Health Promotion International Advance Access originally published online on October 3, 2008
Health Promotion International 2008 23(4):365-371; doi:10.1093/heapro/dan029
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PERSPECTIVES |
Partnership lessons from the Global Programme for Health Promotion Effectiveness: a case study
Research Centre for Health Promotion, Faculty of Psychology, University of Bergen, Norway
* Corresponding author. E-mail: hopecorbin{at}yahoo.com or hope.corbin{at}iuh.uib.no
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONTHE CASEMETHODSRESULTSDISCUSSIONREFERENCES |
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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.
Key words: collaboration; partnership; synergy; health promotion
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONTHE CASEMETHODSRESULTSDISCUSSIONREFERENCES |
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Governments, foundations, NGOs and INGOs establish partnerships to get diverse people and organizations working together, to create the synergy required to accomplish the goals of health promotion (Zuckerman et al., 1995
; Bazzoli et al., 1997; Israel et al., 1998; Mitchell and Shortell, 2000; Lasker et al., 2001). This investment of money and time has certainly brought people together, but has it yielded the intended synergy?
Lasker et al. (Lasker et al., 2001) define synergy as the extent to which the involvement/contribution of different partners improves the ability of the partners to be creative, holistic, realistic, take action, be accountable, respect stakeholders’ needs and obtain community support. They surmise that the key determinants of partnership synergy include resources, partner characteristics, relationships among partners, characteristics of the partnership arrangement and factors outside the partnership (environmental context). In a subsequent quantitative study, with data collected from 815 informants in 63 unique partnerships, they found evidence that leadership effectiveness and partnership efficiency were most closely correlated with the achievement of partnership synergy (Weiss et al., 2002).
Yet synergy is by no means a predictable outcome of partnership (Dowling et al., 2004). Partnerships are notoriously difficult to manage (Wandersman et al., 1997; Mitchell and Shortell, 2000; Walker et al., 2004), and there is some research suggesting that almost 50% of partnerships dissolve prematurely, within their first year (Kreuter and Lezin, 1998). Partners may experience that collective working draws away substantial resources, they may become frustrated by time-consuming consensus-building processes, they may have to compromise their positions or credibility as a result of group decisions, they can experience a loss of control and accountability can become blurred (Dhuly, 1990; Dowling et al., 2004). Blind faith in the value of partnership seems imprudent (Brinkerhoff, 2002).
Thus, the conviction that partnership is a superior way of working in health promotion is not clearly supported or refuted by the empirical literature. Nevertheless, in health promotion, the value of partnering is an article of firmly established faith. Therefore, research is needed to better understand partnership functioning, especially to illuminate factors and process that promote, and that inhibit, good functioning. Using a learning-from-practice model, the present research aimed to identify and differentiate key elements and interactions that lead to synergistic outcomes and avoid antagonistic (negative) outcomes. The main objective was to conduct a case study of the Global Programme for Health Promotion Effectiveness (GPHPE), to better understand:
- The critical elements of inputs, processes and outputs in the functioning of the partnership; and
- The effects those inputs, process and outputs have on one another in the functioning of the partnership.
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THE CASE |
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TOPSUMMARYINTRODUCTIONTHE CASEMETHODSRESULTSDISCUSSIONREFERENCES |
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The goal of the GPHPE is ‘to raise standards of health promoting policy-making and practice worldwide by: reviewing evidence of effectiveness in terms of political, economic, social & health impact; translating evidence to policy makers, teachers, practitioners, researchers; and stimulating debate of the nature of evidence of effectiveness (IUHPE, 2005)’. The GPHPE is co-ordinated by the International Union for Health Promotion and Education (IUHPE) in collaboration with the World Health Organisation (WHO) and supported by agencies and organizations in Kenya, Switzerland, England, The Netherlands, Canada, the USA and India, among others (GPHPE, 2005). The work of the GPHPE is conducted in seven IUHPE administrative regions: Africa, Europe, Latin America, North America, Northwest Asia, Southeast Asia and the Southwest Pacific. Space limits preclude describing the activities of the GPHPE (see McQueen and Jones, 2007
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METHODS |
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In this case study, documents spanning the period from the GPHPE's first meeting in 2001 to December 2005 were analyzed and 20 informants were interviewed by phone by the first author in the period January to April 2006. The interviews lasted between 30 min and 3 h (completed in multiple sessions). A semi-structured interview guide was used, modified as needed during the course of data collection. Its questions were about respondents’ impressions about the workings of the GPHPE, the processes supporting or inhibiting synergy, and interactions of the partners, the partnership environment and aims of the partnership. All interviews were recorded and transcribed. In the analysis phase, all texts were read to gain an overall impression of the data, then detailed analysis was undertaken, organized around the interview guide, with special attention to two types of processes; production processes whereby GPHPE goals were pursued, and maintenance processes whereby the practical functioning of the GPHPE was managed.
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RESULTS |
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The results are presented here in three categories relevant to the data: partnership inputs (elements entering into the partnership), throughput (processes within the partnership) and output (the products).
