community participation nor voting participation was sufficient to influence hospital behavior. The positive finding associated with the interaction between voting participation and community representation on hospital governance underscored the importance of an active political culture in influencing hospital behavior, without which the installation of community representatives on hospital governance might be more symbolic than actually serving the health concerns of community residents.

The Value of Collaboration in Eliminating Barriers to Preventive Care and Screening Among Underserved Populations

Collaboration among a community's institutions and its residents can help increase the use of appropriate screening, preventive, and primary care services. To improve the health of the community, institutions must reach out to their colleagues and other stakeholders. They must not only deal with the structure of the healthcare delivery system but also be responsive to the characteristics of the local population groups they are trying to serve. Over the last several years, a group of 25 community-based partnerships across the country have used a multifaceted model to guide their work in making their communities healthier. Through a wide variety of initiatives tailored to local needs, they have not only improved people's health but also provided a series of benefits to the partnering organizations and the community as a whole.

How physicians' organizations compete: protectionism and efficiency

This article develops a framework that distinguishes four types of competitive strategies that physicians' organizations can adopt in their interactions with health plans. Two types of strategies protect physicians' incomes and autonomy from incursion and control by insurers; the other two enhance the efficiency of health care markets by controlling costs and embedding physicians' caregiving in a community of professionals. The mix of strategies that each organization adopts at any given time depends on the market conditions and regulatory policies it faces, as well as its organizational capacity. The article reviews recent developments in the field that indicate that today's markets and regulations create neither the pressures nor the capacity for physicians' organizations to adopt strategies that enhance efficiency. The managed care backlash has led to a relaxation of pressures to control costs, and the lack of a business case for quality has discouraged embedded caregiving. These developments instead have encouraged and enabled physicians' organizations to adopt strategies that protect their members from the bargaining power and micromanagement of health plans. The article therefore proposes changes in purchasing and regulatory policies to alter the pressures and improve the capacity of physicians' organizations to pursue efficiency and eschew protectionism.

Is the corporate transformation of hospitals creating a new hybrid health care space? A case study of the impact of co-location of public and private hospitals in Australia

A common feature of health reforms in western nations has been the transformation or (re)construction of health and health care as both a commodity and product. In the hospital sector, this transformation has become increasingly evident in the growth of for-profit involvement in service delivery. Investor-owned hospitals are now prominent providers of hospital care in Australia. This paper examines the changing nature of health care space through the changing portrayal and meaning of hospitals as represented by and encoded in the built environment. Public hospitals once occupied 'pride of place'. In contrast, up to the early 1980s, the private sector was seen as a cottage industry. However, increased levels of state subsidisation and government incentives and pro-market policies, combined with market-based opportunities for profit generation, have seen the emergence of large private hospital chains with a new corporate image to hospital care and the blurring of 'public' and 'private'. A significant factor in the reconstruction of hospital space in Australia has been the co-location of private and public hospitals. Co-location is a popular strategy proffered by State governments and one that has been quickly acted on by corporate providers. Using Mayne Health Ltd, Australia's largest for-profit hospital chain, and four specific case studies, this paper explores four variants of co-location. Each of these examples represent a different public and private hospital space. The growth of for-profit hospital chains signifies a new phase in the delivery of health care in Australia but also importantly the creation of a new hybridised 'health care' space. This space is neither private nor public but a reflection of the economic, political and social processes underlying this transformation.

Evaluation Informs Coalition Programming for Environmental Tobacco Smoke Reduction

The objective for this formative evaluation was to establish baseline data for informing a community coalition's strategic planning in environmental tobacco smoke (ETS) risk reduction. The coalition had chosen 3 targeted settings for ETS risk reduction: restaurants, childcare facilities, and government buildings. The evaluation methodology involved telephone interviews (restaurants, n = 805; governmental buildings, n = 258) and mailed surveys (childcare facilities, n = 1,142). Data on county residents and businesses were used for comparison purposes and were analyzed from the Nebraska Social Climate Survey (2001; n = 558). Evaluation baseline findings showed that licensed childcare facilities were more ETS knowledgeable, less ETS tolerant, and more smoke-free than restaurants. Residents were more bothered by ETS than what restaurant proprietors perceived. The majority of governmental buildings were not smoke-free. Conclusions were that community health nurse evaluators can provide coalitions with formative evaluative data to inform strategic planning and increase the likelihood of effective program interventions for community impact on ETS.

Why hospitals offer health promotion: perspectives for collaborating with health promotion practitioners

Most hospitals have expanded their services in recent years to become involved with health promotion programs and activities. A hospital might offer health promotion services to promote health and to raise the health status of its community. However, it might provide health promotion for other reasons, such as to improve the hospital's cost-effectiveness, competitive strategy, organizational legitimacy, or tax exemption. Health promotion practitioners who collaborate with a hospital for health promotion should understand the hospital's reasons for providing health promotion. Furthermore, they should understand that different reasons may lead to different priority populations, resource commitments, organizational structures, work processes, and health outcomes.