Inputs
The most important input for the GPHPE was unanimously the partners themselves. One participant explained:
(I)f it wasn't for the commitment of the people involved in the programme it really wouldn't (exist)—the global programme is as strong as the people involved. I-1The participants spoke of predictable partner contributions such as expertise, skills, and professional work, but they also described other contributions as well such as friendship:
All of these partnerships, the glue behind them is friendship, relationships and friendship. When you're asked to do something and a friend asks you and you have a history and you want to keep that history going– you're inclined to say yes. I-6The majority of partners in the GPHPE have professional responsibilities that mirror or complement the work of the GPHPE. The relevance of their ‘day job’ work to the goals of the GPHPE allows many of them to participate using the resources of the organizations that employ them.
(M)ost of the things that happen in the global programme happen because people commit to doing something that if they come from an institution usually has great interest to their institution. I-1A number of informants described the significant difference in the course of GPHPE activities that had financial support and those that did not:
I can't even tell you the difference it makes to have the (specific) project funded ... . (W)e'll advance in one year—or never mind—nine months, in ways that we never could have without us working every night and every weekend. I-20Financial resources also increase accountability.
When there is not a budget, however small, for a shared activity, the deliverables and the time frames get murky. I-15In addition to partner and financial resources, the raison d'être for the GPHPE's existence—solving the problem of how to better stimulate health promotion policy and best practices—also emerged as a critical input:
Well, the motivation is that it's absolutely obvious that there is a need for building this body of evidence if you want health promotion to be recognized with a stronger and better profile in public health policies, (and) better funded as well. I-11This mission affects collaborative functioning directly by contributing a sense of urgency to get work done:
[There's] definitely a sense of urgency in the field of health promotion to address [effectiveness] issues ... . So I think that there was surely an additional something that made this specific venture motivating, if you will, for people to partake in as compared to maybe other type of endeavours. I-5
Throughput
Communication
The delicate balance between too much and too little communication in the GPHPE was addressed by a number of respondents:
(S)o much paper is generated by this project that I find myself, because I have so many projects to pay attention to, skimming and my attitude toward information from the global programme project is that (specific partner) will bring anything to my attention that I must know and everything else I skim. I-6On the other hand, a large proportion of respondents (sometimes the same respondents) said there was not enough communication from the GPHPE. When asked about what was happening in the various regions of the GPHPE, one participant simply said:
We need an update! I-9A few respondents attributed their lack of knowledge, not to a lack of communication, but to an inability to ‘lift up’ points from the information they did receive.
(W)hat you're tapping into is my ignorance of what's happening in regions and it may be that I am not reading carefully things that are coming my way, but it may also be that it is hard to lift up what's occurring. I mean I have read the reports as they come out. But I don't know that I have an intimate knowledge. I-15The difficulty of achieving exchange at the global level inhibited synergy:
... more regular communication with the global group [is needed] so that people feel like they are aware of what's going on in other places and that they could make the links and get in touch with people for more information ... . It is just to kind of give a tangible feel to something that is very virtual. I-1The data indicated that in the GPHPE, the best communication was in the face-to-face, unfettered exchanges that were conducive to the production of synergy:
(T)here is something important that happens in those meetings that we have at the global level that helps create some kind of synergy with people. I-20
Leadership
Five attributes were identified as critical, based on respondents remarks:
These attributes include professional efficacy;
I think the key factors are (the leader)'s leadership. (The leader) is a person recognised widely in the field. Plus, I would say, having an organisation in the back that has a good reputation ... the combination is very valuable. I-10Good values that inspire confidence;
(P)eople recognize that the IUHPE is an organization that's values really are those of global health promotion generally ... people respect that and feel positive about working with an organization that is attempting to do that. I-4A desire to promote and embody openness, trust, autonomy and patience for working with diverse partners;
(T)here has to be a trusting relationship developed. All sort of things – lots of other things can happen – but without trust, it stops. I-4Skills for resolving conflict;
(T)he weight and the authority of the leader is very important ... . To make everybody understand that (the conflict) is not a life or death issue, and that there is room for everybody. That the cake is big enough, that everybody is going to eat, and that everybody is going to have a good slice, and that everybody is going to enjoy the cake, and that it won't be the dry cake for some and the creamy cake for others, you know? I-11Lastly, a certain degree of pragmatism;
You can't keep enlarging a group and ask everyone for (input), you have to try to be more strategic in who is requested for what kind of feedback or what kind of comments. I-1On the negative side, the data of this study reveal some elements of partnership that can have a negative effect if the leadership does not actively work to prevent them. These negative elements are distrust, unresolved conflict, unrecognized partner contributions and dominance:
If the partners are thinking that one partner is out for self-centred benefit as opposed to the benefit of a group endeavour, then it is a dividing type of situation. And so people are not going to invest in a group effort if they are wary of the motivations of members of the group. I-8
Formal roles and procedures
The formalization of roles and procedures benefited the GPHPE by giving structure to the partnership environment:
(I)t is not enough to just establish the protocol. You have to establish an accountability process, and responsibility for that and consequences. I-8Some informants explained that the GPHPE structure is uniquely designed for co-ordinating between its geographically diverse partners.