Comprehensive Evaluation of a Community Coalition: A Case Study of Environmental Tobacco Smoke Reduction

Community coalitions have become an increasingly popular means for addressing community health issues, yet evaluating their effectiveness and performance has presented formidable challenges. To meet the community's need for health program evaluation, public health nurses will need to become better prepared to deal with the complexities of evaluating coalitions and their multifaceted organizational structures. This article presents the methodology and conceptual framework, Targeting Outcomes of Programs (TOP), used to evaluate the performance and impact of a local community coalition. The case study offered here focuses on a tobacco-prevention coalition composed of 15 public and private agencies and their 121 activities. The TOP evaluation model provided the coalition with formative evaluation, needed to improve the coalition's on-going program delivery, and summative evaluation, needed for annual reviews of the coalition's effectiveness and impact in the community. The methodological approach and instrument presented here provide the public health nurse with a solid conceptual framework for approaching such a task.

Broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research

Over the last 40 years, thousands of communities-in the United States and internationally-have been working to broaden the involvement of people and organizations in addressing community-level problems related to health and other areas. Yet, in spite of this experience, many communities are having substantial difficulty achieving their collaborative objective, and many funders of community partnerships and participation initiatives are looking for ways to get more out of their investment. One of the reasons we are in this predicament is that the practitioners and researchers who are interested in community collaboration come from a variety of contexts, initiatives, and academic disciplines, and few of them have integrated their work with experiences or literatures beyond their own domain. In this article, we seek to overcome some of this fragmentation of effort by presenting a multidisciplinary model that lays out the pathways by which broadly participatory processes lead to more effective community problem solving and to improvements in community health. The model, which builds on a broad array of practical experience as well as conceptual and empirical work in multiple fields, is an outgrowth of a joint-learning work group that was organized to support nine communities in the Turning Point initiative. Following a detailed explication of the model, the article focuses on the implications of the model for research, practice, and policy. It describes how the model can help researchers answer the fundamental effectiveness and "how-to" questions related to community collaboration. In addition, the article explores differences between the model and current practice, suggesting strategies that can help the participants in, and funders of, community collaborations strengthen their efforts.

Management and governance processes in community health coalitions: a procedural justice perspective

Community-based coalitions are a popular strategy for promoting community health despite the fact that coalitions often fail to achieve measurable results. Using a procedural justice framework, this study seeks to advance knowledge about the relationship between coalition governance and management processes and indicators of coalition functioning. Member survey data from 25 coalitions participating in the Community Care Network Demonstration Program were analyzed using two-stage least squares regression. Results show that personal influence in decision making. decision process clarity, and collaborative conflict resolution were significantly associated with procedural fairness perceptions. Procedural fairness perceptions, in turn, were positively associated with member satisfaction with coalition decisions, but not personal engagement in the coalition or organizational integration of coalition goals and activities. Personal influence in decision making and collaborative conflict resolution also exhibited direct relationships with all three indicators of coalition functioning examined in the study.

Public-private partnerships in healthcare: criteria for success

Public-private partnerships present opportunities for healthcare providers to meet the dual challenges of shrinking public funding and increasing demand for care. Partnering with private sector organizations can provide new sources of capital, expertise and technology. Successful partnerships require specific skills and strategies. This article describes a pilot study that explored the literature and the experiences of participants in a small sample of interviews to compile a set of criteria for successful public-private healthcare partnerships.

Evaluating partnerships for community health improvement: tracking the footprints

Private-public partnerships are increasingly seen as an important mechanism for improving community health. Despite their popularity, traditional evaluations of these efforts have produced negative or mixed results. This is often attributed to weak interventions or an insufficient period of time to observe an impact. This study examines two additional possibilities--the need for a well-articulated shared vision and the governance and management capabilities of the partnership itself. We conducted a midstream process evaluation of twenty-five community partnerships associated with the Community Care Network (CCN) Demonstration Program. We examined how the roles of a common shared vision, strong governance, and effective management influence a partnership's ability to achieve its objectives. The findings, based on both qualitative and quantitative analyses, underscore the importance of membership organizations' perceived benefits and costs of participation and management capabilities to the partnership's progress toward a vision. Based on the qualitative data, six key governance and management characteristics are identified that separate the top performing partnerships from the lowest performing ones. We explore the implications of this research for future evaluations of public-private community health partnerships.

Interagency relationships among rural early intervention collaboratives

Interagency collaboration is used to coordinate services and programs, pool resources, or achieve goals. This study utilizes the Interagency Collaboration Model to assess interagency relationships of Early Intervention (EI) collaboratives in three rural Ohio counties. The model includes five constructs: environmental factors (broader community environment), situational factors (organizational factors), task characteristics (project's scope and complexity), interagency processes (between agency processes), and outcomes (end products). Respondents from 42 agencies completed the 18-item Interagency Collaboration Assessment Tool (ICAT) and demographic questions. The ICAT uses a 5-point Likert-type scale to assess the five domains of the model. Respondents included public health nurses, representatives from schools, social service agencies, and hospitals. State policies were perceived as encouraging local interagency collaboration; respondents knew staff and goals of other agencies, but agencies did not share funding sources or provide similar services. Diverse specialists were needed to accomplish goals. Some information was exchanged between agencies. Interagency activities were not perceived to be well coordinated and outcomes were only moderately positive. Path analysis revealed that interagency processes were directly affected by environmental and situational factors, but not task characteristics (R2 = 0.42). Situational factors, and interagency processes predicted outcomes (R2 = 0.60). Awareness of personnel, goals and services of other agencies were key to positive interagency process and perceived outcomes.

Community orientation in hospitals: an institutional and resource dependence perspective

OBJECTIVE

To conceptualize community orientation-defined as the generation, dissemination, and use of community health-need intelligence-as a strategic response to environmental pressures, and to test a theoretically justified model of the predictors of community orientation in hospitals.

DATA SOURCES

The analysis used data for 4,578 hospitals obtained from the 1994 and 1995 American Hospital Association (AHA) Annual Survey and the 1994 Medicare Hospital Cost Report data sets. Market-level data came from the Area Resource File.

STUDY DESIGN

Multiple regression analysis was used to examine the effects of hospital size, dependence on managed care, ownership, network, system and alliance memberships, and level of diffusion of community-orientation practices in the area on the degree of community orientation in hospitals. The model, based on Oliver's (1991) framework of organizational responsiveness to environmental pressures, controlled for the effects of industry concentration and lagged profitability.

PRINCIPAL FINDINGS

Degree of community orientation is significantly related to hospital size; ownership; dependence on managed care; and membership in a network, system, or alliance. It is also significantly related to the diffusion of community-orientation practices among other area hospitals.

CONCLUSIONS

Degree of community orientation is influenced by the nature of environmental pressures and by hospital interests. It is higher in hospitals that are large, nonprofit, or members of a network, system, or alliance; in hospitals that are more dependent on managed care; and in hospitals that operate in areas with higher diffusion of community-orientation activities.

Identification of best practices in the delivery of patient food services through public/private sector partnerships

This article describes the evolution of public/private sector partnership in patient food service delivery and identifies skills required by executives to manage partnerships effectively, features that may be generalized to other areas; and the importance of labour relations. Site visits conducted across Canada demonstrate that when partners understand each other's objectives, commit to providing strong leadership, and create meaningful labour relations and communications strategies, partnerships can be successful.

Collaboration to improve community health: trends and alternative models

BACKGROUND

Many health care organizations have begun to pursue collaborative approaches for addressing community-level health issues. To understand how these community health alliances develop and operate, a descriptive study was conducted within a nationally selected group of 60 local communities and supplemented by detailed case studies in 8 communities.

ALLIANCE MODELS

A broad array of organizations were found to participate in community health alliances. Moreover, alliances were found to vary considerably. Strategically, alliances focused on one of three primary objectives: acquiring needed organizational knowledge and skills; addressing common resource needs; and pursuing a shared organizational mission. Functionally, alliances were observed in the areas of service delivery, planning and policy development, surveillance and assessment, and education and outreach. Structurally, alliances were found to operate through one of four interorganizational arrangements; informal collaboration, contractual agreements, shared governance, and shared ownership.

ALLIANCE DEVELOPMENT

Organizational characteristics such as ownership type, organizational proximity, and market share appear to be important in the development of community health alliances. Community and market characteristics--including health resource availability, HMO penetration, and market consolidation--also appear to be influential in alliance development. Longitudinal observations suggest that alliances evolve over time in response to changing community health needs and organizational objectives.

ALLIANCE MANAGEMENT

Several managerial tasks appear to be important to successful alliance operations, including developing a shared vision of collaboration; devising explicit strategies for addressing participation constraints; ensuring the compatibility of organizational incentives; managing communication and information flows across organizations; and developing appropriate processes for performance monitoring.

CONCLUSIONS

The observed variation in alliance structures and functions appears healthy rather than problematic, as organizations develop arrangements to fit community needs, organizational capacities, and market conditions.

The challenges of governing public-private community health partnerships

This article identifies key challenges that arise in governing public-private partnerships designed to improve community health status. Using telephone interview and focus group data, we describe how the 25 public-private community health partnerships participating in the Community Care Network (CCN) Demonstration Program grapple with three interrelated clusters of governance issues: turf, community accountability, and growth and development.