(T)he operational structure lends it self to being able to bring information up and then take it back down, that sounds hierarchical and its not at all hierarchical ... . I-1On the downside, undefined roles can result from a lack of communication or from different conceptions of how the partnership should function. When roles are unclear, conflicts can arise between partners which can waste valuable face-to-face time:
I was very disappointed that we had to begin all this silly positioning with (a specific partner) ... . I felt it a great waste of my time, at least that I had to spend so much time dealing with (this) non-sense. I-6
Output
Additive output
Additive outcomes are outcomes that have not been affected by the interaction of the partnership:
I have no images of activities in for example (names many regions of the world) that I would label global program health promotion effectiveness activities. At the same time, I have a good and clear image of effectiveness activities in these countries, because I'm well related to key players in those areas, I know their reports, I know what they're working on in the effectiveness arena. But I would have known that without the global program as well. I-9
Synergy
The data suggest that positive interaction enhances the partnership's ability to produce synergistic results.
I think (GPHPE) is bringing people together to do more than we were doing in our separate ways. I-13The data also suggest that the creation of synergy, or partnership success, feeds back into the partnership positively, affecting functioning and thus enhancing the ability of the partnership to attract more partner input and financial resources.
The greatest accomplishment to date has just been ... that I see the global partners growing, diversifying, new people coming on board who are interested and just the ongoing enthusiasm that has been evolving around the relevance of the global programme. I-1
Antagony
Partnership processes which waste partner time or financial resources by definition produce antagony. The data of the present case suggest that antagonistic output often appears to be no output at all:
We did go to the trouble at the end of that meeting (creating a plan), that really has never been used. (People) just didn't get back – despite prompts. I-15and:
The output of the global program, I do not recognize. If you would ask me what has the global program produced, beyond meetings, beyond what is available in the IUHPE journal, etc., I do not recognize something. ... You hear me say I'm not sure whether this has to do with visibility, or with productivity. I can't judge it. I-9
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONTHE CASEMETHODSRESULTSDISCUSSIONREFERENCES |
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The system-like nature of partnership functioning proposed by Wandersman et al. (Wandersman et al., 1997
) is supported by this study, with some important modifications that lead us to propose a new model founded on theirs, as shown in Figure 1.
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The data confirm the importance of the partners themselves and of finance as important inputs, and a unique contribution of this study is its recognition that the nature of the partnership mission also effects partnership functioning. The data suggest that positive cycles of interaction and negative cycles of interaction exist simultaneously within the GPHPE. No respondent interviewed described the interaction of the GPHPE as either all negative or all positive. The data describe three possible types of output: additive, synergistic and antagonistic. In our model, additive results are depicted as by-passing the collaborative context because the existence of the partnership does not affect these results. They would have happened anyway. Synergistic results are a possible output of the collaborative context. An arrow from synergy back into the partnership depicts the positive effect making good progress can have on the functioning of the partnership and in the future recruitment of new resources. Another arrow connects synergy back to the mission; however, this is purely speculative, since the GPHPE does not have a long enough record of accomplishment to demonstrate success in effecting its mission. Antagony may also be an output of the partnership, depicted in the model as being outside the ‘environment’ because the antagonistic output contributes nothing. However, antagony also may feed back into the collaborative context contributing negatively to functioning and future recruitment.
The present study provides insight into the functioning of a global partnership for health promotion, which may enable health promoters to improve the functioning of present and future partnerships. At the same time, more questions are raised than are answered. The data from this study illuminate the central role the partnership mission plays within the partnership. The urgency of the mission can motivate inputs as well as stimulate positive partnership processes. More research is needed to examine these relationships. What attributes of the mission create urgency? What are the optimal degrees of focus and of urgency?
More research is also needed to further explore the influence of output on partnership functioning and inputs, since the GPHPE was too new to have produced the outcomes that would be needed to study this aspect of partnership functioning. Perhaps even more important, research needs to be conducted to measure the impact output has on the partnership mission. In a relatively enduring partnership, the nature of the mission is bound to evolve as experience is gained and as outcomes of various types become manifest. Some of the experience will be outside the partnership and some will be inside, and it is an empirical question how both types of experience shape the evolution of the mission.
The present study indicates some clear interaction between partner input and financial input. The GPHPE was strongly supported by partner resources but under-funded. Another case study exploring a partnership, or multiple partnerships, which have a different balance between these inputs may reveal important information about how to plan and implement partnerships. While some of the evidence from the present case suggests that more financial resources can improve functioning, there was also compelling evidence indicating that funding can complicate functioning and may lead to a loss of autonomy. More research is needed to examine the balance of inputs.
Finally, it is easy to see how antagony has the potential to impact functioning negatively, as partners and funders could see the partnership as a waste of time and/or money. However, it is also possible that antagony could have a positive impact on functioning, as partners learn from the mistakes they made that led to antagony, and improve the functioning of future partnerships. This is important because most organizations working in any given health promotion partnership are quite likely to have the habit of partnership working, providing opportunity for learning and improvement.
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